Treating Widespread Microvascular Disease
In the last post we wrote about microvascular disease as a condition that affects the whole body— every cell and every organ. That fact demands a different approach. It demands whole body treatment with best practice lifestyle and medications. Here is the great news. We have very powerful evidence to inform our approach to these patients.
We can actually see microvascular disease in the picture of the retina in a patient with diabetes above. You can see hard exudates (scattered yellowish dots), microaneurysms (bulges off some blood vessels), and small hemorrhages (blurry red dots). When you see these changes in the eye, you know that there is microvascular disease in the heart, kidney, brain, legs, and other organs.
As we have previously discussed, diabetic eye, nerve, and kidney disease are the conditions that we have previously thought of as due to microvascular disease. We have thought of them as separate issues. The Steno-2 trial enrolled patients with type 2 diabetes and small amounts of protein in the urine. At 13 years of follow-up, optimal medical therapy (OMT) provided powerful protection from all three conditions compared with usual care.
Diabetic kidney damage developed in 20 patients in the intensive-therapy group, as compared with 37 patients in the usual care. That is a 56% reduction. Progression of diabetic eye damage occurred in 41 patients in the intensive-therapy group and in 54 patients in the conventional-therapy group. That is a 43% reduction. The need for laser treatment in the eye was reduced by 55%. Only one third as many intensive-therapy patients became blind in one eye. Autonomic nerve damage progressed in 39 patients in the intensive-therapy group and in 52 patients in the usual care group. That is a 47% reduction. We have also discussed the fact that microvascular disease is a powerful risk for diabetic amputation. Patients treated with OMT only had one third as many amputations.
The Steno-2 trial with thirteen years of follow-up proves that OMT is effective treatment for the microvascular disease that affects every cell and organ in the body. There is no other approach that provides 13 years of follow-up with these very dramatic outcomes. Microvascular disease-disease of the tiniest arteries and capillaries-reduces the ability to supply oxygen and nutrition while removing CO2 and waste from the cells and organs. The protocol for OMT is simple and inexpensive.
Lisinopril or losartan, a thiazide diuretic, amlodipine, and spironolactone or eplerenone for high blood pressure.
Atorvastatin or rosuvastatin for cholesterol
Metformin for type 2 diabetes. Empagliflozin if needed to control glucose further.
Diet and exercise.
If we live long enough, we will all have microvascular disease that develops more rapidly the older we become. Diabetes, hypertension, high cholesterol, obesity and smoking accelerate the process. We can live longer healthier lives now. Let’s get started!