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Previously, we explored blood pressure control in a patient with diabetes. Now, we’ll discuss the value of a fasting lipid panel and treatment for dyslipidemia in this population.
CASE CONTINUED
Mr. W completed a fasting lipid panel, which revealed the following: triglycerides, 145 mg/dL; high-density lipoprotein (HDL) level, 32 mg/dL; and low-density lipoprotein (LDL) level, 108 mg/dL. He is currently receiving low-dose statin therapy. Based on these results, Mr. W fits the criteria for dyslipidemia.
Dyslipidemia
Dyslipidemia marked by elevated LDL levels—as observed in Mr. W—is a well-known contributing factor to development of cardiovascular disease in patients with diabetes. Elevated triglycerides and low HDL levels also are often noted in these patients. Patients with diabetes are particularly vulnerable to atherosclerosis due to a combination of pro-inflammatory factors and hyperglycemic effects. Both the ADA and the AACE agree that lipid management, including fasting lipid panels and appropriate treatment, is of paramount importance in patients with diabetes.7,8
Fasting Lipid Panels
The AACE recommends administering at least annual fasting lipid panels in all adults with diabetes, and LDL goal levels should be based on the cardiovascular risk of the patient.7 For patients with
- established ASCVD, the LDL goal is < 55 mg/dL
- risk factors for ASCVD (eg, hypertension, tobacco use, family history of ASCVD) in addition to diabetes, the LDL goal is < 70 mg/dL
- no risk factors, the LDL goal is < 100 mg/dL.7
Statin Therapy
Research indicates that statins reduce the risk for cardiovascular events and are recommended as first-line treatment for dyslipidemia.2,7 Statin therapy is recommended for patients with LDL levels above goal without contraindications.10 Higher-dose statins have been shown to help improve cardiovascular outcomes, and most—if not all—guidelines recommend up-titration of these medications as tolerated by the patient. 7,8,29 After initiation of statin therapy, clinicians should continue to monitor lipid levels every 4 to 12 weeks after a change in lipid therapy and then schedule monitoring annually.2
Unfortunately, a recent large-scale retrospective study of the medical records of 125,464 patients with type 2 diabetes showed that although 99% of the patients were at high risk for or already had ASCVD, only 63% were receiving the recommended statin therapy.30 Therefore, all patients with diabetes at risk for ASCVD require evaluation to determine the need for statins.
Additional treatments. If the patient’s levels remain above goal, strong consideration should be given to additional therapies. Ezetimibe has been shown to have some benefit in reducing LDL levels and cardiovascular risk.31 PCSK9 inhibitors are a newer treatment for cardiovascular disease and are particularly beneficial for patients with known ASCVD. The FOURIER and ODYSSEY trials demonstrated that PCSK9 inhibitors had relative risk reductions of 48% to 53% for major ASCVD events and showed that these medications help reduce LDL levels and, most importantly, cardiovascular risk.32,33
Continue to: Recommendations for other lipid components
Recommendations for other lipid components—non–HDL-C, apolipoprotein B, or LDL-P—are very specific and consideration may be given for referral to an endocrinologist or lipidologist for evaluation and treatment.7,8 Evidence on reducing cardiovascular risk with therapies for decreasing triglyceride levels is limited. Recently though, icosapent ethyl received FDA approval as an adjunct to maximally tolerated statin therapy to reduce the risk for cardiovascular events in patients with elevated triglyceride levels (≥ 150 mg/dL).34,35 ADA guidelines recommend icosapent ethyl for patients with diabetes, 1 additional cardiovascular risk factor, and triglyceride levels between 135 and 499 mg/dL.2
In Part 4, I’ll explore how clinicians can best monitor for chronic kidney disease in patients with diabetes. We’ll also discuss the medications used for improving kidney health in these patients.
1. Centers for Disease Control and Prevention. Diabetes incidence and prevalence. Diabetes Report Card 2017. www.cdc.gov/diabetes/library/reports/reportcard/incidence-2017.html. Published 2018. Accessed June 18, 2020.
2. Standards of Medical Care in Diabetes—2020 Abridged for Primary Care Providers. American Diabetes Association Clinical Diabetes. 2020;38(1):10-38.
3. Chen Y, Sloan FA, Yashkin AP. Adherence to diabetes guidelines for screening, physical activity and medication and onset of complications and death. J Diabetes Complications. 2015;29(8):1228-1233.
