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Gil C. Grimes, MD September 2006

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Diabetic Medication Update Gil C. Grimes, MD April 2007.

Type II Diabetes Gil C. Grimes, MD Assistant Professor Community and Family Medicine Scott and White Memorial Hospital September 2007.

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1 Gil C. Grimes, MD September 2006
Type II Diabetes Gil C. Grimes, MD September 2006

2 Objectives Define Diagnosis of Diabetes Describe Pathogenesis
Describe risk factors for Type II diabetes Outline complications Delineate options for therapy


4 Definition American Diabetes Association
Fasting plasma glucose is the preferred test Three criteria Symptoms (polyuria, polydypsia, unexplained weight loss) and glucose ≥ 200 mg/dL Fasting plasma glucose ≥ 126mg/dL on 2 occasions 2 hour plasma glucose (after 75 g anhydrous glucose in water) ≥ 200 mg/dL WHO prefers Oral glucose tolerance test National Guideline Clearing House 2002 Aug 22:6574 [Level 5]

5 Definition Results of ADA changes Increased diagnosis of diabetes
Most of these ‘new’ diabetics have normal HgA1c 1 No evidence that Tx at low range impacts quality of life 2 1- JAMA 1999;281:1203 [Level 1c] 2- Am Fam Physician 1998;58:1287 [level 5]

6 Definition Fasting vs. 2 hour glucose tolerance test
Fasting criteria less sensitive for predicting cardiovascular disease Prospective analysis 4,515 pt over 8 years Cardiovascular Health Study Sensitivity ADA fasting 28% Sensitivity WHO criteria 54% Lancet 1999;345(9179):622-5 [Level 1b]

7 Prevalence Estimate 8.3% US adults >20 yo with diabetes1
Estimate 14.4% have either DM or Impaired Glucose Tolerance1 Estimated Lifetime Risk of Diabetes in US2 32.8% males 38.5% female 1- MMWR 2003;52:833 [Level 1c] 2- JAMA 2003;290(14):1884 [Level 2c]

8 Incidence Disease of middle age Mean age in US 46 years 1
Prevalence similar in men and women Fourth most common diagnosis during Family Physician visits 2 1- Ann Fam Med 2005;3(1):60 [Level 2c] 2- Ann Fam Med 2004;2(5):411 [Level 2c]


10 Pathophysiology Insulin resistance Decreased insulin secretion
Usually a receptor or post-receptor defect Manifests as increased insulin requirement Common cause Obesity (especially abdominal) Metabolic syndrome Genetics and lifestyle Decreased insulin secretion Possible accelerated age-related loss beta cell Amyloid deposits in > 70% pancreatic cells diabetics 1 Unclear the role in disease 1- NEJM 2000;343(6);411 [Level 5]


12 Risk Factor Obesity Prospective cohort 37,878 female nurses followed 7 years BMI more powerful predictor (HR 3.22) than activity 1 Single most important predictor in prospective cohort 89,941 followed 16 years 2 1- JAMA 2004;292:1188 [Level 1b] 2- NEJM 2001;345:790 [Level 1b]

13 Risk Factor Obesity Adult diabetics Obese children 2
85.2% obese or overweight 54.8% obese 1 Obese children 2 Multicentric cohort 167 children and adolescents BMI >95% for age 25% age 4-10 impaired glucose tolerance 21% age impaired glucose tolerance 4% age type II DM 1- MMWR 2004;53:1066 [Level 1c] 2- NEJM 2002;346:802 [Level 2c]

14 Risk Factor IGT Population-based cohort study 1342 participants follow-up 6.4 years 1 Performed FPG and 2 hour GTT Odds Ratio for developing DM 10 for IFG 10.9 for isolated IGT 39.5 for both 1- JAMA 2001;285:2109 [Level 2c]

15 Risk Factor IGT Prospective cohort study 1,197 VA patients over 3 years HgA1c.7% led to testing fasting glucose 73 patients developed dm (6.1%) Annual incidence 0.8% if HbA1c<5.5% 2.5% if HbA1c 5.6-6% 7.8% if HbA1c % J Gen Intern Med 2004;19(12):1175 [Level 1b]

