Diabetes mellitus is among the top causes of death in America. Unregulated diabetes may affect related systems such as renal and cardiovascular systems. More than 29 million of the total united states population have diabetes. The cost associated with the management of diabetes is high. In 2012, the cost of diabetes was approximately 245 billion (American Diabetes Association, 2021, p.74). High glucose levels can result in dehydration, polyuria, polydipsia, and weight loss. Since it is associated with metabolic derangements, it may cause sensory and peripheral neuropathy, foot ulcers, myocardial infarction, vision loss, and end-stage renal disease. Proper strategies of reducing blood sugar can decrease complications, although drastic lowering can cause harm.
There are various ways used to measure blood glucose levels. The most effective way is through glycosylated hemoglobin (HbA1C) which measures the average sugar levels for three months. It was a parameter studied in most clinical trials and showed the benefits of improved glycemic control in patients with diabetes. It is an accurate measure in the management of diabetes. Guidelines have recommended intensification of pharmacological management to achieve a specific target of glycosylated hemoglobin depending on the population (American Diabetes Association, 2021, p.76). The targets should benefit the patients and bring no harm.
Management of blood glucose is one of the critical issues in the care of people with diabetes. Glycemic control is done through monitoring of the glycosylated hemoglobin (AC1). There are two main goals of treatment for diabetic patients; regulating the blood sugar level, and second one is to prevent both microvascular and macrovascular associated with diabetes. Blood sugar targets for each individual differ according to the drug they are taking and their condition. For example, a pregnant mother may have a lower blood glucose target.
Self-blood monitoring of blood glucose (SMBG) is also vital in self-management and adjustment of the medications to achieve the target glycemic control. Continuous assessment of blood glucose has played a critical role in the treatment regimen’s effectiveness and safety in patients with T1DM. There is limited data on its effectiveness among T2DM diabetes patients, especially those on intensive insulin regimens (American Diabetes Association, 2021, p.78). According to American Diabetes Association (2021, p.81), Initial testing of HbA1c inform care and treatment of the patients.
Moreover, A1C has a solid predictive capacity of complications of diabetes. Thus, the test should be performed in the initial assessment of all the patients with diabetes. The period of measurement, which is three months, defines whether the glycemic aims were achieved and preserved. Clients with type 2 diabetes whose blood glucose is tightly controlled may only need the test twice a year, while those whose blood has not met the targets blood sugars or under intensive treatment may need to be tested frequently (Imran et al., 2018, p.39). Therefore, the interval of the A1C testing should also depend on the condition of the patient, the physician’s decision, and the treatment regime of the patient.
Glycemic Targets
Workout is a cheap and easy way to decrease sugar levels. However, the glycemic goals majority of the older adults who are nonpregnant are less than 7% (53mmo/l) (Saeed and Ballantyne, 2017, p.19). However, healthcare providers may suggest more stringent goals of 6.5% in patients whose targets can be achieved without marked side effects of the drugs and also hypoglycemia (Tian et al., 2020, p.1291). Studies have shown the glycemic target of 7% reduces microvascular complication cases in type 2 diabetes patients (American Diabetes Association, 2021, p.84). It was associated with a 50-60% reduction in complications in most randomized controlled trials. The majority of the patients with short-term experience marked benefits from the strict glycemic control.
The most common adverse effect includes polypharmacy. The most appropriate patients for the 6.5% glycemic target have type 2 diabetes, short-duration diabetes, patients on metformin only, without cardiovascular disease, or patients with long life expectancy (Miyamoto and Shikata, 2021, p.70). Less stringent targets such as more than 8% (64mmol/l) are appropriate for patients with microvascular and macrovascular complications, history of severe hypoglycemia, cardiovascular diseases, long-standing history of diabetes, and other comorbidities (American Diabetes Association, 2021, p.81). It also includes whose patients whose self-management has not been achieved through education, diet, and treatment regimen.
Thus, the targets should be reassessed based on life expectancy, cardiovascular disease, macro and microvascular complications, other comorbidities, patient preference and resources, and support systems. The UK Prospective Diabetes (UKPD) studies have shown that having a tight glycemic control reduces the risk of kidney disease, peripheral neuropathy as wells, as macrovascular complications (Imran et al., 2018, p.42). Studies have shown that lowering blood glucose to 6% further reduces microvascular chances, although the absolute risk reduction decreases (Rodriguez-Gutierrez et al., 2019, p.371). Due to the significant increase in hypoglycemia in T1DM and polypharmacy in T2DM the risk of low glycemic goals outweighs the advantages of the microvascular complications. There is enough evidence on reducing or slow the progression of cardiovascular risks in T2DM when tight glycemic control is affected (Qaseem et al., 2018, p.572). Therefore, tight glycemic control reduces the rates of myocardial infarction at considerable rates.
Disadvantages of Tight Glycemic Control
Although most of the guidelines recommend tight glycemic control, they may have less significant effects on reducing microvascular and macrovascular risks in patients who have already complicated diabetes (Miyamoto and Shikata, 2021, p.69). According to ADVANCE studies, there was no significant decrease in the cardiovascular cases for the patients who had a vascular disease (Tian et al., 2020, p.1293). The vascular complication reduction did not reach statistical significance as per ACCORD (Singleton et al., 2020, p.2190). Some of the medications are related to lower cardiovascular risk.
