Hospitalisation Costs

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Summary

With regard to the hospitalisation costs of diabetic patients, cardiovascular disease accounts for more than 60 % of total costs, while renal disease, neurological disease and peripheral arterial disease accounts for around 10 %, placing prevention of cardiovascular disease among the top priorities for diabetic patients.¹⁵ Therefore, a multifactorial approach should be taken into consideration for an effective risk reduction. This includes glucose control, blood pressure control, lipid control, antithrombotic agents, diet and physical activity for an adequate management of the micro- and macrovascular complications.¹⁶ Since type 2 DM is in fact a cardiometabolic disease, the treatment goals are multifactorial. Thus, the aim for HbA1c should be lower than 7 %, while still avoiding hypoglycaemia, blood pressure <140/85 mmHg, low density lipoprotein (LDL) -cholesterol <70 mg/dL and diet controlled weight reduction.1 In order to achieve these goals, hypoglycaemic agents will be necessary besides diet control, and metformin can be used as a first-line agent in patients who do not have renal insufficiency, liver disease or hypoxia.³ Evidence for this indication arises from a Cochrane review of randomised controlled trials and the much feared side effect of lactic acidosis proved to be low and no higher than with other hypoglycaemic agents. However, the review was not able to assess the risk of lactic acidosis in the presence of hypoxic co-conditions, so more research should be undertaken on this population.3 In a subgroup of overweight patients randomised to metformin or conventional therapy in the UKPDS trial, metformin reduced the risk for any diabetesrelated endpoint, myocardial infarction and all-cause mortality by approximately one-third; benefits which remained during 10 years of monitoring.¹⁷ Sulphonylurea can be used for patients who have contraindications to metformin or in whom metformin was not able to control their glycaemia. The guidelines advise that in patients with fasting plasma glucose >14 mmol/L despite maximal treatment with metformin and sulphonylurea should be referred to the next level of care.³ Several other hypoglycaemic drugs are commonly employed for diabetes but lack enough data to recommend their use as treatments to reduce cardiovascular events.¹⁸ Acarbose, an alpha-glucosidase inhibitor, reduced the rate of myocardial infarction by 91 % and a composite of cardiovascular events by 49 % in patients with impaired glucose tolerance in the Study to Prevent Non-Insulin-Dependent Diabetes Mellitus (STOP-NIDDM) trial.¹⁹ However, cardiovascular risk reduction with acarbose has not been reported in diabetes. Neither incretin mimetics, dipeptidyl peptidase IV (DPP IV) nor sodium-glucose co-transporter 2 (SGLT2) inhibitors have thus far (in clinical trial data) demonstrated cardiovascular event reduction.¹⁸

Statins should be given to all type 2 diabetic patients over the age of 40 years who do not have established cardiovascular disease, but with cardiovascular risk factors (one of which is DM), in order to prevent major cardiovascular events. Trials which reported the outcome of coronary events in diabetic patients showed a 17–36 % reduction in the odds of people receiving statins.³ A subsequent meta-analysis regarding the use of statins in primary and secondary prevention confirmed that statins offer benefits for people at high-risk of cardiovascular diseases including patients with diabetes.³

Lowering blood pressure in diabetic patients reduces the risk of micro- and macrovascular complications. Low-dose thiazides/ angiotensin-converting enzyme (ACE) inhibitors are recommended as first-line treatment of hypertension in diabetic patients, and they can be combined. Beta-blockers are not recommended for initial management of hypertension in patients with DM, but can be used if thiazides or ACE inhibitors are contraindicated.³

However, in clinical practice approximately only 12.2 % of patients achieve treatment goals.²⁰ According to the National Health and Nutrition Examination Survey (NHANES), during the 1999 and 2002 period, 7 % of the patients were achieving all three goals, HbA1c <7 %, blood pressure <130/80 mmHg and cholesterol <100 mg/dL (which rose to 12.2 % between 2003 and 2006).²⁰

Due to the fact that microvascular disease develops later in the progress of diabetes and is a direct manifestation of glucose toxicity, tight glycaemic control improves the outcome. By contrast, macrovascular disease can unfold up to 15 years prior to the diagnosis of DM and with HbA1c much lower than expected, increasing the risk of complications. Furthermore, epidemiological studies have shown that tight glycaemic control can in fact pose risks of a cardiovascular nature to individuals with high cardiovascular risk factors, possibly through pathological hypoglycaemic events. Therefore, further research into the effects of micro- and macrovascular complications is rendered necessary.²¹

It could be said that lower is not always better when it comes to HbA1c levels but that the earliest is the best concerning the management of DM and cardiovascular risks. Prevention of cardiovascular disease should be based on total cardiovascular risk, and since DM is an independent risk factor by itself, a need for an interdisciplinary approach, such as between the cardiologist and the diabetologist, arises.