16 Risk Factor Activity Prospective cohort from Nurses Health Study 68,497 women without DM 1 1515 new cases of DM Each 2 hours/day sedentary increase risk obesity 5% and DM 7% TV Watching associated with 23% increase risk obesity and DM 14% 1- JAMA 2003;289(14):1785 [Level 1b]

17 Risk Factor Diet Western Diet associated with increased risk of DM
42,504 men age followed 12 years 1,321 developed DM Relative Risk 1.59 diet alone Relative Risk 1.96 diet and sedentary Ann Intern Med 2002;136:201 [Level 1c]

18 Risk Factor Diet Western Diet associated with increased risk of DM
69,554 women age followed 14 years 2,699 developed diabetes Relative Risk 1.49 diet Relative Risk per increase serving Red meat 1.38 Processed meat 1.73 Arch Intern Med 2004;164(20):2235 [Level 1c]

19 Risk Factor Diet High glycemic index foods low fiber diet associated with increased risk of DM 1 Prospective cohort 91,249 women, 741 cases of DM, followed 8 years Higher glycemic index higher the risk for developing diabetes (RR 1.27) Higher cereal fiber reduces risk (RR 0.64) 1- Am J Clin Nutr 2004;80:348 [Level 1c]

20 Risk Factor Gestational DM
Prospective cohort 696 women with GDM 1 Followed with GTT post-partum and every 5 years Risk of abnormal GTT 42.4% at 11 years Risk of DM 13.8% Prospective cohort 481 women with diet controlled GDM 2 40% incidence after10 years 27% impaired GTT 1- Diabetes Care 2003;26:1199 [Level 1c] 2- Diabetes Care 2004;27:1194 [Level 1c]

21 Risk Factor PCOS Prospective cohort 67 women with PCOS for 6.2 years 1
54 with normal GTT subsequently 17% developed DM 13 with impaired GTT subsequently 54% developed DM 1- Hum Reprod 2001;16:1995 [Level 1c]

22 Risk Factor Medications
Prospective double blind RCT 44 postmenopausal women not on HRT Raloxifen or estrogen vs.. placebo Looked at effects on insulin sensitivity Used glucose tolerance test to check for insulin sensitivity Insulin Sensitivity decreased in raloxifene J Am Geriatric Soc 2003;51(5):683-8 [Level 2b]

23 Risk Factor Medications
Gatifloxacin et al may affect glycemic control as seen in two case control studies 788 case patients in ED or hospital with hypoglycemia Gatifloxacin OR 4.3 Levofloxacin OR 1.5 470 case patients with hospital diagnosed hyperglycemia Gatifloxacin OR 16.7 Moxifloxacin OR 1.7 NEJM 2006 March 30 early release on-line [Level 3b]


25 Complications Prospective population study 13,105 subjects followed for 20 years 1 1.5-2 fold increase risk of death in men & women 1.5-2 fold increase of MI in men fold increase risk of MI in women 1.5-2 fold increase risk of Stroke in men 2-6.5 fold increase risk in stroke in women 1- Arch Intern Med 2004;164:1422 [Level 1c]

26 Complications Prospective cohort 4,662 men aged followed 2-4 years 1 Increase HgA1c associated with increasing mortality All cause RR 2.2 Cardiovascular disease RR 3.3 Ischemic disease RR 4.2 1- BMJ 2001;322:15 [Level 1c]

27 Complication Macrovascular
Macrovascular complications 75-80% diabetic deaths related to atherosclerosis 75% accelerated CAD 25% accelerated CVD and PVD >50% diabetics hypercholesterolemic DynaMed accessed March

28 Complication CAD Meta-analysis of 37 prospective studies 447,064 patients Rate of Fatal CAD 5.4% vs. 1.6% for diabetics Women RR 3.50 Men RR 2.06 BMJ 2006;332(7533):73-8 [Level 1a]

29 Complication CAD Diabetes may be as risky as a prior MI 1
Prospective cohort 9,434 men age followed 25 years Diabetes similar mortality to prior MI Diabetics without prior MI= risk of prior MI 2 Risk of MI 3.5% in non-DM no prior MI 18.8% for prior MI non-DM 20.2% for DM without prior MI 45% for DM with prior MI 1- Arch Intern Med 2004;164:1438 [Level 1c]] 2- NEJM 1998;339:229 [Level 2b]

