Management of Necrobiosis Lipoidica in Patients with Diabetes and Cardiovascular Risk Factors

Glycemic Control

The American Diabetes Association recommends targeting HbA1c <7% for most adults, with consideration of <6.5% in patients with microvascular complications, as poor glycemic control is strongly associated with the development and progression of necrobiosis lipoidica 1
Initiate or optimize metformin as first-line therapy, with a maximum dose of 2000 mg daily in divided doses, and consider adding a second agent such as a GLP-1 receptor agonist or SGLT2 inhibitor if HbA1c remains above target after 3 months 1, 2

The American Heart Association recommends targeting blood pressure <130/80 mmHg in patients with diabetes and evidence of microvascular disease, with initiation or optimization of an ACE inhibitor or ARB as first-line antihypertensive therapy 3, 4
If blood pressure is ≥160/100 mmHg or 20/10 mmHg above target, initiate combination therapy immediately, and consider adding a thiazide diuretic if needed to achieve target 3, 5

The American College of Cardiology recommends initiating at least moderate-intensity statin therapy immediately in patients with type 2 diabetes and multiple cardiovascular risk factors, with a target LDL cholesterol <1.8 mmol/L (very high ASCVD risk) or <2.6 mmol/L (high ASCVD risk) 3, 6, 7, 8
Statins are the preferred lipid-lowering drugs, and should be initiated at moderate intensity, with dose adjustment based on response, and consideration of alternative targets such as LDL-C reduction by ≥50% if baseline is very high and target cannot be reached after 3 months 3, 7, 8

The American Diabetes Association recommends annual comprehensive eye examination by ophthalmologist or optometrist, annual screening for diabetic kidney disease via urine albumin-creatinine ratio and eGFR, and annual comprehensive foot examination using 10-g monofilament testing plus assessment of vibration perception or ankle reflexes 6, 9

Monitor HbA1c every 3 months until target is reached, then at least twice yearly, and assess blood pressure at every routine visit, with monitoring of lipid profile periodically after statin initiation 1, 4, 5