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diabetes mellitus

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mortality associated with type 2 diabetes

  • a 50 year old with type 2 diabetes with no history of vascular disease has life expectancy reduced by 6 years compared to non-diabetics (these compares to 7 years reduction for smokers vs non-smokers)1)
    • ~40% of the years lost from diabetes can be attributed to nonvascular conditions including 10% attributable to death from cancer
    • vascular, cancer and noncancer, nonvascular mortality rises with fasting glucose above 6 mmol/L to 50% greater at levels of 7mmol/L, and 100% greater for vascular deaths at levels of 8mmol/L or higher.
  • intensive glucose lowering with HbA1c target of < 6% instead of usual 7-7.9% target resulted in INCREASED 5 year mortality in type 2 diabetics.2)

RAAS blockade and chronic renal impairment

  • agents which block the renin-angiotensin-aldosterone-system (RAAS) have been used in the hope that they will reduce risk of chronic renal impairment in diabetics.
  • in 2013, several trials of dual therapy (eg. ACEI with aldosterone inhibitor) called this strategy into question as risks of hyperkalaemia and episodes of acute renal failure appeared to outweigh benefits despite showing increased efficacy at lowering BP and decreasing albuminuria 3):
    • VA NEPHRON-D trial: ARB +/- ACEI - trial stopped for safety reasons
    • ALTITUDE: (ACEI or ARB) + aliskiren (a direct renin inhibitor) - trial stopped for safety reasons
    • ONTARGET: ACEI + ARB
1)
NEJM 364;9 March 2011 p829-841
2)
NEJM 364:9 March 3, 2011 p818-828
3)
NEJM Nov 14, 2013 editorial
dm.txt · Last modified: 2016/05/20 03:00 by gary1