What is the best way to prevent diabetic retinopathy in a patient with type 2 diabetes (T2D), hypertension, and hyperlipidemia, currently taking lisinopril (angiotensin-converting enzyme inhibitor) and simvastatin (HMG-CoA reductase inhibitor), with a hemoglobin A1c (HbA1c) of 7.5% and low-density lipoprotein (LDL) of 69?

Optimal Strategy for Preventing Diabetic Retinopathy

Increasing lisinopril is the best intervention among the options provided to prevent diabetic retinopathy in this patient, as optimizing blood pressure control with ACE inhibitors has proven benefit in reducing retinopathy progression, and his current blood pressure of 139/80 mmHg is above the recommended target of <130/80 mmHg. 1, 2

Blood Pressure Optimization: The Priority Intervention

Your patient's blood pressure of 139/80 mmHg exceeds guideline targets for diabetic retinopathy prevention. The evidence strongly supports:

• Target blood pressure should be <130/80 mmHg in patients with diabetes and hypertension to reduce retinopathy risk and progression 1, 2
• ACE inhibitors (like his current lisinopril) are specifically recommended as preferred first-line agents for patients with diabetes, especially for retinopathy prevention 1, 2, 3
• Blood pressure control has demonstrated beneficial effects on retinopathy progression, with tight control reducing progression by 34% and visual acuity deterioration by 47% 1, 3
• The European Society of Cardiology gives this a Class I, Level A recommendation for primary prevention of diabetic retinopathy 1

Increasing his lisinopril dose from 10 mg directly addresses a modifiable risk factor that is currently suboptimal.

Why the Other Options Are Less Appropriate

Aspirin: No Benefit for Retinopathy

• Aspirin has no effect on retinopathy progression, development, or vitreous hemorrhage 3
• While retinopathy is not a contraindication to aspirin for cardioprotection, it provides no specific benefit for preventing diabetic retinopathy 1

Semaglutide: Potential Harm with Rapid Glycemic Improvement

• His HbA1c of 7.5% is only modestly elevated and already near the target of <7% recommended for retinopathy prevention 1, 2
• GLP-1 receptor agonists like semaglutide have been associated with mild worsening of diabetic retinopathy in randomized trials when they cause rapid A1C reduction 3
• The risk relates to the speed of glycemic improvement rather than the drug itself, but this makes aggressive glucose lowering less appropriate as the primary intervention 3
• Gradual glycemic improvement is preferred in patients at risk for retinopathy 3

Switching to Atorvastatin: Marginal Benefit

• His LDL is already at 69 mg/dL, which is below the target of <100 mg/dL and even meets the optional target of <70 mg/dL for high-risk patients 1
• While lipid lowering should be considered to reduce retinopathy progression (Class IIa recommendation), his lipids are already well-controlled 1
• The evidence for statins specifically preventing retinopathy is limited, with one small study showing simvastatin retarding progression in hypercholesterolemic patients 4
• Fenofibrate (not atorvastatin) is the lipid-lowering agent with the strongest evidence for retinopathy benefit, particularly in patients with dyslipidemia and early retinopathy 1, 3, 5

Comprehensive Prevention Strategy Beyond the Question

While increasing lisinopril is the best single intervention among your options, optimal retinopathy prevention requires:

Glycemic Control

• Target HbA1c <7% for most patients 1, 2
• His current 7.5% warrants modest improvement, but avoid rapid reduction 3
• Intensive glycemic control reduces retinopathy risk by approximately 54% in type 1 diabetes and shows similar benefits in type 2 diabetes 3

Screening Requirements

• Immediate dilated comprehensive eye examination by an ophthalmologist or optometrist at the time of type 2 diabetes diagnosis 1, 2, 6
• Annual follow-up examinations thereafter 1, 6

Additional Considerations

• If dyslipidemia worsens or triglycerides become elevated, consider adding fenofibrate, which reduces retinopathy progression by 40% when combined with statins 1, 5
• Monitor for microalbuminuria annually, as nephropathy and retinopathy frequently coexist 2

Critical Pitfalls to Avoid

• Do not delay blood pressure optimization thinking that 139/80 mmHg is "close enough" to target—every mmHg matters for microvascular protection 1, 2
• Do not add aggressive glucose-lowering therapy without considering the risk of rapid A1C reduction worsening retinopathy 3
• Do not assume aspirin helps retinopathy despite its cardiovascular benefits 3
• Do not skip the baseline eye examination—this patient needs immediate ophthalmologic evaluation given his new diabetes diagnosis 1, 6