4. Mehta S, Mocarski M, Wisniewski T, et al. Primary care physicians’ utilization of type 2 diabetes screening guidelines and referrals to behavioral interventions: a survey-linked retrospective study. BMJ Open Diabetes Res Care. 2017;5(1):e000406.
5. Center for Disease Control and Prevention. Preventive care practices. Diabetes Report Card 2017. www.cdc.gov/diabetes/library/reports/reportcard/preventive-care.html. Published 2018. Accessed June 18, 2020.
6. Arnold SV, de Lemos JA, Rosenson RS, et al; GOULD Investigators. Use of guideline-recommended risk reduction strategies among patients with diabetes and atherosclerotic cardiovascular disease. Circulation. 2019;140(7):618-620.
7. Garber AJ, Handelsman Y, Grunberger G, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm—2020 executive summary. Endocr Pract Endocr Pract. 2020;26(1):107-139.
8. American Diabetes Association. Comprehensive medical evaluation and assessment of comorbidities: standards of medical care in diabetes—2020. Diabetes Care. 2020;43(suppl 1):S37-S47.
9. Beck J, Greenwood DA, Blanton L, et al; 2017 Standards Revision Task Force. 2017 National Standards for diabetes self-management education and support. Diabetes Educ. 2017;43(5): 449-464.
10. Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Educ Couns. 2016;99(6):926-943.
11. Association of Diabetes Care & Education Specialists. Find a diabetes education program in your area. www.diabeteseducator.org/living-with-diabetes/find-an-education-program. Accessed June 15, 2020.
12. Estruch R, Ros E, Salas-Salvadó J, et al; PREDIMED Study Investigators. Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts. NEJM. 2018;378(25):e34.
13. Centers for Disease Control and Prevention. Tips for better sleep. Sleep and sleep disorders. www.cdc.gov/sleep/about_sleep/sleep_hygiene.html. Reviewed July 15, 2016. Accessed June 18, 2020.
14. Doumit J, Prasad B. Sleep Apnea in Type 2 Diabetes. Diabetes Spectrum. 2016; 29(1): 14-19.
15. Marso SP, Daniels GH, Brown-Frandsen K, et al; LEADER Steering Committee on behalf of the LEADER Trial Investigators. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016;375:311-322.
16. Perkovic V, Jardine MJ, Neal B, et al; CREDENCE Trial Investigators. Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. N Engl J Med. 2019;380(24):2295-2306.
17. Trends in Blood pressure control and treatment among type 2 diabetes with comorbid hypertension in the United States: 1988-2004. J Hypertens. 2009;27(9):1908-1916.
18. Emdin CA, Rahimi K, Neal B, et al. Blood pressure lowering in type 2 diabetes: a systematic review and meta-analysis. JAMA. 2015;313(6):603-615.
19. Vouri SM, Shaw RF, Waterbury NV, et al. Prevalence of achievement of A1c, blood pressure, and cholesterol (ABC) goal in veterans with diabetes. J Manag Care Pharm. 2011;17(4):304-312.
20. Kudo N, Yokokawa H, Fukuda H, et al. Achievement of target blood pressure levels among Japanese workers with hypertension and healthy lifestyle characteristics associated with therapeutic failure. Plos One. 2015;10(7):e0133641.
21. Carey RM, Whelton PK; 2017 ACC/AHA Hypertension Guideline Writing Committee. Prevention, detection, evaluation, and management of high blood pressure in adults: synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension guideline. Ann Intern Med. 2018;168(5):351-358.
22. Deedwania PC. Blood pressure control in diabetes mellitus. Circulation. 2011;123:2776–2778.
23. Catalá-López F, Saint-Gerons DM, González-Bermejo D, et al. Cardiovascular and renal outcomes of renin-angiotensin system blockade in adult patients with diabetes mellitus: a systematic review with network meta-analyses. PLoS Med. 2016;13(3):e1001971.
24. Furberg CD, Wright JT Jr, Davis BR, et al; ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288(23):2981-2997.
25. Sleight P. The HOPE Study (Heart Outcomes Prevention Evaluation). J Renin-Angiotensin-Aldosterone Syst. 2000;1(1):18-20.
26. Tatti P, Pahor M, Byington RP, et al. Outcome results of the Fosinopril Versus Amlodipine Cardiovascular Events Randomized Trial (FACET) in patients with hypertension and NIDDM. Diabetes Care. 1998;21(4):597-603.
