Monday, October 7, 2019

Retrospective #233: Multifactorial Approach to Prevent CVD in T2DM

Michael Marre, a French physician who heads the diabetes department at a Paris hospital, gave an oral presentation at the 2014 American Diabetes Association 74th Scientific Sessions in San Francisco. It was reported on in Medscape Medical News, an aggregator of medical news for physicians. The title of his talk: “Multifactorial Approach to Prevent Cardiovascular Disease in Type 2 Diabetes,” subtitled “Identifying Diabetes and Cardiovascular Risks.” The risk part was okay, the multifactorial approach to prevent CVD ho-hum, and the comment section priceless. Here’s my prĂ©cis.
Dr. Marre’s definitions: “Diabetes mellitus is a metabolic disorder caused by both a defect in insulin secretion and in insulin action. It is an important contributor to vascular damage. Remember that, by definition, diabetes induces microvascular complications, and it is also a huge risk factor for macrovascular complications.” I might quibble with “caused by” and argue that it is diabetes controlled to the ADA Standard of Care that induces microvascular complications, but still, his view conforms to the medical establishment’s, so you can’t blame him for their dereliction.
To his credit, Dr. Marre states that “you can take some prevention measures, which include lifestyle interventions that can reduce the risk for diabetes by 50%.” He adds, though, “If that’s not enough, you can add some pharmacotherapy” and then launches into a litany of meds that can possibly “delay or postpone the progression to diabetes mellitus.” His primer continues: “In fact, an individual evaluation must include an assessment of the classic risk factors, the glycemic status, the macrovascular disease, and the microvascular disease:
     The classic risk factors are family history, lifestyle, smoking, hypertension and dyslipidemia (cholesterol issues).
     Macrovascular disease: coronary status, cerebral vascular disease, peripheral arterial disease, and heart failure.
     Microvascular disease: retinopathy, nephropathy, and neuropathy, and
     Don’t forget arrhythmias, especially atrial fibrillation
To his credit, Dr. Marre says “Cardiovascular risk requires multifactorial management, with an emphasis on lifestyle intervention. Look at what the patient eats and drinks.” He advocates “a Mediterranean diet from your birth date.” Okay, I’ll admit a Mediterranean diet would be a better choice of what to eat and drink than the Standard American Diet (SAD), but hey, so would almost any way of eating. And Dr. Marre says, he is “from the Mediterranean area.”
Summarizing, Dr. Marre’s management and control recommendations are pretty much pro forma “establishment”:
     Maintain blood pressure below 140/85 mm Hg. This is the objective for patients without any renal impairment. If the patient has a slight increase in microalbuminuria, then the blood pressure objective must be below 130/80.
     Look at the low-density lipoprotein (LDL) cholesterol level, which must be below 1.8 mmol/L (70 mg/dL).
     Glycemic control, as assessed by A1c, must be below 7%.
Dr. Marre cautions, “For blood pressure lowering, do not forget to prescribe as first-line therapy a rennin-angiotensin-aldosterone inhibitor. This is mandatory.” That’s an ACE inhibitor, like Enalapril. Whew! I take one.
For lipid control, use a statin for first-line therapy, and prescribe an appropriate dose. [another pill]. Antiplatelet therapy [low-dose aspirin] is recommended for secondary prevention of cardiovascular disease. “Often,” he said, “you have to combine several antidiabetic agents [more pills or injections] to achieve good glycemic control, but as most of our patients are overweight or obese, use Metformin as much as possible in first-line therapy.” Again, whew!
But wait a minute! What happened to those lifestyle interventions? To “looking at what the patient eats and drinks”? Here is a doctor lecturing on the basics of clinical care for the overweight or obese Type 2 diabetic patient, to avoid the co-morbidities of micro and macrovascular disease, and all he has to offer, except lip service, is a cocktail of pills?
There were just five comments. The first four were “the usual”; the fifth, most unusual: “This is rubbish and when I open it, I am struck by several ads for Victoza I cannot get rid of. What can I expect from a site that is financed by industry? Oh, Eric Topol, how can you possibly work here and look yourself in the mirror every morning.” Signed: Anders Hernborg, Swedish GP. Anders Hernborg is a mostly retired, MD, “independent researcher” and “activist.” Of the 22 published scientific papers which he has co-authored, one is titled “Advertising or Science?” Being “mostly retired” makes time for research and writing. Telling the truth may also be a certain way to become “mostly retired.”

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