Forum One: Current Recommendations about Intensification of Metabolic Control in Non-Insulin-dependent Diabetes Mellitus

Goals and methods of treatment should be individually adjusted

The conference participants recognized that the recommendation for intensive treatment of hyperglycemia requires individualization because this level of aggressive management is inappropriate in certain circumstances, for example, situations in which the patient is unable or unwilling to comply with the prescribed treatment regimen, the risk for or from hypoglycemia is excessive, or concomitant diseases are present that would adversely influence the risk/benefit ratio or substantially shorten life expectancy. Examples of such patients include the very old or those with significant dementia, those with malignancies not responsive to various therapies, those who have already developed renal failure, and those with advanced cardiovascular disease manifested by stroke, multiple myocardial infarctions, severe congestive heart failure, or major amputations. Under such circumstances, the primary care provider should still try to achieve the best glycemic control possible using the simplest regimen with the least possible risk.

Required comprehensive care should include treatment of hyperglycemia, hypertension, and dyslipidemia as well as patient education and prevention of risks for retinopathy, nephropathy, neuropathy, and cardiovascular disease

The basic level of care for diabetes should meet or exceed the standards recently adopted by the American Diabetes Association [1]. Non–insulin-dependent diabetes mellitus is a unique disorder, differing in many aspects from other chronic multisystem diseases. It is managed in large part by lifestyle modifications of diet and exercise. When necessary, oral hypoglycemic agents, insulin, or both may also be required in addition to medications for treatment of hypertension and dyslipidemia. Pharmacologic therapy requires continuous close medical supervision and education to be effective. The interaction between treatment methods is often complex and problematic to institute and monitor. The achievement of normal or near-normal glucose levels requires comprehensive training in self-management and monitoring of blood glucose levels. Continuing patient education and reinforcement are necessary to ensure that treatment goals are understood and that appropriate attention is given to meal planning, exercise, and therapeutic regimens. Home or self-monitoring of capillary blood glucose is one of the most important recent developments available to improve glycemic control. This technique enables the patient to be involved in self-management and understand the influence of therapy on blood glucose levels. Because home glucose monitoring facilitates glycemic control and reinforces adherence to therapy, consideration should be given to having all diabetic patients do such measurements. The frequency and pattern of home glucose monitoring should be appropriate to the therapeutic regimen being used and increase in complexity as treatment goes from diet and exercise therapy alone to several daily injections of insulin.

The death rate from coronary heart disease is markedly increased by the presence of diabetes when associated with hypertension, dyslipidemia, and smoking [5]. Therefore, it is vital to focus efforts on reducing cardiovascular risk factors as well as glycemia by optimizing blood pressure, lipoprotein levels, diet, and body weight. Unless contraindications exist, exercise should also be an integral component of the treatment program for diabetes. The highest priority should be given to reducing elevated blood pressure because strong evidence exists for its effectiveness in diabetic patients and because it also delays or reduces the risk for renal insufficiency [6, 7]. Another priority should be to encourage and assist patients to stop cigarette smoking, given the overall evidence of its adverse effects on cardiovascular and peripheral vascular events. No data exist from a randomized trial done specifically with diabetic patients to prove that treatment of dyslipidemia accompanying NIDDM is as beneficial as it now appears to be in nondiabetic patients. Nevertheless, from the available evidence, correction of abnormal low- and high-density lipoprotein cholesterol and triglyceride levels is recommended [8]. Reasonable target levels are specified in the American Diabetes Association standards of care [1]. Although diet and exercise regimens alone may not often result in complete normalization of cardiovascular risk factors, they are beneficial, and adherence should be constantly encouraged and reinforced because the response to subsequent institution of pharmacologic therapy will be enhanced. Drug treatment of hypertension and dyslipidemias should be introduced promptly when the response to diet and exercise therapy is inadequate.

To optimize management and delay or prevent the potentially devastating consequences of the complications [9], NIDDM is best managed by a comprehensive, multifaceted team approach, which involves active participation by the physician, nurse, diabetes educator, dietitian, and behavioral therapist. Effective management is time consuming and requires many expensive resources. However, a preventive approach with the expectancy of reduced complications is likely to be cost effective [10].

Progressive or staged treatment of hyperglycemia in NIDDM should be initiated at the earliest possible opportunity

Management of NIDDM should follow a staged or stepped approach beginning with dietary modification and exercise therapy. Intensive management should be initiated from the time of diagnosis. When diet and exercise therapies are ineffective for maintaining plasma glucose levels within the glycemic objectives shown in Table 1, oral antidiabetic agents are usually instituted. Oral medication should not be used as a substitute for diet and exercise therapy, but as adjunctive therapy. The recent introduction of metformin into the American market adds an oral agent that can be used alone or combined with the sulfonylureas [11]. Insulin therapy should be reserved for patients in whom an adequate trial of diet, exercise, and oral antidiabetic agent therapies, according to the stepwise approach advocated by the American Diabetes Association [12], has failed to achieve appropriate control. Some insulin treatment regimens commonly used in NIDDM are reviewed in other articles in this supplement. The primary objective of insulin treatment should be to achieve the best possible glycemic control with the least risk for hypoglycemia using the simplest regimen. Thus, insulin treatment may progress from single injections of longer-acting insulins to multiple injections of long- and short-acting insulins similar to those required by patients with IDDM. Although the issue remains unsettled and somewhat controversial, no direct compelling evidence exists that exogenous insulin administration causes cardiovascular disease in NIDDM or IDDM.

Resources necessary to implement the above recommendations should be made available to the health care providers of patients with NIDDM

In setting all the above recommendations, it was understood that most patients with NIDDM are currently being cared for by generalists and that the recommended level of care might be difficult for many health care providers to institute because of the need for extensive resources. Additional barriers to effective management might include the difficulty encountered by health personnel in keeping up with rapid advances in technology and knowledge related to diabetes management. Ongoing efforts to simplify and improve the delivery of new information in diabetes management were proposed. The proposed development of a National Diabetes Education Program (NDEP) to develop and foster information about diabetes treatment is a major step in this direction. At present, full implementation of intensive metabolic control as recommended may be restricted to those practices and institutions with adequate resources and to patients with adequate insurance. To overcome this limitation, it was emphasized that the relevant governmental and private-paying agencies responsible for health care to diabetic persons should recognize and fund sufficient resources to provide optimal care.

Dr. Henry: Veterans Affairs Medical Center, San Diego (V-111G), 3350 La Jolla Village Drive, San Diego, CA 92161.