27. Schrier RW, Estacio RO, Jeffers B. Appropriate Blood Pressure Control in NIDDM (ABCD) Trial. Diabetologia. 1996;39(12):1646-1654.
28. Hansson L, Zanchetti A, Carruthers SG, et al; HOT Study Group. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) Randomised Trial. Lancet. 1998;351(9118):1755-1762.
29. Baigent C, Blackwell L, Emberson J, et al; Cholesterol Treatment Trialists’ (CTT) Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet. 2010;376(9753):1670-1681.
30. Fu AZ, Zhang Q, Davies MJ, et al. Underutilization of statins in patients with type 2 diabetes in US clinical practice: a retrospective cohort study. Curr Med Res Opin. 2011;27(5):1035-1040.
31. Cannon CP, Blazing MA, Giugliano RP, et al; IMPROVE-IT Investigators. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015; 372:2387-2397
32. Sabatine MS, Giugliano RP, Keech AC, et al; the FOURIER Steering Committee and Investigators. Evolocumab and clinical outcomes in patients with cardiovascular disease. N Engl J Med. 2017;376:1713-1722.
33. Schwartz GG, Steg PG, Szarek M, et al; ODYSSEY OUTCOMES Committees and Investigators. Alirocumab and Cardiovascular Outcomes after Acute Coronary Syndrome | NEJM. N Engl J Med. 2018;379:2097-2107.
34. Icosapent ethyl [package insert]. Bridgewater, NJ: Amarin Pharma, Inc.; 2019.
35. Bhatt DL, Steg PG, Miller M, et al; REDUCE-IT Investigators. Cardiovascular risk reduction with icosapent ethyl for hypertriglyceridemia. N Engl J Med. 2019;380:11-22
36. Bolton WK. Renal Physicians Association Clinical practice guideline: appropriate patient preparation for renal replacement therapy: guideline number 3. J Am Soc Nephrol. 2003;14(5):1406-1410.
37. American Diabetes Association. Pharmacologic Approaches to glycemic treatment: standards of medical care in diabetes—2020. Diabetes Care. 2020;43(suppl 1):S98-S110.
38. Qaseem A, Barry MJ, Humphrey LL, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Oral pharmacologic treatment of type 2 diabetes mellitus: a clinical practice guideline update from the American College of Physicians. Ann Intern Med. 2017;166(4):279-290.
39. Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group. KDIGO 2017 Clinical Practice Guideline Update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease–mineral and bone disorder (CKD-MBD). Kidney Int Suppl (2011). 2017;7(1):1-59.
40. Pop-Busui R, Boulton AJM, Feldman EL, et al. Diabetic neuropathy: a position statement by the American Diabetes Association. Diabetes Care. 2017;40(1):136-154.
41. Gupta V, Bansal R, Gupta A, Bhansali A. The sensitivity and specificity of nonmydriatic digital stereoscopic retinal imaging in detecting diabetic retinopathy. Indian J Ophthalmol. 2014;62(8):851-856.
42. Pérez MA, Bruce BB, Newman NJ, Biousse V. The use of retinal photography in non-ophthalmic settings and its potential for neurology. The Neurologist. 2012;18(6):350-355.
Clinician Reviews in partnership with
Courtney Bennett Wilke is an Assistant Professor at Florida State University College of Medicine, School of Physician Assistant Practice, Tallahassee.
Clinician Reviews in partnership with
Courtney Bennett Wilke is an Assistant Professor at Florida State University College of Medicine, School of Physician Assistant Practice, Tallahassee.
Clinician Reviews in partnership with
Courtney Bennett Wilke is an Assistant Professor at Florida State University College of Medicine, School of Physician Assistant Practice, Tallahassee.
Previously, we explored blood pressure control in a patient with diabetes. Now, we’ll discuss the value of a fasting lipid panel and treatment for dyslipidemia in this population.
CASE CONTINUED
Mr. W completed a fasting lipid panel, which revealed the following: triglycerides, 145 mg/dL; high-density lipoprotein (HDL) level, 32 mg/dL; and low-density lipoprotein (LDL) level, 108 mg/dL. He is currently receiving low-dose statin therapy. Based on these results, Mr. W fits the criteria for dyslipidemia.
