MKSAP quiz: Type 1 diabetes management
This month's quiz asks readers to evaluate a patient with type 1 diabetes who is motivated to reduce her risks.
A 24-year-old woman is evaluated for management of type 1 diabetes mellitus. She was first diagnosed at 13 years of age. Having recently completed nursing school, the patient is motivated to gain control of diabetes to prevent complications, particularly diabetic neuropathy. Her only medication is insulin lispro, delivered through continuous subcutaneous insulin infusion pump therapy.
On physical examination, blood pressure is 142/92 mm Hg; the remainder of the vital signs is normal. BMI is 26. A comprehensive foot examination is normal.
Laboratory studies show hemoglobin A1c level of 8.7% and an LDL cholesterol level of 110 mg/dL (2.8 mmol/L).
Which of the following is the most appropriate measure to reduce the risk of diabetic neuropathy?
A. Improve blood pressure control
B. Improve glycemic control
C. Improve lipid control
D. Initiate pregabalin
E. Weight loss
MKSAP Answer and Critique
The correct answer is B. Improve glycemic control. This item is available to MKSAP 18 subscribers as item 8 in the Endocrinology and Metabolism section. More information about MKSAP 18 is available online.
According to high-quality evidence, enhanced glucose control significantly prevents the development of clinical neuropathy and reduces nerve conduction and vibration threshold abnormalities in type 1 diabetes mellitus. Glycemic control can delay progression of neuropathy in type 2 diabetes. Other than glucose control, no other preventive strategies are available for diabetic neuropathy. Hemoglobin A1c goals in patients with diabetes should be individually tailored taking into account the demonstrated benefits with regard to prevention and delay in microvascular complications with the risk of hypoglycemia. A reasonable goal of therapy might be a hemoglobin A1c value less than or equal to 7% for most patients, with higher targets for older adult patients and those with comorbidities or a limited life expectancy and more stringent control for those patients with type 1 diabetes and during pregnancy.
The American Diabetes Association advocates for a target systolic blood pressure between 125 and 130 mm Hg in select patients (young, long life expectancy, increased risk of stroke), if this can be accomplished safely. While this patient will benefit from improved blood pressure control by reducing the risk of cardiovascular disease, it will have no impact on her risk for the development of diabetic neuropathy.
While lifestyle intervention to improve the lipid profile should be undertaken in all patients with diabetes, for patients without cardiovascular disease and under age 40 years, statin therapy should be considered only in those with multiple cardiovascular disease risk factors; the American College of Cardiology/American Heart Association risk calculator can determine the 10-year atherosclerotic cardiovascular disease risk to guide therapeutic management. Improved lipid control, while indicated and beneficial for the prevention of cardiovascular disease, does not assist in the prevention of diabetic neuropathy.
Although pregabalin is indicated to treat painful diabetic neuropathy, it does not prevent diabetic neuropathy.
Although weight loss should be discussed as part of a therapeutic lifestyle plan, there is no data to suggest weight loss prevents the development of diabetic neuropathy.
Key Point
- Enhanced glucose control significantly prevents the development of clinical neuropathy and reduces nerve conduction and vibration threshold abnormalities in type 1 diabetes mellitus.