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Animal studies have suggested that treatment with antioxidants, such as vitamin E, may attenuate some vascular dysfunction associated with diabetes, but treatment with antioxidants has not yet been shown to alter the development or progression of retinopathy or other microvascular complications of diabetes.1,6 Growth factors, including vascular endothelial growth factor (VEGF), growth hormone, and transforming growth factor β, have also been postulated to play important roles in the development of diabetic retinopathy. Combination therapy with a statin plus other drugs, such as fibrates or niacin, may be necessary to achieve ideal lipid control, but patients should be monitored closely for possible adverse reactions of therapy.15 Aspirin therapy (75-162 mg/day) is indicated in secondary prevention of CVD and should be used in patients with diabetes who are > 40 years of age and in those who are 30-40 years of age if other risk factors are present.

Practice Recommendations

Patients with type 1 diabetes of > 5 years' duration should have annual screening for microalbuminuria, and all patients with type 2 diabetes should undergo such screening at the time of diagnosis and yearly thereafter. All patients with diabetes should have serum creatinine measurement performed annually. Patients with microalbuminuria or macroalbuminuria should be treated with an ACE inhibitor or ARB unless they are pregnant or cannot tolerate the medication. Patients who cannot tolerate one of these medications may be able to tolerate the other. Potassium should be monitored in patients on such therapy. Patients with a GFR < 60 ml/min or with uncontrolled hypertension or hyperkalemia may benefit from referral to a nephrologist.15

Patients with type 1 diabetes should receive a comprehensive eye examination and dilation within 3-5 years after the onset of diabetes. Patients with type 2 diabetes should undergo such screening at the time of diagnosis. Patients should strive for optimal glucose and blood pressure control to decrease the likelihood of developing diabetic retinopathy or experiencing progression of retinopathy.15

All patients with diabetes should undergo screening for distal symmetric polyneuropathy at the time of diagnosis and yearly thereafter. Atypical features may prompt electrophysiological testing or testing for other causes of peripheral neuropathy. Patients who experience peripheral neuropathy should begin appropriate foot self-care, including wearing special footwear to decrease their risk of ulceration. They may also require referral for podiatric care. Screening for autonomie neuropathy should take place at the time of diagnosis in type 2 diabetes and beginning 5 years after the diagnosis of type 1 diabetes. Medication to control the symptoms of painful peripheral neuropathy may be effective in improving quality of life in patients but do not appear to alter the natural course of the disease. For this reason, patients and physicians should continue to strive for the best possible glycemic control.

In light of the above strong evidence linking diabetes and CVD and to control and prevent the microvascular complications of diabetes, the ADA has issued practice recommendations regarding the prevention and management of diabetes complications.

Blood pressure should be measured routinely. Goal blood pressure is < 130/80 mmHg. Patients with a blood pressure ≥ 140/90 mmHg should be treated with drug therapy in addition to diet and lifestyle modification. Patients with a blood pressure of 130-139/80-89 mmHg may attempt a trial of lifestyle and behavioral therapy for 3 months and then receive pharmacological therapy if their goal blood pressure is not achieved. Initial drug therapy should be with a drug shown to decrease CVD risk, but all patients with diabetes and hypertension should receive an ACE inhibitor or ARB in their antihypertensive regimen.15

Lipid testing should be performed in patients with diabetes at least annually. Lipid goals for adults with diabetes should be an LDL < 100 mg/dl (or < 70 mg/dl in patients with overt CVD), HDL > 50 mg/dl, and fasting triglycerides < 150 mg/dl. All patients with diabetes should be encouraged to limit consumption of saturated fat, trans fat, and cholesterol. Statin therapy to lower LDL by 30-40% regardless of baseline is recommended to decrease the risk of CVD in patients > 40 years of age. Patients < 40 years of age may also be considered for therapy. In individuals with overt CVD, special attention should be paid to treatment to lower triglycerides or raise HDL. Combination therapy with a statin plus other drugs, such as fibrates or niacin, may be necessary to achieve ideal lipid control, but patients should be monitored closely for possible adverse reactions of therapy.15

Aspirin therapy (75-162 mg/day) is indicated in secondary prevention of CVD and should be used in patients with diabetes who are > 40 years of age and in those who are 30-40 years of age if other risk factors are present. Patients < 21 years of age should not receive aspirin therapy because of the risk of Reye's syndrome. Patients who cannot tolerate aspirin therapy because of allergy or adverse reaction may be considered for other antiplatelet agents."

In addition to the above pharmacological recommendations, patients with diabetes should be encouraged to not begin smoking or to stop smoking to decrease their risk of CVD and benefit their health in other ways. It should also be noted that statins, ACE inhibitors, and ARBs are strongly contraindicated in pregnancy.