Is medical nonadherence or modifiable risk factors the primary concern for a patient with stroke and type 2 diabetes?

From the Guidelines

Both medical nonadherence and modifiable risk factors are significant concerns for patients with stroke and type 2 diabetes, but addressing modifiable risk factors should be the primary focus. For these patients, comprehensive management should target blood pressure control (goal <130/80 mmHg) using medications like ACE inhibitors (e.g., lisinopril 10-40 mg daily) or ARBs (e.g., losartan 50-100 mg daily), along with glucose management (target HbA1c <7%) using medications such as metformin (starting at 500 mg twice daily) and possibly GLP-1 receptor agonists or SGLT2 inhibitors. Statin therapy (e.g., atorvastatin 40-80 mg daily) is essential regardless of baseline cholesterol levels. Lifestyle modifications including Mediterranean or DASH diet, regular physical activity (150 minutes weekly of moderate exercise), smoking cessation, and limiting alcohol consumption are crucial components of care. While medication adherence is important, focusing on these modifiable risk factors provides a more comprehensive approach to reducing recurrent stroke risk by addressing the underlying pathophysiology, including atherosclerosis, hypertension, and metabolic dysfunction. Patients should be educated that controlling these risk factors can reduce recurrent stroke risk by up to 80% 1.

Key considerations for managing modifiable risk factors include:

• Blood pressure control: ACE inhibitors or ARBs, with a goal of <130/80 mmHg
• Glucose management: metformin, with a target HbA1c <7%
• Statin therapy: essential regardless of baseline cholesterol levels
• Lifestyle modifications: Mediterranean or DASH diet, regular physical activity, smoking cessation, and limiting alcohol consumption These interventions can significantly reduce the risk of recurrent stroke and improve overall outcomes for patients with stroke and type 2 diabetes 1.

It is also important to note that while medical nonadherence is a concern, addressing modifiable risk factors provides a more comprehensive approach to reducing recurrent stroke risk. Patients should be educated on the importance of controlling these risk factors and the potential benefits of doing so, including a reduced risk of recurrent stroke by up to 80% 1.

In terms of specific recommendations, the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack suggests that adhering to pharmacological secondary prevention strategies is an important self-care behavior in stroke secondary prevention 1. Additionally, the Canadian Stroke Best Practice Recommendations suggest assessing patients for adherence to individualized secondary prevention plans at each stroke prevention visit with healthcare team members 1.

Overall, addressing modifiable risk factors should be the primary focus for patients with stroke and type 2 diabetes, with a comprehensive approach that includes medication management, lifestyle modifications, and patient education.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Modifiable Risk Factors for Stroke

• Hypertension, diabetes, atrial fibrillation, dyslipidemia, smoking, and alcohol abuse are identified as modifiable risk factors for stroke 2, 3
• Lifestyle and behavioral modification, such as dietary changes or smoking cessation, can reduce stroke risk and the risk of other cardiovascular diseases 3
• Medical conditions like hypertension and diabetes that increase stroke risk can be managed through treatment and lifestyle changes 3, 4

Management of Risk Factors

• Studies have shown that there is room for improvement in the management of modifiable risk factors such as hypertension, hyperlipidemia, diabetes, and smoking 5
• Management of hypertension and lipid profiles can be improved through active involvement of stroke prevention clinics and use of medications like ramipril 5, 4
• Diabetes management is crucial in reducing the risk of stroke, and comprehensive medical management includes antihypertensive and lipid-lowering therapy, as well as antiplatelet therapy 4, 6

Medical Nonadherence

• There is no direct evidence in the provided studies to suggest that medical nonadherence is the primary concern for a patient with stroke and type 2 diabetes
• However, the studies emphasize the importance of managing modifiable risk factors to reduce the risk of stroke, which implies that adherence to treatment plans is crucial 2, 3, 5, 4, 6