DM - management of CVD/ CKD

Question 1

Blood pressure management in diabetes

Answer 1

BP goal: <130/80mmHg
- reduces CVD mortality
- slows CKD progression

BP lowering agents of choice (with or w/o diabetic kidney disease): ACEi/ ARBs

Question 2

Lipid management in diabetes

Answer 2

Primary prevention:
*goal: reduce LDL cholesterol by 50% from baseline + target LDL cholesterol: <1.8mmol/L (<70mg/dL)
- 40-75 y/o: MODERATE-intensity statin [eg. ator 10-20mg]
*consider high intensity if additional ASCVD risk factors

secondary prevention (those WITH atherosclerotic cardiovascular disease):
*Goal: LDL-cholesterol reduction by 50% from baseline + target LDL cholesterol: <1.4mmol/l (<55mg/dL)
- HIGH-intensity statin therapy [ator 40-80mg, rosu 20-40mg]
- addition of ezetimibe/ PCSK9 inhibitor recommended if goal not achieved
**21% reduction in major CV events for every 39mg/Dl (1mmol/L) of LDL-c lowering (irrespective of baseline LDL-c)

Question 3

what is diabetic kidney disease (DKD)

Answer 3

Clinical presentation:
- presence of albuminuria WITHOUT gross hematuria
- ABSENCE of signs/ symptoms of other primary causes of kidney damage
- other considerations:
–> long duration of diabetes
–> presence of RETINOPATHY (esp T1DM)
*DKD may present in T2DM w/o retinopathy
–> gradually decrease in eGFR

Question 4

Role of antiplatelet agent (aspirin) in diabetes

Answer 4

Aspirin as PRIMARY prevention strategy: diabetics with INCREASED CV risk (need risk-benefit discussion w pt) *50-70y/o
*not recommended for pts >70y/o (risk > benefit)
**if low risk of ASCVD (eg. <50y.o diabetics AND NO OTHER major ASCVD risk factors): NOT RECOMMENDED

ASCVD risk factors: LDL-C >/=2.6mmol/L, high BP, smoking, CKD, albuminuria, family history of premature ASCVD

Intermediate risk (eg. younger pts with >/=1 risk factors/ older pts with no risk factors): clinical judgement

SECONDARY PREVENTION STRATEGY for those with diabetes AND HISTORY OF ASCVD

Question 5

Management of CKD in diabetes

Answer 5

*PRIMARY PREVENTION OF CKD: BG & BP control
- ACEi/ARB NOT recommended for primary prevention for DM with NORMAL BP

MICRO/MACRO-albuminuria: ACEi/ ARB
- reduces kidney disease progression
*titrate to max tolerated dose

T2DM + DKD + eGFR >20ml/min/1.73m2: SGLT2i
- reduce kidney disease progression & CV events
*use concurrently with ACEi/ARB

micro/macroalbuminuria + eGFR >25ml/min/1.73m2: Finerenone (non-steroidal mineralocorticoid receptor antagonist)
- slow CKD progression
- reduce risk of kidney failure, MI, HF, hospitalisation & CV death (in pts w CKD associated w T2DM)
- lesser risk of gynecomastia (vs spironolactone)
*SE: HYPERKALEMIA, hypotension

Question 6

preventive immunisation in diabetes

Answer 6

• annual influenza vaccine
• pneumococcal polysaccharide vaccine
• Hep B vaccine
• shingles (herpes zoster) vaccine

Question 7

Benefits of CGM (continuous glucose monitoring)

Answer 7

*wearable device, measures interstitial glucose

• Improves A1c reduction
• Reduces hypoglycemia
• Eliminates use of a glucometer, lancet & blood test strip -> more discreet & regular monitoring

*T1DM: insulin pumps (+/- integration with CGM)

Question 8

Comparisons of various glucose monitoring

Answer 8

*blood glucose monitoring (BGM), intermittently scanned CGM (isCGM), real-time CGM (rtCGM)

Measurement:
BGM - via pt action only, finger-prick testing
isCGM - via pt action through scanning of sensor *measures interstitial glucose
rtCGM- NO pt action required *measures interstitial glucose

Hypoglycemia:
BGM - proactive check when symptomatic/ by direct action
isCGM - information recorded (retrospectively), required direct action q8h
rtCGM - automatically detected

Alarm/ warning:
BGM/ isCGM - NIL
rtCGM - YES

Management:
BGM, isCGM - by pt
rtCGM - can link to insulin titration algorithm

Question 9

What is Time-In-Range (TIR) and how is it relevant in DM management?

Answer 9

70% of TIR correlates with A1c of 7%

TIR correlates with risk of complications
*for each 10% lower TIR:
- 64% MORE retinopathy
- 40% MORE microalbuminuria