Diabetes mellitus type 2 secondary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

The most important aspect of secondary prevention in diabetes mellitus type 2 is to decrease the mortality from macrovascular complications. Among the preventive measures, lipid control, smoking cessation, treatment of hypertension and regular ophthalmologist visit in order to prevent retinopathy are the most important ones.

Secondary Prevention

• Secondary prevention is focused on decreasing the macrovascular complications. Application of effective strategies can result in up to 50% risk reduction in macrovascular complications.
• Effective measures in this case include:
  • Glycemic control
  • Treatment of lipid disorders
    • Triglyceride level should be less than 150 mg/dL (1.7 mmol/L)
    • Favorable HDL levels is >40 mg/dL (1.0 mmol/L) for men and >50 mg/dL (1.3 mmol/L) for women.
    • Statin treatment for preventive measures should be considered for all diabetic patients. The following table summarizes the statin therapy strategies:

Abbreviations: CVD: Cardiovascular disease

Age	Risk factors	Recommended statin dose†
<40 years	None CVDrisk factor(s)¶ Overt CVDΔ	None Moderate or high High
40 to 75 years	None CVD risk factors Overt CVD	Moderate High High
>75 years	None CVD risk factors Overt CVD	Moderate Moderate or high High

^† :In addition to lifestyle therapy.

¶ :CVD risk factors include LDL cholesterol ≥100 mg/dL (2.6 mmol/L), high blood pressure, smoking, and overweight and obesity.

Δ :Overt CVD includes those with previous cardiovascular events or acute coronary syndromes.

• Blood pressure control
  • Blood pressure should be measured on every visits. Goal of blood pressure in diabetic patient is less than 140/90.
  • The Heart Outcomes Prevention Evaluation (HOPE) study suggested that the angiotensin-converting enzyme inhibitor ramipril could reduce vascular disease and mortality among patients at increased risk. This effect was thought to be independent of control of blood pressure. However, subsequent studies have shown this result was more likely due to the administration of ramipril at night and recording blood pressure during the day when the least effect of ramipril was present.

• Microvascular disease complications. Clinical practice guidelines by the American Diabetes Association in 2019 stated to avoid diabetic complications:
  • The ADA recommends “Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes."
  • The ADA recommends “Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist at the time of the diabetes diagnosis.”
  • The ADA recommend that “If there is no evidence of retinopathy for one or more annual eye exam and glycemia is well controlled, then exams every 1–2 years may be considered."
  • The ADA recommend that “If any level of diabetic retinopathy is present, subsequent dilated retinal examinations should be repeated at least annually by an ophthalmologist or optometrist.
  • The ADA recommend that “If retinopathy is progressing or sight-threatening, then examinations will be required more frequently

• Smoking cessation

• Using Aspirin

• Weight reduction

• Vaccination including, annual influenza, pneumococcal vaccination and hepatitis B.

• Regular dental care