Dyslipidemia
Dyslipidemia marked by elevated LDL levels—as observed in Mr. W—is a well-known contributing factor to development of cardiovascular disease in patients with diabetes. Elevated triglycerides and low HDL levels also are often noted in these patients. Patients with diabetes are particularly vulnerable to atherosclerosis due to a combination of pro-inflammatory factors and hyperglycemic effects. Both the ADA and the AACE agree that lipid management, including fasting lipid panels and appropriate treatment, is of paramount importance in patients with diabetes.7,8
Fasting Lipid Panels
The AACE recommends administering at least annual fasting lipid panels in all adults with diabetes, and LDL goal levels should be based on the cardiovascular risk of the patient.7 For patients with
- established ASCVD, the LDL goal is < 55 mg/dL
- risk factors for ASCVD (eg, hypertension, tobacco use, family history of ASCVD) in addition to diabetes, the LDL goal is < 70 mg/dL
- no risk factors, the LDL goal is < 100 mg/dL.7
Statin Therapy
Research indicates that statins reduce the risk for cardiovascular events and are recommended as first-line treatment for dyslipidemia.2,7 Statin therapy is recommended for patients with LDL levels above goal without contraindications.10 Higher-dose statins have been shown to help improve cardiovascular outcomes, and most—if not all—guidelines recommend up-titration of these medications as tolerated by the patient. 7,8,29 After initiation of statin therapy, clinicians should continue to monitor lipid levels every 4 to 12 weeks after a change in lipid therapy and then schedule monitoring annually.2
Unfortunately, a recent large-scale retrospective study of the medical records of 125,464 patients with type 2 diabetes showed that although 99% of the patients were at high risk for or already had ASCVD, only 63% were receiving the recommended statin therapy.30 Therefore, all patients with diabetes at risk for ASCVD require evaluation to determine the need for statins.
Additional treatments. If the patient’s levels remain above goal, strong consideration should be given to additional therapies. Ezetimibe has been shown to have some benefit in reducing LDL levels and cardiovascular risk.31 PCSK9 inhibitors are a newer treatment for cardiovascular disease and are particularly beneficial for patients with known ASCVD. The FOURIER and ODYSSEY trials demonstrated that PCSK9 inhibitors had relative risk reductions of 48% to 53% for major ASCVD events and showed that these medications help reduce LDL levels and, most importantly, cardiovascular risk.32,33
Continue to: Recommendations for other lipid components
Recommendations for other lipid components—non–HDL-C, apolipoprotein B, or LDL-P—are very specific and consideration may be given for referral to an endocrinologist or lipidologist for evaluation and treatment.7,8 Evidence on reducing cardiovascular risk with therapies for decreasing triglyceride levels is limited. Recently though, icosapent ethyl received FDA approval as an adjunct to maximally tolerated statin therapy to reduce the risk for cardiovascular events in patients with elevated triglyceride levels (≥ 150 mg/dL).34,35 ADA guidelines recommend icosapent ethyl for patients with diabetes, 1 additional cardiovascular risk factor, and triglyceride levels between 135 and 499 mg/dL.2
In Part 4, I’ll explore how clinicians can best monitor for chronic kidney disease in patients with diabetes. We’ll also discuss the medications used for improving kidney health in these patients.
Previously, we explored blood pressure control in a patient with diabetes. Now, we’ll discuss the value of a fasting lipid panel and treatment for dyslipidemia in this population.
CASE CONTINUED
Mr. W completed a fasting lipid panel, which revealed the following: triglycerides, 145 mg/dL; high-density lipoprotein (HDL) level, 32 mg/dL; and low-density lipoprotein (LDL) level, 108 mg/dL. He is currently receiving low-dose statin therapy. Based on these results, Mr. W fits the criteria for dyslipidemia.