30 Complication HTN Prospective cohort 49,582 Finish subjects without stroke or CAD at baseline followed 19.1 years followed for stroke HTN Stage I HR 1.35 mortality 1.47 HTN Stage II HR 1.98 mortality 2.62 DM HR 2.54 mortality 3.06 HTN I and DM HR 3.51 mortality 5.99 HTN II and DM HR 4.50 mortality 9.27 Stroke 2005;36(12): [Level 1b]

31 Complication PAD Prospective cohort 1,294 patients with DM-2
Subgroup of 531 with sufficient screening for PAD PAD at entry 13.6% (161 patients) 14 developed PAD (75 patients) Incidence of new PAD 3.7 per 100 pt years Diabetes Care 2206;29(3): [Level 2b]

32 Complication Microvascular
Microangiopathy Retinopathy (RR20) #1 cause of new blindness #3 cause of blindness Neuropathy (ESRD RR25) Nephropathy BMJ 2000;320(7241):1062 [Level 5}

33 Complication Coma Hyperosmolar Coma Most common in elderly patients
Also occurs in children 8 case reports in obese children Causes Infection 20-25% New onset DM 30-50% Drugs, Stress (MI etc.) 20-30% mortality Endocr Pract 2005;11(1):23-9 [Level 4]

34 Complication Hypoglycemia
Mild episodes common Retrospective cross-sectional analysis of 1,055 outpatients Prevalence of symptoms Diet controlled 12% (9 of 76) Oral agents 16% (56 of 346) Insulin use 30% (193 of 633) Severe Hypoglycemia 0.5% (5 of 1055) all using insulin Risk factors Younger age Insulin use Lower HbA1c at follow-up Arch Intern Med 2001;161(13):654-9 [Level 2b]


36 Treatment Goals American Diabetes Association Recommendations
Control of glycemia is important Goal is HgA1c less than7%Grade B Pre-meal glucose mg/dL Post-meal glucose <180mg/dL Blood pressure <130/80 Lipid control LDL <100 mg/dL Triglycerides <150 mg/dL HDL >40 mg/dL men or >50 mg/dL women Diabetes Care 2006 Jan;29(suppl 1):S4-S42

37 Cost-effectiveness CDC cost-analysis
Hypothetical cohort patients >25 yo new diabetes Antihypertensive Therapy Improved quality of life and cost savings age 25-84 Very cost-effective 85-94 Intensive Glycemic Control Increase cost and improved outcome Decreasing effect on quality of life Decreasing cost effectiveness with increasing age Lipid management improved quality of life at increased cost JAMA 2002;287(19): [Level 2b]

38 Lifestyle Changes Dietary changes and exercise works
20-50% of patients can control their diabetes with diet, exercise and weight reduction Current trial lookAHEAD is recruiting patients for lifestyle management study

39 Exercise Exercise training reduces the HgA1c
Metanalysis of 14 trials duration 8 weeks HgA1 c 7.65% vs. 8.31% 1 Increased activity reduces risk of MI, Stroke Walking 2 hours/week lower mortality NNT 61 for one year 2 1- JAMA 2001;286:1218 [Level 1a] 2- Circ 2003;163:1440 [Level 1c]

40 Dietary Advice Systematic review of 18 RCT lasting 6 months where dietary advice main intervention Diets examined: low-fat/high –carb, high-fat/low-card, low-cal (1,000 kcal/day), very-low-calorie (500 kcal/day) Data did no provide robust conclusions on effectiveness of dietary advice Exercise improves glycemic control Cochrane Library 2004 Issue2:CD [Level 1a]

41 High Fiber Diet 13 patients with DM-2 randomized in crossover fashion 6 week each arm ADA diet 8gm soluble fiber 16 gm insoluble fiber High-fiber 25 gm soluble fiber and 25 gm insoluble fiber Mean pre-prandial glucose 142 vs. 130 (p=0.04) Mean HbA1c 7.2% vs. 6.9% (p=0.09) Mean LDL 142 mg/dL vs. 133 mg/dL (p=0.11) May not be generalizable due to meals etc. NEJM 2000;342(19): [Level 1b]

42 Glycemic Index 8 men with DM-2 at VA facility randomized in crossover trial Low-biologically-available-glucose diet HbA1c 9.8% vs. 7.6% Took place in research center 1 Low glycemic meals may reduce hyperinsulinism Evidence limited Small studies with methodological problems 1- Diabetes 2004;53(9): [Level 1b] 2- JAMA 2002;287(18): [Level 3a]

