Eyeworld

EW RETINA 20 January 2011 by Maxine Lipner Senior EyeWorld Contributing Editor Retinopathy progression in type 2 diabetes delayed Two strategies help to forestall retinopathy F or patients with type 2 dia- betes, tight glycemic con- trol as well as the addition of fenofibrate to a statin medication decrease the progression of retinopathy, accord- ing to Craig M. Greven, M.D., pro- fessor and chairman, Department of Ophthalmology, Wake Forest Uni- versity School of Medicine, Win- ston-Salem, N.C. Results published in the July 2010 issue of the New England Journal of Medicine indicated that with intensive glycemic treat- ment, rates of progression at 4 years were 7.3% versus 10.4% with stan- dard therapy. Investigators were spurred to look at tighter glycemic and lipid control by earlier studies. "We've known for a long time that in pa- tients with type 1 diabetes, optimiz- ing blood sugar control is beneficial in preventing the progression of dia- betic retinopathy," Dr. Greven said. "We've also known that blood sugar control is important in type 2 dia- betes." Investigators wanted to look at this more closely. "The question that we really wanted to answer is whether controlling blood sugar to near normal levels in this high-risk pressure doesn't have any effect on diabetic retinopathy, but we didn't see a statistically significant effect by lowering it to the level of 120 mm Hg of mercury." New insights Dr. Greven hopes that practitioners come away from the study with new insight into the role of glycemic lev- els on retinopathy progression. "I think the take-home message is that in this high-risk group of patients, tight glycemic control did decrease the risk of retinopathy progression, but the increased mortality and in- creased number of hypoglycemic events needs to be looked at and weighed by the physicians manag- ing the patients," Dr. Greven said. Overall, Dr. Greven sees the data as having important clinical implica- tions. "In this subgroup of type 2 di- abetics who are at high risk for cardiovascular events, the addition of fenofibrate to a statin is benefi- cial," he said. "That will impact care because it has never been a standard therapy for preventing the progres- sion of diabetic retinopathy in the past." EW Editors' note: Dr. Greven has no finan- cial interests related to his comments. Contact information Greven: 336-716-4091, cgreven@wfubmc.edu Diabetic retinopathy Source: Boots, WebMD population is beneficial as well," Dr. Greven said. "The same with blood pressure and with controlling lipids in the lipid arm of the study." Included in the study were 10,251 participants with type 2 dia- betes who were at elevated risk for cardiovascular disease. "Everyone was randomized to either standard glycemic control or intense control," Dr. Greven said. "Then about half of the patients were also randomized to blood pressure control." Glycemic levels for those in the intense control group were targeted at less than 6%, while those in the standard group were between 7–7.9%. Yet another subgroup was targeted for lipid control, with some patients targeted to receive 160 mg daily of fenofibrate plus simvastatin and others to receive placebo plus simvastatin. Medical success "The key finding was that intensive glycemic control was beneficial in preventing the progression of dia- betic retinopathy," Dr. Greven said. "But the patients who had intensive glycemic control did have an in- creased mortality rate and an in- creased number of episodes of what we call hypoglycemic events." As a result, investigators recommend that each patient's treatment be individu- alized with a primary care physician and an ophthalmologist to deter- mine just how tightly the glycemic levels should be controlled. In the lipid trial, patients were randomized to receive fenofibrate plus a statin versus statin therapy alone. "Fenofibrate is designed to lower triglycerides and increase HDL [high-density lipoprotein] levels," Dr. Greven said. "What we found is that the patients who received both the fenofibrate and the statin did statistically better than patients who took the statin alone." At the four- year mark, progression of diabetic retinopathy was 6.5% in the fenofi- brate group versus 10.2% with placebo. In another portion of the study, investigators honed in on blood pressure. "We know that blood pres- sure has an effect on the progression of diabetic retinopathy from previ- ous studies," Dr. Greven said. "In this study what was different was that we were trying to lower blood pressure to what we would consider near normal levels." Systolic blood pressure for those in the aggressively treated group was targeted at less than 120 mm Hg versus 140 mm Hg in the other group. "We found there was no real difference in bringing the blood pressure to a normal level," Dr. Greven said. "I wouldn't want doctors to think that blood Hemorrhage risk for certain AMD patients P atients who have neovascular age-related macular degeneration and also take daily antiplatelet or anticoagulant (AP/AC) medication may be at higher risk of experiencing intraocular hemorrhage, according to a study released in the December issue of Retina. The retrospective cross-sectional study, which took place in a tertiary univer- sity setting, studied data on 195 eyes of 195 patients without previous intraocular hemorrhage over a 73-month period. Ninety-six of 195 patients (49.2%) were taking daily AP/ACs (aspirin, clopido- grel, and/or warfarin). Of patients taking daily AP/AC agents, 63.5 percent had ei- ther subretinal hemorrhage or vitreous hemorrhage compared with 29.2 percent of patients not taking (odds ratio = 4.21; 95 percent confidence interval = 1.42- 8.46; P < 0.001), the study found. "Antiplatelet or anticoagulant usage was an independent risk factor for the development of intraocular hemorrhage," the study said. "The use of any agent resulted in a significantly increased risk of developing intraocular hemorrhage. Additionally, presence of bilateral neovascular AMD was a significant association in those taking daily AP/ACs, whereas age was a significant association in those not taking daily AP/AC agents." Gender, hypertension and diabetes were not found to be significantly associ- ated with hemorrhage in patients taking daily AP/AC agents.

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