Tight glycemic control may have marked hypoglycemia complications in T1DM and polypharmacy in T2DM. Some evidence does not support tight glycemic control because studies have shown that it does not prevent 10 of the 11 common microvascular complications (Imran et al., 2018, p.41). Achieving the targets has no impact on the progression of end-stage renal disease. The putative effect recorded in some studies regarding amputation is not precise as tight glycemic controls reduce myocardial infarction rates by 15% only (Rodriguez-Gutierrez et al., 2019, p.376). The narrow focus on glycemic targets has reduced stress on the other interventions of preventing microvascular complications.
Cardiovascular Risk Assessment in Diabetes
Cardiovascular Disease Risk (CVD) risk assessment is critical in diabetic patients as it informs the decision made by the clinician regarding the treatment regimen and other therapeutic interventions. ADA (2021, p.70) recommends using a risk factor approach in the assessment of CVD threat. The risk factor included in the assessment consists of low-density lipoprotein (LDL) of more than 100mg/dl, smoking, obesity, hypertension, and family history of atherosclerotic cardiovascular disease (ASCVD) (Saeed and Ballantyne, 2017, p.17). Moreover, people with diabetes have the highest cardiac or cardiovascular disease risks.
Identification of the Risk Factors
Some of the modifiable risk factors or features include age. Studies have shown a high risk of CVD in men aged 48 years and women aged 54 years (Tian et al., 2020, p.1295). Shifting from to moderate risk from the lower category occurs at 35 years in males and 45 in females. Men are at a greater danger of CVD when matched to women in the healthy population (Saeed and Ballantyne, 2017, p.19). In diabetic patients, women are at a more significant threat of CVD as compared to their male counterparts. Studies showed a substantial rise in CVD risk in T2DM females than in T2DM males (American Diabetes Association, 2021, p.69). Studies have shown a 50% increase in the risk of coronary artery risk in women (Saeed and Ballantyne, 2017, p.16). This is due to the less favorable risks such as hyperlipidemia in women.
T2DM is associated with higher CVD compared to T1DM. Evidence has shown individuals with T2DM are at a higher risk of getting myocardial infarction (Saeed and Ballantyne, 2017, p.19). The association between the myocardial infarction and the family history of CAD is significant. Diabetic patients with first-degree relatives with CAD developed myocardial infarction compared to those that no family history of coronary artery disease (American Diabetes Association, 2021, p.84). Smoking is a modifiable cause of CVD in diabetic patients.
Furthermore, evidence has shown that the risk of myocardial infarction was high in men and women who smoked more than five packs of a cigarette than those who do not smoke (Sehgal et al., 2020, p.276). The active smoker is at higher risk of CVD compared to both former smokers and nonsmokers. In both T2DM and T1DM, hypertension is a significant cause of complications. From the body of evidence, lowering the systolic blood pressure by 10mmhg lowers cardiovascular events by more than 50%. ADA (2021, p.72), Recommends a target blood pressure of 140/90mmhg in diabetic patients. A study that followed diabetic patients for 16 years reported that CVD deaths were higher in patients with LDL than 100mg/dl compared to those with normal LDL (Tian et al., 2020, p.1296). Moreover, cholesterol increased CVD risk, potentiated by diabetes (Bertoluci and Rocha, 2017, p. 16). It is worth noting that patients with diabetics have a high risk of high cholesterol levels.
Identification of the Risk Enhancing Factors
The last part is to identify risk enhancing factors essentially. These are significant threat aspects that may alter the development of CVD events in different subsets of diabetes. The double risk enhancing characteristics stated the following factors as enhancements of the disease (Imran et al., 2018, p.38). Family background of ASCVD, long-lasting kidney illness, metabolic disorder, chronic inflammatory disorders, primary high cholesterol levels, lipid abnormalities, and biomarkers such as C reactive proteins (Bertoluci and Rocha, 2017, p.10). The above are the main risk factors associated with CVD occurrences.
Estimation of CVD Risk using Risk Score Calculators
The calculators assess cardiovascular risks depending on the magnitude of the independent risk factors through a formula. The generated score is based on the different outcomes. There are approximately 110 calculators, and 45 of them are specific to diabetic patients. UKDPS is the most popular global calculator (Kavaric et al., 2018, p.605). The components include age, gender, smoking status, LDL, race, ethnicity, duration of diabetes, systolic blood pressure, and atrial fibrillation. Patients with more than ten years of diabetes are considered to be at higher risk of diabetes. There are various calculators, and the clinician should choose the appropriate one for them.
Reference List
American Diabetes Association, (2021), ‘6. Glycemic targets: standards of medical care in diabetes – 2021’, Diabetes Care, 44(Supplement 1), pp. S73-S84. Web.
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Sehgal, A., Sibia, R.P.S., Kaur, J., Bhajni, E. and Sehgal, V.K., 2020, ‘A cross-sectional study to evaluate cardiovascular risk score in type 2 diabetes mellitus’, International Journal of Applied and Basic Medical Research, 10(4), p.276. Web.
Singleton, M.J., Soliman, E.Z., Bertoni, A.G., Whalen, S.P., Bhave, PD, and Yeboah, J., (2020), ‘Effect of intensive glycemic and blood pressure control on QT prolongation in diabetes: The ACCORD trial’, Diabetes, 69(10), pp.2186-2193. Web.
Tian, J., Ohkuma, T., Cooper, M., Harrap, S., Mancia, G., Poulter, N., Wang, J.G., Zoungas, S., Woodward, M., and Chalmers, J., (2020), ‘Effects of intensive glycemic control on clinical outcomes among patients with type 2 diabetes with different cardiovascular risk levels and hemoglobin A1c in the ADVANCE trial’, Diabetes Care, 43(6), pp.1293-1299. Web.