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■ CONFERENCE REPORTS Clinical Medicine 2009, Vol 9, No 4: 353–7 Management of type 2 diabetes: NICE guidelines Latika Sibal and Philip D Home The National Institute for Health and Clinical Excellence (NICE) diuretic may be added (the last with caution if the individual is guideline on the management of type 2 diabetes, prepared by the already taking an ACEI or an A2RB). Royal College of Physicians (RCP),1 was the subject of a confer- ence at the College in June 2008. This report highlights some themes of that meeting, concentrating on where aspects of car- Other aspects of cardiovascular risk protection diovascular risk management differ from non-diabetic people, The Steno 2 follow-up study has demonstrated that comprehen- on specific recommendations in regard to microvascular compli- sive CV risk factor treatment, including BP lowering, use of cations, on the guideline’s key recommendations, and on recent ACEI, glucose lowering, lowering cholesterol and triglyceride, aspects of blood glucose control. This review does not seek to be raising high-density lipoprotein (HDL) cholesterol and the use comprehensive. of aspirin, was associated with remarkable absolute reductions in death, CV events, diabetic nephropathy and laser photocoag- Blood pressure management ulation when compared to conventional management.7 Numbers needed to treat over 13 years were five to eight in these Lowering of blood pressure (BP) in type 2 diabetes is associated people with microalbuminuria. not just with a reduction in the risk of cardiovascular disease (CVD) but also eye and kidney microvascular complications.2 A BP-lowering strategy is thus particularly effective and cost effec- Antiplatelet therapy tive in those with diabetes and kidney, eye, or cerebrovascular Antiplatelet therapy has an established role in the management damage, with interventional thresholds and targets of 130/80 of people at high risk of CV events and thus, by extrapolation of mmHg in these people and 140/80 mmHg in all others. The evidence, in people with diabetes. A post-hoc analysis of 3,866 strategy should include lifestyle advice, medications if lifestyle people with diabetes within a larger study compared aspirin advice does not achieve targets, and monitoring every one or with clopidogrel in the secondary prevention of CVD.8 A signif- two months, with intensification of therapy if not to target. icant benefit of clopidogrel with a relative risk reduction of Notably, for type 2 diabetes, there is no general threshold 12.4% (absolute 2.1%) was found, alongside a reduction of 37% below which BP lowering ceases to be beneficial3; accordingly for re-hospitalisation for any bleeding event (p 0.031). lower BP if easily attained without side effects is desirable. However, in the absence of useful health-economic analysis, the Overall, the best evidence for prevention of renal disease and new guideline chose to follow NICE guidance advising the use of retinopathy is for the renin–angiotensin system blockers (RAS clopidogrel instead of aspirin only in the presence of definite blockers).4–6 Therefore, a generic 24-hour angiotensin-converting aspirin intolerance (except in the context of acute cardiovascular enzyme inhibitor (ACEI) should be used first line, with an events and procedures).9 The appropriate dose of aspirin to be angiotensin-2 receptor blocker (A2RB) substituted in the event used in people with type 2 diabetes is unclear. Accordingly the of significant ACEI intolerance, usually a cough, but not if standard 75 mg dose is recommended for: hyperkalaemia or decreased renal function is the problem. In people of Afro-Caribbean descent, either combination ACEI • those 50 years old (and BP 145/90 mmHg) diuretic therapy or ACEI calcium-channel blocker (CCB) is
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