American College of Physicians: Internal Medicine — Doctors for Adults ®

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The word from recent studies about treatment outcomes

From the January 1996 ACP Observer, copyright © 1996 by the American College of Physicians.

By William A. Check

Results of the Diabetes Control and Complications Trial (DCCT) showing a reduction in complications of type 1 diabetes with intensive control of blood glucose are extrapolatable to type 2, says Frank Vinicor, FACP, MPH. Dr. Vinicor serves as president of the American Diabetes Association and as director of the CDC's division of diabetes.

Dr. Vinicor believes DCCT results are applicable for several reasons. Pathophysiology of the lesions is the same in both types of diabetes, and epidemiological studies show that the development of microvascular complications is the same in both types and correlates with the degree of hyperglycemia. In addition, a recent paper from Japan* showed that intensive insulin therapy prevents microvascular complications in type 2 patients.

"[The study] was not as large or as long as the DCCT but had the same general findings," Dr. Vinicor notes. Intensive therapy reduced rates of retinopathy, microalbuminuria and neuropathy.

Dr. Vinicor notes "an appropriate concern" about side effects of intensive control, and some physicians question whether tight control is feasible in type 2 patients. Both the Veterans Affairs Cooperative Study on Glycemic Control and Complications in NIDDM and the early phases of the ongoing United Kingdom Prospective Diabetes Study show that improved blood glucose regulation is achievable, he says. Both studies also show that the risk for severe hypoglycemia in type 2 patients is about one-thirtieth that in type 1 patients. To concerns that hyperinsulinemia might be atherogenic, Dr. Vinicor says, "I would say the pendulum has swung back to the middle on that."

Dr. Vinicor emphasizes that glucose control is not dichotomous. "DCCT clearly shows that any improvement results in a decreased likelihood of having microvascular complications," he says. "You donŐt necessarily need multiple visits to multiple diabetes specialists and multiple injections to get a benefit."

A recent study published in the Journal of the American Medical Association compared outcomes in persons with moderate type 2 diabetes treated by specialists or general internists. "That was an observational study that demonstrated little difference in outcome," Dr. Vinicor says.

"I am a believer in the role of the internist in treating both type 1 and type 2 diabetes," he says. "But in more severe patients, such as those with foot ulcers, specialists clearly achieve better outcomes."

*Ohkubo Y, Kishikawa H, Araki E, et al. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: A randomized prospective 6-year study. Diabetes Research and Clinical Practice, 1995; 28:103-117.

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