INSULIN THERAPY FOR NON-INSULIN-DEPENDENT DIABETES - MINIMAL OR INTENSIVE

The indications for continuous insulin therapy during non-insulin-depe ndent diabetes (NIDD) are numerous. In addition to patients with a con traindication to oral treatment, the greatest cause is ''failures resu lting from the use of hypoglycaemic agents''. According to data in lar ge series published to date, these secondary failures occur at an annu al rate ranging from 2 to 10 % and are more frequent in subjects whose weight is normal or moderately high. in current medical practice in F rance, the indications for insulin therapy are considered late, in the presence of severe hyperglycaemia indicative of beta-cell failure. Fr om then on, the problem raised is that of the glycaemic goal to be rea ched, which has an influence on the therapeutic strategy to he adopted . in addition to the risk of microangiopathy, NIDD patients run a very high risk of macroangiopathy, particularly when insulin therapy is in itiated late. In patients whose life expectancy is fairly long (7 to 1 0 years or more), a body of convergent clinical and epidemiological ev idence favours strict glycaemic control, i.e. intensive insulin therap y. The results of the DCCT are apparently applicable to NIDD with resp ect to microangiopathy, and hyperglycaemia is an independent risk fact or for cardiovascular disease in NIDD patients. Strict glycaemic contr ol is often associated with improvement in certain risk factors (lipid s, hemorheology). Despite the fact that no large controlled prospectiv e study similar to the DCCT is currently available for NIDD, efficient insulin therapy ensuring good glycaemic balance should be performed i n these patients. However, the difficulties inherent to the implementa tion of intensive insulin therapy during NIDD should not he neglected: hypoglycaemic risk, weight gain, problems in elderly subjects, diffic ulties in instructing patients, and follow-up. Finally, the return to adequate glycaemic control should he coordinated with an overall care plan for risk factors relative to macroangiopathy.