43 Protein Restriction ADA recommendation for patients with any chronic kidney disease Limit protein intake 0.8g/kg/day Grade B Diabetes Care 2006;29(suppl 1):S4-S42

44 Medications Initial Monotherapy Sulfonylureas inexpensive
Metformin inexpensive Rosiglitazone and pioglitazone are expensive and lacking long-term data Nateglinide less effective than repaglinide Acarobose and miglitol less effective poorly tolerated Medical Letter 2002;1:1

45 Medications When monotherapy fails
Add second drug with different mechanism of action Metformin (vs. pioglitazone) probably better choice for 2nd agent 1 Dual therapy fails add insulin with metformin Less expensive than triple oral therapy No difference in diabetic control compared 2 1- Diab Care 2004;27:141 [Level 1b] 2- Diab Care 2003;26:2238 [Level 1c]

46 Medications Systematic Review of 63 RCTs duration 3 months reporting HbA1c Studied sulfonylureas, metformin, alpha-glucosidase inhibitors, thiazolidinediones, non-sulfonylurea secreatagogues Medications at maximal doses were equally effective (except nateglinide and alpha-glucosidase inhibitors) Only Sulfonylureas and metformin demonstrate long term vascular risk reduction Metformin has advantage of lack of weight gain and lack of hypoglycemia JAMA 2002;287(3): Level 1a)

47 Sulfonylureas Increase insulin secretion by pancreas Take before meals
Contraindicated in sulfa allergic patients Second generation safer in renal disease Multiple drug interactions

48 Sulfonylureas First generation have more interactions Acetoheaxmide
Chlorpropamide Disulfram reaction more likely May aggravate CHF or fluid retention May Cause SIADH Tolazamide Caution in renal dysfunction Tolbutamide BID dosing decreases GI side effects

49 Sulfonylureas Second-generation agents have fewer interactions
Glipizide and Glyburide are less likely to have disulfram reaction Gluburide is renally eliminated watch in renal disease Glipizide little benefit to doses >20mg/day

50 Sulfonylureas and hypoglycemia
52 sulfonylurea-treated subjects with DM mean age 65 RCT glyburide or glipizide 1 Participated in 23 hour fasting study 1 week placebo vs. 10mg/day or 20 mg/day of active drug No hypoglycemia observed in 156 fasting studies Second study glipizide similar results 2 1- JAMA 1998;279(2): [Level 1b] 2- JAMA 1999;281(12):1084- [Level 1b]

51 Metformin Mechanism Improves response to insulin
Decreased endogenous glucose production Decreased hepatic gluconeogenesis 1 Improves response to insulin Enhanced insulin-mediated glucose uptake Increased use of glucose in intestine and adipose Reduced GI glucose absorption Does not stimulate insulin secretion Requires insulin to be effective 1- NEJM 1998;338(13): Level 1c

52 Metformin Side effects 0.003% lactic acidosis Gastrointestinal upset
Nausea, anorexia, diarrhea, abdominal discomfort, metallic taste Dose-related Minimized by taking with meals and gradually increasing the dose 0.003% lactic acidosis

53 Metformin Risk factors for lactic acidosis
Renal impairment (Creat> 1.5 mg/dL men >1.4 mg/dL women) CHF on medications Hepatic insufficiency Hypoxia Perioperative from major surgery Binge drinking Iodinated contrast agents

54 Metformin Preventive measures Dissent on contraindications exists 1-3
Hold prior to procedure Restart after 48 hours if renal function is normal Dissent on contraindications exists 1-3 Use in pt with CHF associated with decreased mortality 1,883 patients with DM and CHF HR 0.66 for metformin vs. sulfonylurea and metformin 0.54 1- CMAJ :173(5): Level 5 2- BMJ 2003;326(7379):4 Level 5 3- Diabetes Care 2005;28(10):2345 Level 2b

55 Metformin Systematic review 29 RCT 5,259 patients mean follow-up 3 years Reduction of mortality from MI in obese or overweight patients Improves glycemic control, weight, lipids, insulinemia, and diastolic pressure Cochrane Library 2005 Issue 3:CD Level 1c

