MANAGEMENT OF DIABETIC AND THROMBOGENIC RISK FACTORS

Reducing cardiovascular risk in diabetic patients

• Careful diabetic control is essential.
• Correct obesity by energy restriction and suitable exercise.
• Diet similar to lipid-lowering diet, but with carbohydrate limited to 50 - 55% food energy. Free sugar is severely restricted.
• Monitor plasma lipids and HDL regularly.
• Smoking cessation is particularly important; young patients should be encouraged not to commence.
• Lipid-lowering drugs:
  • consider if lipid abnormality persists despite above measures
  • fibrates are of most use for combined hyperlipidaemia, and statins are effective when elevated cholesterol and LDL predominate
  • target levels:
    • LDL cholesterol < 3.5 mmol/l (<135 mg/dl)
    • plasma triglyceride < 2.3 mmol/l (<200 mg/dl)
    • LDL/HDL cholesterol < 4.0 ratio
• Good control of hypertension (ACE inhibitors and calcium blockers are suitable).

Reducing thrombogenic risk factors

• The effect of antiplatelet drugs is maximal when these are combined with:
  • smoking cessation
  • a lipid-lowering diet
  • control of arterial hypertension

Drug therapy

• The recommended dosage of aspirin is 75 - 160 mg per day, taken after food.
• For prevention of thrombosis in coronary bypass grafts aspirin is given alone, or has been combined with dipyridamole. Ticlopidine (250 mg b.d.) or sulphinpyrazone (40 mg b.d.) can be used as an alternative to this association.
• Heamorrhagic stroke and gastrointestinal bleeding were reported in early studies of oral anticoagulants and thrombolytic agents. In more recent studies these are uncommon.
• Hypersensitivity is a minor side effect reported for all antithrombotic drugs that precludes their use in some patients.

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