A RISK-BENEFIT ASSESSMENT OF CONVENTIONAL VERSUS INTENSIVE INSULIN THERAPY

Some retrospective nonrandomised or cross-sectional studies have shown that higher blood glucose levels are associated with more pronounced microvascular complications in patients with insulin-dependent diabete s mellitus (IDDM). The prospective randomised studies had, until recen tly, been less definitive. Intensified treatment, and thus lower blood glucose levels, has led to an initial worsening of retinopathy, but t his tendency towards more advanced retinopathy has been transient. Alb uminuria and manifest neuropathy have been retarded to some extent. To day, 2 long term randomised studies, the Stockholm study and the Diabe tes Control and Complications Trial (DCCT), have proven that a lowerin g of mean blood glucose levels, measured as a lower glycosylated haemo globin (HbA1c) value, retards or halts retinopathy, nephropathy and pe ripheral neuropathy. Intensified treatment, whether performed with mul tiple injections or insulin pumps, leads to some weight gain and a 3-f old increase in the frequency of severe hypoglycaemic episodes. Hypogl ycaemia did not cause long term reduced cognitive function in either s tudy, but was unpleasant to the patients. A great majority of patients in the Stockholm study stated that their well-being had increased whi le participating in the study. The Stockholm programme required 35 min utes extra per patient per month, and a physician and a nurse could tu tor 400 patients. This would bring a significant reduction of serious complications and a gain in terms of patient discomfort and cost. A pr ogramme of intensified treatment for IDDM is generally indicated and i s possible to carry out.