56 Glitazones Mechanism of action Adverse Effects
Decrease insulin resistance at peripheral sites and liver Decrease hepatic glucose production Adverse Effects Fluid retention and heart failure Retrospective study 5,441 patients DM-2 on glitazones vs. 28,103 controls Mean follow-up 9 months CHF 2.3% treatment group vs. 1.4% controls NNH 111 Diabetes Care 2003;26(11): Level 2b

57 Glitazones Adverse Effects Hepatotoxicity
Extracted to some degree from data on troglitazone and case reports Review 22 studies >6,000 patients LFT measured q4weeks x3 months then q6-12 weeks ALT Levels >3x ULN 0.32% rosiglitazone 0.17% placebo 0.4% sulfonylurea, metformin, insulin Diabetes Care 2002;25(5): Level 2b

58 Glitazones Adverse Effects Drug Interactions
Macular Edema case reports usually in patients with peripheral edema 1 Drug Interactions Gemfibrozil inhibits metabolism or rosiglitazone and possibly pioglitazone Randomized crossover trial 10 health volunteer 2 1- FDA MedWatch 2006 Jan5 Level 4 2- Diabetologia 2003;46(10): Level 2c

59 Alpha-glucosidase inhibitors
Works by inhibiting post-prandial absorption of glucose Side effects Flatulence, cramps, abdominal distention, borborygmus, diarrhea May interfere with glucose therapy for hypoglycemia 2 Improved glycemic control and insulin levels No effect on lipids or body weight Unknown effectiveness on morbidity and mortality 1 1- Cochrane Library 2005 Issue 2:CD Level 1c 2- The Medical Letter 1996;38(967):9

60 Pramlintide Symlim Synthetic analog of human amylin
Use with insulin therapy Injected prior to major meals Mechanism of action Modulates gastric emptying Increases feeling of satiety Injection medication Adverse effects Hypoglycemia especially in DM-1 or gastroparesis Should not be used in pt unable to determine when blood sugar is low Nausea, vomiting, abdominal pain, headache, fatigue, dizziness FDA Talk Paper 2005 March 17

61 Pramlintide Drug Interactions Cost AWP $79.50 per month
May decrease absorption of oral drugs Not recommended with anticholinergics, acarbose, or miglitol Cost AWP $79.50 per month Am J Health Syst Pharm 2005;62(8): Level 2b

62 Exenatide Byetta Used with metformin or sulfonylurea or both
Injected prior to morning and evening meal Mechanism of action Incretin mimetic, stimulates glucagon-like peptide-1 receptor Stimulates production of insulin in the presence of high blood glucose Inhibits release of glucagon Slows gastric emptying Associated appetite suppression and weight loss Prescriber’s Letter 2005 Detail Document

63 Exenatide Adverse Effects Cost $147-172 per moth
Hypoglycemia seen in patients on sulfonylurea ( % dose dependent) Nausea, vomiting, diarrhea, dizziness, headache, dyspepsia Withdrawal due to adverse effects 7% vs. 3% May alter absorption of oral medications Cost $ per moth Prescriber’s Letter 2005 Detail Document

64 Insulin Therapy Bedtime NPH with sulfonylurea
Better than NPH alone for control Allows for lower insulin dose Based on metanalysis of 16 studies 1 Metformin as well reduces weight gain 2 Addition of PNH vs.. 70/30 reduces hypogylcemia, reduces weight gain, not as effective 3 1- Arch Intern Med 1996;156:259 [Level 1c] 2- Cochrane 2004:CD [Level 1a] 3- J Fam Pract 2004;53:393 [Level 2a]

65 Insulin Therapy Long acting glargine insulin
With sulfonylurea/metformin may be better than NPH for glycemic control 1 Second study 70/30 associated with improved control vs. glargine but more hypoglycemic episodes 2 1- Diabetes Care 2005;28:254 [Level 3] 2- Diabetes Care 2005;28:260 [Level 3]

66 Inhaled Insulin Exubera
Inhaled 10 minutes prior to meal dosed in milligrams 0.05 mg/kg rounding down 1mg ≈ 3 units regular & 3mg ≈ 8 units Three 1mg doses is not equal to one 3mg dose Mechanism of action Small particle size 1-3 microns dry powder Deposited in alveoli Absorbed into capillary bloodstream 6-10% of inhaled insulin reached systemic circulation Prescriber’s Letter 2006 Detail Document

