Guidelines for diabetes - challenges of implementing clinical practice guidelines in daily practice

Abstract:

Diabetes mellitus is a complex, chronic disease with good glycemic control resulting in a reduction in the occurrence and progression of microvascular and macrovascular complications. In order to achieve this, there is a need for permanent medical care, but also considerable involvement of the patients. A modern pharmacotherapeutic approach determines diagnosing the presence of atherosclerotic cardiovascular disease (ACVD) in diabetic patients. The main clinical manifestations of ACVD in patients with diabetes are coronary disease, ischemic stroke, peripheral arterial disease, and heart failure. As far as glycemic control is concerned, an individual approach is recommended with the general goal of HbA1c ≤ 7.0%, avoiding hypoglycemia and tolerating polypharmacy. If the polypharmacy is not tolerated and if it affects the intensive treatment of cardiovascular risk factors, a less intensive target with HbA1c ≤ 7.5% can be tolerated. In patients without the known ACVD, the goal is to aggressively lower HbA1c ≤ 6.5% because it significantly reduces the risk of microvascular complications of diabetes mellitus and may also contribute to the reduction of ACVD. When selecting therapy, it is necessary to evaluate the cardiovascular safety of medication and it is important to keep in mind the results of randomized studies involving the most vulnerable patients. Along with optimal glycemic control, it is necessary to aggressively treat cardiovascular risk factors, especially LDL cholesterol and arterial pressure, thus significantly improving cardiovascular outcomes. Lifestyle changes (body fat reduction, healthy eating habits and increased physical activity) should be recommended to all patients with diabetes mellitus, regardless of their cardiovascular risk. The specificity of care for these patients in family medicine practice is the constant monitoring of the presence of complications, glycemic control, target setting and active monitoring, recognition of clinical context and prognosis, and patient education. 

Key words:
diabetes mellitus; cardiovascular disease; therapy; family medicine