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INTENSIVE THERAPY DELAYS SEQUELAE IN IDDM.

The symptoms of hyperglycemia in diabetics can usually be controlled without achieving normoglycemia. Whether more intensive therapy can prevent microvascular, macrovascular, and neurologic complications has been unclear. The long- awaited results of the Diabetes Control and Complications Trial address this question.

The multicenter study randomized 1441 patients with mild or no retinopathy (average age, 27) to intensive or conventional therapy. Intensive therapy involved an insulin pump or at least 3 daily insulin injections guided by at least 4 daily blood sugar measurements; conventional therapy involved 1 to 2 daily injections, usually without daily dose adjustments. Patients were followed for a mean of 6.5 years.

Patients receiving intensive therapy achieved lower blood sugar and glycosylated hemoglobin levels than conventionally treated patients, although they generally did not become normoglycemic. Their adjusted risks for development of retinopathy, progression of retinopathy, and proliferative or severe nonproliferative retinopathy were 47 to 76 percent lower; their risk for albuminuria was 54 percent lower; and their risk for neuropathy was 60 percent lower. These benefits began to manifest at about 3 years. There was also a trend toward fewer macrovascular complications. Severe hypoglycemia was more common with intensive therapy, however (62 vs. 19 episodes per 100 patient-years).

Comment: Like another recent trial (see Journal Watch accession number 930806003), this study shows that intensive therapy offers young insulin-dependent diabetics better outcomes with acceptable levels of risk. Important questions remain about whether the benefit/risk ratio will be as good in the 90 percent of diabetics who are older and not insulin-dependent, and whether macrovascular complications will be slowed.

— ALK

Published in Journal Watch General Medicine October 5, 1993

Citation(s):

The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993 Sep 30 329 977-986.

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