67 Inhaled Insulin Adverse Effects Hypoglycemia Cough Dry Mouth
Related to rate of absorption and duration of action Similar rate to injection insulin Cough Mild and non-productive Occurs within second to minutes Decreases with continued use Dry Mouth Mild to moderate severity Prescriber’s Letter 2006 Detail Document

68 Inhaled Insulin Contraindications
Hypersensitivity to human insulin Smoking within the last 6 months Unstable or poorly controlled lung disease Speed of onset similar to rapid acting insulin Prescriber’s Letter 2006 Detail Document

69 Aspirin Prospective 5.2 year follow up on 2,368 pts with CAD and DM-2
Observational study Cardiac mortality 10.9% those taking Aspirin Cardiac Mortality 15.9% for those not taking aspirin Am J Med 1998;105(6):494-9 Level 2c

70 ACE Inhibitors Reduce albumin excretion rate in normotensive diabetics but no evidence of effect on ESRD, glomerular filtration rate, or side effects 1 Enalipril has long term reduction of frequency and severity of albuminuria and reduces the rate of rise of creatinine 2 HOPE trial discloses that ACE inhibitors help with a wide range of morbidity and mortality 3 1- Cochrane 2001;1:CD [Level 1a] 2- Arch Intern Med 1996;156:286 [Level 1c] 3- Lancet 2000;355:253 [Level 1c]

71 Cardiovascular Disease Prevention
Meta-analysis of placebo controlled RCTs 7 lipid lowering trials 6 hypertension trials 5 glucose control trial Results for risk reduction combined outcome coronary heart disease death and non-fatal MI Lipid lowering 0.75 ( ) Hypertension control 0.73 ( ) Glucose control 0.87 ( ) person-years of Lipid tx or HTN tx to prevent one cardiovascular event Am J Med 2001;111(8): Level 1a

72 American College of Physicians EB guidelines
Recommendation 1: Lipid-lowering therapy should be used for secondary prevention of cardiovascular mortality and morbidity for all patients (both men and women) with known coronary artery disease and type 2 diabetes. Recommendation 2: Statins should be used for primary prevention against macrovascular complications in patients (both men and women) with type 2 diabetes and other cardiovascular risk factors. Recommendation 3: Once lipid-lowering therapy is initiated, patients with type 2 diabetes mellitus should be taking at least moderate doses of a statin. Recommendation 4: For those patients with type 2 diabetes who are taking statins, routine monitoring of liver function tests or muscle enzymes is not recommended except in specific circumstances. Ann Intern Med 2004;140(8): Level

73 Lipid Management Statin therapy for patients with DM-2
Coronary artery disease (Grade A) Age >40 plus CV risk factors LDL>100 with lifestyle changes (Grade A) Routine use in others (Grade C) Am Fam Physician 2005;72(5):866 FPIN questions

74 Lipid Management 2,838 Patients with DM-2 for 6 months LDL <161.5 mg/dL 1 other risk factor, no prior CAD RCT of Atorvastatin 10 mg vs. placebo Median f/u 3.9 years Risk Reduction Tx vs. placebo 3.6% vs. 5.5% for composite (MI, USA, CHD Death, Cardiac arrest) 1.7% vs. 2.4% coronary revascularization 1.5% vs. 2.8% stroke 5.8% vs. 9% primary end point (any of above) NNT31 Lancet 2004;364(9435): Level 1c

75 Control the Blood Pressure
Aggressive blood pressure control pays off for diabetics 1 Goal of less than 135 and less than 80 Decreases clinically relevant macrovascular events Decreases clinically relevant microvascular events Prolongs life 1- Ann Intern Med 2003;138:593 [Level 1a]

76 Blood pressure and Lipids
Meta-analysis of 18 trials looking at Lipid control, HTN control, and Glucose control Primary aggregate end point (CHD, death non-fatal MI) Lipid management RR 0.75 NNT 106 HTN management RR 0.87 NNT 157 Glucose management RR0.87 NS Am J Med 2001;111: Level 1a

77 Control the Blood Pressure
“We do not intend to suggest that glycemic control is an ineffective intervention, but rather that treatment of hypertension should be prioritized and stressed as the most important intervention for the average population of persons with type 2 diabetes” 1- Ann Intern Med 2003;138:593 [Level 1a]


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