Insulin initiation and titration can be challenging for many primary care providers who are involved in the treatment of patients with type 2 diabetes. Despite the introduction of advanced insulin analogs and improvements in insulin delivery devices, many patients with type 2 diabetes continue to experience suboptimal glycemic control. With an increasing number of treatment options available, type 2 diabetes management is moving away from a “one-size-fits-all” approach and toward individualized treatment regimens based on particular patient needs. Given this, nurse practitioners, physician assistants, pharmacists, and certified diabetes educators are becoming increasingly valuable resources in busy primary care practices.

Nine patients with Type I diabetes mellitus, diastolic blood pressure of 90 to 100 mmHg and persistent microalbuminuria of greater than or equal to 30 micrograms/min were treated with 50 to 100 mg atenolol daily for 3 years in an uncontrolled pilot study to assess the effect of long-term reduction of blood pressure on microalbuminuria. Treatment with atenolol prevented progression of microalbuminuria with a median (range) urinary albumin excretion rate before treatment of 74 (33 to 196) micrograms/min and 50 (5 to 123) micrograms/min after 3 years of therapy (p less than 0.05). Blood pressure was significantly reduced from 156 (121 to 187) mmHg systolic and 95 (90 to 100) mmHg diastolic before treatment to 143 (112 to 168) mmHg systolic (p less than 0.04) and 82 (66 to 84) mmHg diastolic (p less than 0.0003) at 3 years. Measurements of renal function and diabetic control remained unchanged throughout the study period. These results suggest that early and prolonged use of antihypertensive therapy is beneficial in slowing down progression of microalbuminuria.

Chronic kidney disease associated with Type 2 diabetes is linked to significant increase in morbidity, reduced quality of life, and early death. Current guidelines recommend targets for the management of hyperglycemia, hypertension, and dyslipidemia but there remains a residual risk of chronic kidney disease progression and adverse cardiovascular outcomes in patients with Type 2 diabetes. The 2022 consensus report from the American Diabetes Association and Kidney Disease: Improving Global Outcomes support the use of sodium–glucose co-transporter 2 inhibitors and nonsteroidal mineralocorticoid receptor antagonists to improve kidney and cardiovascular outcomes. Coordination between those working in the primary care setting and those in endocrinology and nephrology clinics may optimize the prevention of chronic kidney disease progression in patients with Type 2 diabetes. Nurse practitioners, physician assistants, and primary care physicians play an important role in making timely patient referrals to kidney specialists. This article explores the use of novel therapies capable of reducing the risk of cardiovascular disease and chronic kidney disease progression beyond what can be achieved with control of blood glucose, blood pressure, and lipid levels. It also discusses the importance of monitoring at-risk patients to facilitate early diagnosis and initiation of effective kidney-protective therapy. [Media: see text] [Figure: see text]

The exercise-induced increase in albumin excretion was measured in six patients with insulin-dependent diabetes mellitus, in whom there was no evidence of established diabetic renal disease. Urinary albumin excretion was measured on urine samples taken at rest and immediately after a 20 minute period of exercise on a bicycle ergometer at 600 kpm/min. Following a three week course of aspirin (330 mg)--dipyridamole (75 mg) taken three times daily there was significant reduction in exercise-induced albuminuria (expressed as the ratio of albumin excretion rate during exercise to that at rest before exercise) when compared to administration of placebo (P less than 0.05). These results suggest that aspirin-dipyridamole might modify the development of persistent proteinuria in patients with insulin-dependent diabetes mellitus.

Cardiovascular disease (CVD) is a common and serious comorbidity of type 2 diabetes mellitus (T2DM), and cardiovascular (CV) risk assessment has become an important aspect of evaluating new therapies for T2DM before approval by the FDA. Since 2008, in order to establish safety, new therapies for T2DM have been required to demonstrate that they will not result in an unacceptable increase in CV risk. Studies performed for this purpose are termed CV outcome trials, or CVOTs. This article reviews CVOTs completed to date for the class of long-acting glucagon-like peptide-1 receptor agonists (GLP-1RAs; liraglutide, exenatide extended-release, albiglutide, dulaglutide, semaglutide injectable, semaglutide oral) and implications for clinical management of T2DM. All CVOTs have confirmed long-acting GLP-1RAs to be noninferior to (not worse than) placebo with regard to first occurrence of a primary outcome of three-point major adverse cardiovascular events (MACE; composite outcome of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke). Further, a number of the studies demonstrated a statistically significant reduction in primary outcomes of three-point MACE with GLP-1RA treatment compared with placebo. As a result, the product labeling for liraglutide, semaglutide injectable, and dulaglutide has been updated with an indication for reducing the risk of MACE in adults with T2DM and established CVD (all) or multiple CV risk factors (dulaglutide only). These findings have brought about an exciting paradigm shift from concern about not inflicting CV harm to the exciting prospect of reducing risks of CV outcomes. Major diabetes care guidelines now encourage early consideration of GLP-1RA use in patients with atherosclerotic CVD.