Outpatient screening and treatment goals-diabetes mellitus

(Diabetes Care 2022;45;S83 & S144)

• ✓ HbA1C q3–6mo, goal <7% for most Pts. Goal <6.5% if low-risk hypoglycemia; ≤8% if h/o severe hypoglycemia, elderly or other comorbid.
• Microvascular complications (nephropathy, retinopathy, neuropathy) ↓↓ by strict glycemic control (NEJM 1993;329:977).
• Effect of strict glycemic control on macrovascular complications (ASCVD) more nuanced. Benefit in T1D (NEJM 2005;353:2643) & T2D, but emerged after a decade (NEJM 2015;372:2197). In shorter-term trials (~5 yrs), modest ↓ in risk of MI, but no effect on death and even ↑ in some studies, potentially because of hypoglycemia (Lancet 2009;373:1765).
• Microalbuminuria screening yearly with spot microalbumin/Cr ratio, goal <30 mg/g
• Wt loss (dietary/drugs) can regress or resolve DM (Endo Rev 2018;39:79; NEJM 2018;379:1107)
• BP ≤130/80 if high CV risk, ≤140/90 if lower risk; benefit of ACEI/ARB
• Lipids: statin initiation in all diabetics age 40–75 if LDL-C >70 (see “Lipid Disorders”)
• ASA in 2° prevention; ? role in 1°, balancing ↓ MACE & ↑ bleeding (NEJM 2018;379:1529)
• Dilated retinal exam and comprehensive foot exam