Aspirin is no longer recommended for primary prevention in Type 2 DM, as it’s now clear that risks outweigh benefits (SIGN 2010). When starting drugs for primary prevention of CV disease, the batting order should probably be 1. statins, 2. antihypertensives (remember first-choice is ACE, or ARB if ACE not tolerated), 3. glucose-lowering therapy. (Evidence is conflicting on whether the last actually reduces CV risk or not.)
There is little evidence that BM monitoring is needed for patients on any oral therapy except sulfonylureas, as the risk of hypoglycaemia isn’t really high enough. Patients on sulfonylureas should test if they’re ill, driving, or feel symptomatically hypoglycaemic.
HbA1c goals should probably be around 7 – 7.5%. Getting good control is especially important early on (probably worth aiming for 7%).
Pioglitazone, despite its other problems, has actually been found to reduce rates of cardiovascular events in one RCT and some observational studies.
(Pulse on-line learning module – Professor Roger Gadsby, primary care lead for diabetes and on guideline development committee)
Further details from another Pulse online module:
Low GI diets have been shown in a Cochrane review to improve HbA1c control by around 0.5%. Find a table of GI of foods here.
More detail on the ‘batting order’ for CV reduction in DM as mentioned above – A meta-analysis in the Lancet in 2009 showed that NNT to prevent one MI was 23 for cholesterol lowering, 8 – 30 for antihypertensive treatment, and 131 for intensive glucose control.