TARGETS OF THERAPY FOR NIDDM

Non-insulin-dependent diabetes (NIDDM) is a common multimetabolic diso rder with potential (and potentially severe) long-term complications a ffecting large and small blood vessels. Where microvascular complicati ons (retinopathy, nephropathy and neuropathy) are concerned, the Diabe tes Control and Complications Trial (DCCT), as well as much circumstan tial evidence, suggests that hyperglycaemia is the main aetiological f actor and this is likely to apply in NIDDM as well as IDDM. Unfortunat ely, achieving normoglycaemia in NIDDM is not easy and it is unclear w hether insulin has advantages over oral hypoglycaemic agents or vice v ersa. Turning to macrovascular disease, it is unclear which of the man y potentially atherogenic abnormalities - hypertension, hyperinsulinae mia, hyperlipidaemia, etc - are most important. A further problem is t hat macrovascular disease is already well developed in many patients w hen NIDDM is diagnosed and we do not know whether secondary prevention is effective. Nevertheless, it is sensible to try to reverse the athe rogenic milieu and this should be done in the first instance by lifest yle modification rather than drugs. Even if we cannot manipulate the b iochemistry to prevent small or large vessel complications, much can s till be done; proactive foot care can prevent ulceration, timely laser treatment can prevent visual loss and thrombolytic therapy is relativ ely more effective in diabetic patients with myocardial infarction tha n in their non-diabetic peers. Finally, patients with NIDDM need inten sive education and each needs an individualised treatment plan and goa ls.