Although diabetes is mainly characterized by high blood glucose (hyperglycaemia), treatment of hyperglycaemia alone does not always reduce the risk of all complications. This is especially true with the risks for cardiovascular diseases and death. The reason for this is that cardiovascular diseases have multiple other risk factors that tend to co-exist in a person with diabetes, such as high blood pressure, high cholesterol levels, albuminuria, smoking, being overweight or obese, sedentary lifestyle, and others. Hence, the most effective treatment to prevent diabetes complications is to treat all these risk factors concurrently, also known as the "multifactorial intervention."
The effects of multifactorial intervention as the treatment for type 2 diabetes was investigated in the STENO 2 Trial, where it was shown that multifactorial intervention reduced the risk of cardiovascular events by 59% and death by 46%. On top of that, patients who received multifactorial intervention also had lower risks for progression of diabetic kidney disease, kidney failure, progression of diabetic retinopathy, and autonomic neuropathy. These findings from STENO 2 Trial consolidated the position of the multifactorial intervention as the mainstay of treatment to prevent diabetes complications.
STENO 2 Trial: Cardiovascular events in patients receiving multifactorial intervention (intensive therapy) versus conventional therapy (click on image to zoom).
STENO 2 Trial: Diabetic nephropathy, retinopathy, and neuropathy in patients receiving multifactorial intervention (intensive therapy) versus conventional therapy (click on image to zoom).
In recent years, newer treatments developed for diabetes, namely the SGLT-2 inhibitor and GLP-1 receptor agonist classes of medications, have been shown to further reduce the risk of cardiovascular disease, death, diabetic kidney disease, and even heart failure. These medications are currently recommended for people with diabetes who also have existing or at high risk of cardiovascular diseases, heart failure, or kidney disease as the evidence for benefit for these people is very robust.
EMPA REG Outcomes Trial: The primary outcomes (composite of non-fatal cardiovascular events and cardiovascular deaths), cardiovascular deaths, all-cause deaths, and hospitalizations for heart failure in patients receiving empagliflozin, an SGLT-2 inhibitor, versus standard treatment (click on image to zoom).
However, it is important to note that treatment of hyperglycaemia is not without its own benefit. Extensive observational data demonstrated that every percentage of reduction in HbA1c will translate towards reduction in diabetes complications. It is important to keep blood glucose control within target as much as possible, while treating other cardiovascular risk factors at the same time.