A 56-year-old man comes to the office for follow up. He has type 2 diabetes mellitus of 15 years' duration, hypertension, and hyperlipidemia. His diabetes mellitus is currently managed with metformin and glimepiride. Hemoglobin A1c level is 8.5%. Switching to insulin therapy to attain better glycemic control is discussed with the patient. Achieving a goal hemoglobin A1c of 6.5% with use of insulin is most likely to reduce the risk of which of the following complications over the next 5 years?

Question

A 56-year-old man comes to the office for follow up. He has type 2 diabetes mellitus of 15 years' duration, hypertension, and hyperlipidemia.  His diabetes mellitus is currently managed with metformin and glimepiride.  Hemoglobin A1c level is 8.5%.  Switching to insulin therapy to attain better glycemic control is discussed with the patient.  Achieving a goal hemoglobin A1c of 6.5% with use of insulin is most likely to reduce the risk of which of the following complications over the next 5 years?

Quizplus · Accepted Answer

11ec25c8_d256_bf79_bc81_1f4e56a93d13_MD0003_00 Chronic hyperglycemia in diabetes mellitus is linked to increased mortality and morbidity from microvascular (eg, retinopathy, nephropathy) and macrovascular (eg, cardiovascular disease) complications. However, use of pharmaceutical interventions to achieve glycemic control appears to have mixed effects on reduction of mortality and macrovascular complications. Major randomized controlled trials (eg, United Kingdom Prospective Diabetes Study [UKPDS], Action to Control Cardiovascular Risk in Diabetes [ACCORD]) suggest that intensive glycemic control (ie, hemoglobin A1c between 6.0% and 7.0%) with insulin and/or sulfonylureas (eg, glipizide) significantly improves microvascular endpoints, such as retinopathy and nephropathy. In contrast, these trials suggest that intensive glycemic control does not reduce macrovascular complications (eg, stroke, myocardial infarction) or all-cause mortality (Choices A, C, and E). Strict glycemic control with insulin is also associated with significantly increased risk of hypoglycemia (Choice B). Furthermore, the ACCORD trial showed that very intensive glycemic targets (ie, A1c between 6.0% and 6.5%) appear to increase risk of all-cause and cardiac mortality. Given the established benefits of glycemic control on the risk of microvascular complications and the potential risk of overly strict glycemic control, the recommended target hemoglobin A1c for most nonelderly patients is 7.0%. In addition, efforts to reduce the risk of macrovascular complications should also include careful management of other lifestyle and cardiac risk factors (ie, smoking, blood pressure, lipids). Educational objective: In patients with diabetes mellitus, intensive blood glucose control with insulin decreases the risk of microvascular complications (eg, retinopathy, nephropathy) but has an uncertain effect on macrovascular outcomes (eg, stroke, myocardial infarction) and mortality. Very strict glycemic control (eg, goal A1c ≤6.5%) is associated with increased risk of hypoglycemia and increased cardiovascular mortality. Therefore, the recommended target hemoglobin A1c for most nonelderly patients is 7.0% References: Individualizing targets and tactics for high-risk patients with type 2 diabetes: practical lessons from ACCORD and other cardiovascular trials. (http://www.ncbi.nlm.nih.gov/pubmed/22996182)

A 56-Year-Old Man Comes to the Office for Follow Up