Dyslipidemia
Dyslipidemia marked by elevated LDL levels—as observed in Mr. W—is a well-known contributing factor to development of cardiovascular disease in patients with diabetes. Elevated triglycerides and low HDL levels also are often noted in these patients. Patients with diabetes are particularly vulnerable to atherosclerosis due to a combination of pro-inflammatory factors and hyperglycemic effects. Both the ADA and the AACE agree that lipid management, including fasting lipid panels and appropriate treatment, is of paramount importance in patients with diabetes.7,8
Fasting Lipid Panels
The AACE recommends administering at least annual fasting lipid panels in all adults with diabetes, and LDL goal levels should be based on the cardiovascular risk of the patient.7 For patients with
- established ASCVD, the LDL goal is < 55 mg/dL
- risk factors for ASCVD (eg, hypertension, tobacco use, family history of ASCVD) in addition to diabetes, the LDL goal is < 70 mg/dL
- no risk factors, the LDL goal is < 100 mg/dL.7
Statin Therapy
Research indicates that statins reduce the risk for cardiovascular events and are recommended as first-line treatment for dyslipidemia.2,7 Statin therapy is recommended for patients with LDL levels above goal without contraindications.10 Higher-dose statins have been shown to help improve cardiovascular outcomes, and most—if not all—guidelines recommend up-titration of these medications as tolerated by the patient. 7,8,29 After initiation of statin therapy, clinicians should continue to monitor lipid levels every 4 to 12 weeks after a change in lipid therapy and then schedule monitoring annually.2
Unfortunately, a recent large-scale retrospective study of the medical records of 125,464 patients with type 2 diabetes showed that although 99% of the patients were at high risk for or already had ASCVD, only 63% were receiving the recommended statin therapy.30 Therefore, all patients with diabetes at risk for ASCVD require evaluation to determine the need for statins.
Additional treatments. If the patient’s levels remain above goal, strong consideration should be given to additional therapies. Ezetimibe has been shown to have some benefit in reducing LDL levels and cardiovascular risk.31 PCSK9 inhibitors are a newer treatment for cardiovascular disease and are particularly beneficial for patients with known ASCVD. The FOURIER and ODYSSEY trials demonstrated that PCSK9 inhibitors had relative risk reductions of 48% to 53% for major ASCVD events and showed that these medications help reduce LDL levels and, most importantly, cardiovascular risk.32,33
Continue to: Recommendations for other lipid components
Recommendations for other lipid components—non–HDL-C, apolipoprotein B, or LDL-P—are very specific and consideration may be given for referral to an endocrinologist or lipidologist for evaluation and treatment.7,8 Evidence on reducing cardiovascular risk with therapies for decreasing triglyceride levels is limited. Recently though, icosapent ethyl received FDA approval as an adjunct to maximally tolerated statin therapy to reduce the risk for cardiovascular events in patients with elevated triglyceride levels (≥ 150 mg/dL).34,35 ADA guidelines recommend icosapent ethyl for patients with diabetes, 1 additional cardiovascular risk factor, and triglyceride levels between 135 and 499 mg/dL.2
In Part 4, I’ll explore how clinicians can best monitor for chronic kidney disease in patients with diabetes. We’ll also discuss the medications used for improving kidney health in these patients.
1. Centers for Disease Control and Prevention. Diabetes incidence and prevalence. Diabetes Report Card 2017. www.cdc.gov/diabetes/library/reports/reportcard/incidence-2017.html. Published 2018. Accessed June 18, 2020.
2. Standards of Medical Care in Diabetes—2020 Abridged for Primary Care Providers. American Diabetes Association Clinical Diabetes. 2020;38(1):10-38.
3. Chen Y, Sloan FA, Yashkin AP. Adherence to diabetes guidelines for screening, physical activity and medication and onset of complications and death. J Diabetes Complications. 2015;29(8):1228-1233.
4. Mehta S, Mocarski M, Wisniewski T, et al. Primary care physicians’ utilization of type 2 diabetes screening guidelines and referrals to behavioral interventions: a survey-linked retrospective study. BMJ Open Diabetes Res Care. 2017;5(1):e000406.
5. Center for Disease Control and Prevention. Preventive care practices. Diabetes Report Card 2017. www.cdc.gov/diabetes/library/reports/reportcard/preventive-care.html. Published 2018. Accessed June 18, 2020.
6. Arnold SV, de Lemos JA, Rosenson RS, et al; GOULD Investigators. Use of guideline-recommended risk reduction strategies among patients with diabetes and atherosclerotic cardiovascular disease. Circulation. 2019;140(7):618-620.
7. Garber AJ, Handelsman Y, Grunberger G, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm—2020 executive summary. Endocr Pract Endocr Pract. 2020;26(1):107-139.
8. American Diabetes Association. Comprehensive medical evaluation and assessment of comorbidities: standards of medical care in diabetes—2020. Diabetes Care. 2020;43(suppl 1):S37-S47.
