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16-07-2015 | Retinopathy | Article

Medical management of diabetic retinopathy

Authors: Samuel L Thomsen, R Joel Welch, Diana V Do

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Hyperglycemia, through several complex physiologic mechanisms, is thought to be the principal cause of the microvascular damage seen in diabetic retinopathy (DR) [1,2]. Consequently, several studies have demonstrated the importance of maintaining a normal or near-normal glycemic status in patients with DR [3–6]. Additionally, there are data suggesting that hypertension, a common comorbidity with diabetes mellitus, may exacerbate the microvascular damage caused by hyperglycemia [7]. Therefore, it is generally accepted that blood pressure control is also warranted for diabetic patients with retinopathy [4–6]. Currently, the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) [8,9] suggest that reasonable goals for glycated hemoglobin (HbA1c) and blood pressure (BP) in non-pregnant adult patients with diabetes are:
• HbA1c<7%; and
• BP<140/80mmHg
Comprehensive care for the diabetic patient should include, at minimum, an annual dilated eye exam; an eye care professional will determine if more frequent exams are necessary. During pregnancy, diabetic retinopathy can worsen and extra ophthalmologic screening is required.
For women with pre-existing diabetes who become pregnant, the ADA currently suggests an HbA1c goal of <6%, if it can be achieved without excessive hypoglycemia [8].

Literature
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  2. Sheetz, MJ, King GL. Molecular understanding of hyperglycemia’s adverse effects for diabetic complications. JAMA. 2002; 288:2579-2588.
  3. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977-986.
  4. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837-853.
  5. ACCORD Study Group, ACCORD Eye Study Group, Chew EY, el al. Effects of medical therapies on retinopathy progression in type 2 diabetes. N Engl J Med. 2010;363:233.
  6. Patel A, MacMahon S, Chalmers J, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358:2560-2572.
  7. Mehler PS, Jeffers BW, Estacio R, Schrier RW: Associations of hypertension and complications in non-insulin-dependent diabetes mellitus. Am J Hypertens. 1997;10:152-161.
  8. American Diabetes Association. Standards of Medical Care in Diabetes – 2014. Diabetes Care. 2014;37(suppl 1):S14-S80.
  9. Ryden L, Grant PJ, Anker SD, et al. ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Diab Vasc Dis Res. 2014;11:133-173.
  10. Nathan DM, Kuenen J, Borg R, Zheng H, Schoenfeld D, Heine RJ; A1c-Derived Average Glucose Study Group. Translating the A1C assay into estimated average glucose values. Diabetes Care. 2008;31:1473-1478.
  11. Riddle MC, Ambrosius WT, Brillon DJ, et al. Action to Control Cardiovascular Risk in Diabetes Investigators. Epidemiologic relationships between A1C and all-cause mortality during a median 3.4-year follow-up of glycemic treatment in the ACCORD trial. Diabetes Care. 2010;33:983-990.
  12. Estacio RO, Jeffers BW, Gifford N, Schrier RW. Effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes. Diabetes Care. 2000;23(suppl 2):B54.
  13. Matthews DR, Stratton IM, Aldington SJ, et al. Risks of progression of retinopathy and vision loss related to tight blood pressure control in type 2 diabetes mellitus: UKPDS 69. Arch Ophthalmol. 2004;122:1631.
  14. Chew EY, Mills JL, Metzger BE, et al. Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy Study. National Institute of Child Health and Human Development Diabetes in Early Pregnancy Study. Diabetes Care. 1995;18:631-637.
  15. Early Treatment Diabetic Retinopathy Study Research Group: Effects of aspirin treatment on diabetic retinopathy. ETDRS Report Number 8. Ophthalmology. 1991;98(5 suppl):757-765.

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