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 Table of Contents  
COMMENTARY
Year : 2014  |  Volume : 1  |  Issue : 4  |  Page : 245-246

Role of metabolic control to prevent and treat sight threatening diabetic retinopathy in diabetic cases


Department of Vitreoretina, SB. Dr. Sohan Singh Eye Hospital, Amritsar, Punjab, India

Date of Submission30-May-2014
Date of Decision09-Nov-2014
Date of Acceptance11-Nov-2014
Date of Web Publication11-Dec-2014

Correspondence Address:
Bodhraj Dhawan
SB. Dr. Sohan Singh Eye Hospital, Amritsar, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-9906.146804

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  Abstract 

Metabolic control is the first step in managing microvascular complications of diabetes including diabetic retinopathy. Important parameters proved to be of the key role in managing diabetic retinopathy and preventing sight-threatening complications thereof include blood sugar levels, serum lipid profile, hemoglobin levels and renal function tests. The severity of hyperglycemia and hypertension are main modifiable factors which may prevent the development of diabetic retinopathy. Thus, all the diabetics have to be compliant in having a good metabolic control which not only prevents or slows down risk of visual loss, but also is associated with a better cardiovascular activity ultimately contributing to a better quality-of-life in these subjects.

Keywords: Diabetic retinopathy, metabolic control, lipid profile


How to cite this article:
Dhawan B, Vig V. Role of metabolic control to prevent and treat sight threatening diabetic retinopathy in diabetic cases . J Obes Metab Res 2014;1:245-6

How to cite this URL:
Dhawan B, Vig V. Role of metabolic control to prevent and treat sight threatening diabetic retinopathy in diabetic cases . J Obes Metab Res [serial online] 2014 [cited 2021 May 15];1:245-6. Available from: https://www.jomrjournal.org/text.asp?2014/1/4/245/146804


  Introduction Top


The prevalence diabetes mellitus (DM) in developing countries especially India has been increasing over years now. India harbors more than 62 million diabetic individuals currently diagnosed with the disease that is largest in the world. This makes us the diabetic capital of the world. [1] It is predicted that by 2030 DM may afflict up to 79.4 million individuals in India, while China (42.3 million) and the United States (30.3 million) will also see significant increases in those affected by the disease. [2],[3]

Diabetic retinopathy is the commonest microvascular complication of DM, and it has serious implications in term of a huge burden of blindness and visual impairment.

Metabolic control in diabetes helps us not only in preventing sight-threatening complications, but also in effective treatment of diabetic retinopathy.


  Components of metabolic control Top


Systemic therapies are designed to target the key modifiable risk factors, which in the case of diabetic retinopathy are metabolic and blood pressure control. There may also be a role for modification of the renin-angiotensin system and for lipid lowering agents. At present, the major risk factors that cannot easily be modified include duration of diabetes, residual beta-cell function, insulin resistance, and genetic predisposition.

Modifying metabolic control

Improving glycemic control and lowering the level of glycosylated hemoglobin (HbA1c) is, at present, the most effective medical treatment to slow the progression of diabetic retinopathy. [4] Central to the discovery that optimal metabolic control could reduce the incidence and progression of DR were the Diabetes Control and Complications Trial (DCCT) in type 1 diabetics [5] and the United Kingdom Prospective Diabetes Study (UKPDS) in type 2 diabetics. [6] Intensive glycemic control was found to have effects that persist well beyond the course of treatment. The DCCT and UKPDS established optimizing metabolic control as a priority and led to the suggestion that it should be implemented early and maintained for as long as is safely possible.

The American Diabetes Association and the European Association for the Study of Diabetes consensus statement in 2009 [7] give detailed guidance on the medical management of type 2 diabetes in the form of a treatment algorithm. Their recommendations emphasize the following:

  • Achievement and maintenance of near normoglycemia (HbA1c <7.0%)
  • Initial therapy with lifestyle intervention and metformin
  • Rapid addition of medications, and transition to new regimens, when target glycemic goals are not achieved or sustained
  • Early addition of insulin therapy in patients who do not meet target goals.


Modifying blood pressure ± the renin-angiotensin system

Hypertension is a major risk factor for DR and DME. The Wisconsin Epidemiological Study of Diabetic Retinopathy found that progression of retinopathy was associated with higher diastolic blood pressure at baseline and an increase in diastolic blood pressure over a 4-year follow-up period. [8]

The UKPDS demonstrated that control of blood pressure (systolic blood pressure <150 mmHg) led to a reduction in the progression of retinopathy and reduced need for laser treatment in the tight blood pressure control group compared with the less tight control group. [9]

Enalapril and losartan increased the likelihood of slowing the progression of retinopathy by 65% and 70% respectively, apparently independent of changes in blood pressure. [10]

Lipid-lowering agents

Lipid-lowering agents may decrease the risk of vision loss in patients with DR. [11] The American Diabetes Association has set desirable low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglyceride levels as <100, >40 in men/>50 in women, and <150 mg/dl, respectively. The first line of lipid-lowering therapy is usually treatment with a statin, and this is sometimes started even when cholesterol levels are within the normal range because cardiovascular disease is such an important cause of morbidity and mortality in diabetics. In cases where statins fail to lower lipid levels, fibrates might help to lower risk. [12]


  Conclusion Top


Improved glycemic control and blood pressure control remain the most effective ways of reducing morbidity from diabetic retinopathy.

 
  References Top

1.
Joshi SR, Parikh RM. India- Diabetes capital of the world: Now heading towards hypertension. J Assoc Physicians India 2007;55:323-4.  Back to cited text no. 1
    
2.
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.  Back to cited text no. 2
    
3.
Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes atlas: Global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract 2011;94:311-21.  Back to cited text no. 3
    
4.
Fong DS, Aiello LP, Ferris FL 3 rd , Klein R. Diabetic retinopathy. Diabetes Care 2004;27:2540-53.  Back to cited text no. 4
    
5.
The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993;329:977-86.  Back to cited text no. 5
    
6.
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352:837-53.  Back to cited text no. 6
    
7.
Nathan DM, Buse JB, Davidson MB, Ferrannini E, Holman RR, Sherwin R, et al. Medical management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy: A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2009;32:193-203.  Back to cited text no. 7
    
8.
Klein R, Klein BE, Moss SE, Cruickshanks KJ. The Wisconsin epidemiologic study of diabetic retinopathy: XVII. The 14-year incidence and progression of diabetic retinopathy and associated risk factors in type 1 diabetes. Ophthalmology 1998;105:1801-15.  Back to cited text no. 8
    
9.
Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ 1998;317:703-13.  Back to cited text no. 9
    
10.
Mauer M, Zinman B, Gardiner R, Suissa S, Sinaiko A, Strand T, et al. Renal and retinal effects of enalapril and losartan in type 1 diabetes. N Engl J Med 2009;361:40-51.  Back to cited text no. 10
    
11.
Chew EY, Klein ML, Ferris FL 3 rd , Remaley NA, Murphy RP, Chantry K, et al. Association of elevated serum lipid levels with retinal hard exudate in diabetic retinopathy. Early Treatment Diabetic Retinopathy Study (ETDRS) Report 22. Arch Ophthalmol 1996;114:1079-84.  Back to cited text no. 11
    
12.
Valensi P, Picard S. Lipids, lipid-lowering therapy and diabetes complications. Diabetes Metab 2011;37:15-24.  Back to cited text no. 12
    



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