9. Beck J, Greenwood DA, Blanton L, et al; 2017 Standards Revision Task Force. 2017 National Standards for diabetes self-management education and support. Diabetes Educ. 2017;43(5): 449-464.
10. Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Educ Couns. 2016;99(6):926-943.
11. Association of Diabetes Care & Education Specialists. Find a diabetes education program in your area. www.diabeteseducator.org/living-with-diabetes/find-an-education-program. Accessed June 15, 2020.
12. Estruch R, Ros E, Salas-Salvadó J, et al; PREDIMED Study Investigators. Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts. NEJM. 2018;378(25):e34.
13. Centers for Disease Control and Prevention. Tips for better sleep. Sleep and sleep disorders. www.cdc.gov/sleep/about_sleep/sleep_hygiene.html. Reviewed July 15, 2016. Accessed June 18, 2020.
14. Doumit J, Prasad B. Sleep Apnea in Type 2 Diabetes. Diabetes Spectrum. 2016; 29(1): 14-19.
15. Marso SP, Daniels GH, Brown-Frandsen K, et al; LEADER Steering Committee on behalf of the LEADER Trial Investigators. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016;375:311-322.
16. Perkovic V, Jardine MJ, Neal B, et al; CREDENCE Trial Investigators. Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. N Engl J Med. 2019;380(24):2295-2306.
17. Trends in Blood pressure control and treatment among type 2 diabetes with comorbid hypertension in the United States: 1988-2004. J Hypertens. 2009;27(9):1908-1916.
18. Emdin CA, Rahimi K, Neal B, et al. Blood pressure lowering in type 2 diabetes: a systematic review and meta-analysis. JAMA. 2015;313(6):603-615.
19. Vouri SM, Shaw RF, Waterbury NV, et al. Prevalence of achievement of A1c, blood pressure, and cholesterol (ABC) goal in veterans with diabetes. J Manag Care Pharm. 2011;17(4):304-312.
20. Kudo N, Yokokawa H, Fukuda H, et al. Achievement of target blood pressure levels among Japanese workers with hypertension and healthy lifestyle characteristics associated with therapeutic failure. Plos One. 2015;10(7):e0133641.
21. Carey RM, Whelton PK; 2017 ACC/AHA Hypertension Guideline Writing Committee. Prevention, detection, evaluation, and management of high blood pressure in adults: synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension guideline. Ann Intern Med. 2018;168(5):351-358.
22. Deedwania PC. Blood pressure control in diabetes mellitus. Circulation. 2011;123:2776–2778.
23. Catalá-López F, Saint-Gerons DM, González-Bermejo D, et al. Cardiovascular and renal outcomes of renin-angiotensin system blockade in adult patients with diabetes mellitus: a systematic review with network meta-analyses. PLoS Med. 2016;13(3):e1001971.
24. Furberg CD, Wright JT Jr, Davis BR, et al; ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288(23):2981-2997.
25. Sleight P. The HOPE Study (Heart Outcomes Prevention Evaluation). J Renin-Angiotensin-Aldosterone Syst. 2000;1(1):18-20.
26. Tatti P, Pahor M, Byington RP, et al. Outcome results of the Fosinopril Versus Amlodipine Cardiovascular Events Randomized Trial (FACET) in patients with hypertension and NIDDM. Diabetes Care. 1998;21(4):597-603.
27. Schrier RW, Estacio RO, Jeffers B. Appropriate Blood Pressure Control in NIDDM (ABCD) Trial. Diabetologia. 1996;39(12):1646-1654.
28. Hansson L, Zanchetti A, Carruthers SG, et al; HOT Study Group. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) Randomised Trial. Lancet. 1998;351(9118):1755-1762.
29. Baigent C, Blackwell L, Emberson J, et al; Cholesterol Treatment Trialists’ (CTT) Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet. 2010;376(9753):1670-1681.
30. Fu AZ, Zhang Q, Davies MJ, et al. Underutilization of statins in patients with type 2 diabetes in US clinical practice: a retrospective cohort study. Curr Med Res Opin. 2011;27(5):1035-1040.
31. Cannon CP, Blazing MA, Giugliano RP, et al; IMPROVE-IT Investigators. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015; 372:2387-2397
32. Sabatine MS, Giugliano RP, Keech AC, et al; the FOURIER Steering Committee and Investigators. Evolocumab and clinical outcomes in patients with cardiovascular disease. N Engl J Med. 2017;376:1713-1722.
