An Italian study that compared optimal medical therapy (OMT) vs usual care also showed reduction of major cardiovascular events and all-cause mortality on long-term follow-up. After only three and a half years of intervention, OMT reduced the risk of dying or having a major cardiovascular event by about half. The Steno-2 trial is the only other trial that documented that benefit.
The Italian study and the Steno-2 trial both used specific protocols to achieve their results. To see the specific protocol used in Italy, click on intervention by randomization. Both protocols can be improved on. The Italian study used ACE inhibitors and ARBs together to treat hypertension. It would be better to use an ACE inhibitor OR an ARB with spironolactone or eplerenone as the fourth drug in the hypertension protocol. That blocks the aldosterol side of renin-angiotensin activation. SGLT2 inhibitors like empagliflozin and GLP-1 agonists like liraglutide were not available. They should be added when metformin and carb restriction fail to achieve glucose goals. They did use aspirin and these patients have a risk high enough to justify it. That should continue in these high-risk patients with kidney and eye damage.
They also randomized by clinic rather than patient. Half the clinics provided OMT and half continued to do what they were doing. That means your clinic can produce much better diabetes outcomes if they develop focused primary care chronic cardiometabolic condition teams and use an OMT protocol to treat patients with diabetes. Let’s get started.
Awesome content, as always, and gives great tactical guidance to include in our clinic protocols. Thanks Bill