Interesting info from Medscape

[Guest guest]

Got this from the latest update from the medscape site. Found it very

interesting though I'm still mulling it over... Note the differences in the

HbA1c levels hoped for between the type 1's and 2's. Could this be where

the doctors are coming up with the 7? Also... I did not know that ACE

inhibitors reduced insulin resistance. Did you?

Glycemic Control

Two prospective studies have shown an association between glycemic control

and chronic diabetic complications in type 2 diabetes. The Kumamoto study[2]

used thin, insulin-requiring, Japanese type 2 patients and used a protocol

similar to that used by the DCCT. As expected, the outcomes were similar,

with a 2.0% difference in HbA1c level being associated with a 69% decrease

in retinopathy and a 70% decrease in nephropathy. The United Kingdom

Prospective Diabetes Study (UKPDS) showed that with a 0.8% difference in

HbA1c level (7.1% vs 7.9%), there was a 17% to 21% decrease in retinopathy,

a 24% to 33% decrease in nephropathy, and a 16% decrease in macrovascular

disease.[3] A later analysis of the UKPDS showed that the lower the HbA1c

level was, the lower was the incidence of retinopathy, nephropathy,

neuropathy, amputations, cataracts, congestive heart failure, myocardial

infarctions, and stroke. Of special importance was the finding that there

was no threshold below which a further reduction in the incidence of

diabetic complications did not occur.[4] This is particularly important

since a recent population study showed that even within the normal,

nondiabetic HbA1c range the lower the HbA1c level attained, the lower was

the incidence of cardiac events[5]; therefore, the lower the HbA1c level in

the type 2 patient, the better is the outcome. Fortunately, lower HbA1c

levels are easier to achieve in the type 2 patient than in the type 1

patient because severe hypoglycemia is less common, and severe hypoglycemia

is rare in patients taking metformin and/or a thiazolidinedione (TZD).

Angiotensin-Converting Enzyme Inhibitors

Prevention of almost all diabetic complications can be helped by using an

ACE inhibitor.[9] This is particularly true for microvascular complications,

but the Heart Outcomes Prevention Evaluation (HOPE) study, where type 2

diabetic patients without known ischemic heart disease but with at least one

other cardiac risk factor were included, showed significant decreases in the

incidence of myocardial infarction, stroke, and congestive heart failure

with only a 4 mm Hg drop in blood pressure in those patients taking the ACE

inhibitor ramipril when compared with those taking placebo.[10] This

suggests that ACE inhibitors have an effect in lowering cardiac events in

addition to lowering blood pressure. In my opinion, use of an ACE inhibitor

is mandatory in the type 2 diabetic patient, since ACE inhibitors also

significantly lower insulin resistance.

Rita