33. Schwartz GG, Steg PG, Szarek M, et al; ODYSSEY OUTCOMES Committees and Investigators. Alirocumab and Cardiovascular Outcomes after Acute Coronary Syndrome | NEJM. N Engl J Med. 2018;379:2097-2107.
34. Icosapent ethyl [package insert]. Bridgewater, NJ: Amarin Pharma, Inc.; 2019.
35. Bhatt DL, Steg PG, Miller M, et al; REDUCE-IT Investigators. Cardiovascular risk reduction with icosapent ethyl for hypertriglyceridemia. N Engl J Med. 2019;380:11-22
36. Bolton WK. Renal Physicians Association Clinical practice guideline: appropriate patient preparation for renal replacement therapy: guideline number 3. J Am Soc Nephrol. 2003;14(5):1406-1410.
37. American Diabetes Association. Pharmacologic Approaches to glycemic treatment: standards of medical care in diabetes—2020. Diabetes Care. 2020;43(suppl 1):S98-S110.
38. Qaseem A, Barry MJ, Humphrey LL, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Oral pharmacologic treatment of type 2 diabetes mellitus: a clinical practice guideline update from the American College of Physicians. Ann Intern Med. 2017;166(4):279-290.
39. Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group. KDIGO 2017 Clinical Practice Guideline Update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease–mineral and bone disorder (CKD-MBD). Kidney Int Suppl (2011). 2017;7(1):1-59.
40. Pop-Busui R, Boulton AJM, Feldman EL, et al. Diabetic neuropathy: a position statement by the American Diabetes Association. Diabetes Care. 2017;40(1):136-154.
41. Gupta V, Bansal R, Gupta A, Bhansali A. The sensitivity and specificity of nonmydriatic digital stereoscopic retinal imaging in detecting diabetic retinopathy. Indian J Ophthalmol. 2014;62(8):851-856.
42. Pérez MA, Bruce BB, Newman NJ, Biousse V. The use of retinal photography in non-ophthalmic settings and its potential for neurology. The Neurologist. 2012;18(6):350-355.
1. Centers for Disease Control and Prevention. Diabetes incidence and prevalence. Diabetes Report Card 2017. www.cdc.gov/diabetes/library/reports/reportcard/incidence-2017.html. Published 2018. Accessed June 18, 2020.
2. Standards of Medical Care in Diabetes—2020 Abridged for Primary Care Providers. American Diabetes Association Clinical Diabetes. 2020;38(1):10-38.
3. Chen Y, Sloan FA, Yashkin AP. Adherence to diabetes guidelines for screening, physical activity and medication and onset of complications and death. J Diabetes Complications. 2015;29(8):1228-1233.
4. Mehta S, Mocarski M, Wisniewski T, et al. Primary care physicians’ utilization of type 2 diabetes screening guidelines and referrals to behavioral interventions: a survey-linked retrospective study. BMJ Open Diabetes Res Care. 2017;5(1):e000406.
5. Center for Disease Control and Prevention. Preventive care practices. Diabetes Report Card 2017. www.cdc.gov/diabetes/library/reports/reportcard/preventive-care.html. Published 2018. Accessed June 18, 2020.
6. Arnold SV, de Lemos JA, Rosenson RS, et al; GOULD Investigators. Use of guideline-recommended risk reduction strategies among patients with diabetes and atherosclerotic cardiovascular disease. Circulation. 2019;140(7):618-620.
7. Garber AJ, Handelsman Y, Grunberger G, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm—2020 executive summary. Endocr Pract Endocr Pract. 2020;26(1):107-139.
8. American Diabetes Association. Comprehensive medical evaluation and assessment of comorbidities: standards of medical care in diabetes—2020. Diabetes Care. 2020;43(suppl 1):S37-S47.
9. Beck J, Greenwood DA, Blanton L, et al; 2017 Standards Revision Task Force. 2017 National Standards for diabetes self-management education and support. Diabetes Educ. 2017;43(5): 449-464.
10. Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Educ Couns. 2016;99(6):926-943.
11. Association of Diabetes Care & Education Specialists. Find a diabetes education program in your area. www.diabeteseducator.org/living-with-diabetes/find-an-education-program. Accessed June 15, 2020.
12. Estruch R, Ros E, Salas-Salvadó J, et al; PREDIMED Study Investigators. Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts. NEJM. 2018;378(25):e34.
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