Diabetes complications - What can be done to slow them?

[xMenace]

What can be done to slow diabetes complications?

The part that bothers me is hi-lighted in red. These do seem logical recommendations based on common sense, but are they? Many of us here are proving that exceptional control can be achieved. And it seems the risk of hypoglycemic incidents is not only not increased but possibly decreased. I know since improving my A1C my hypos have dropped dramatically: good control is good control of all facets, not just A1Cs. I have no idea why patients with far avanced complications wouldn't want tight control. Can kids safely obtain tight control? Why not?

Any thoughts on these? On what can be done to improve the control of all diabetics? How does one get these recommendations updated?

What can be done to slow diabetes complications?
Feb 6, 2008, 12:05

Findings from the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) have clearly shown that aggressive and intensive control of elevated levels of blood sugar in patients with type 1 and type 2 diabetes decreases the complications of nephropathy, neuropathy, retinopathy, and may reduce the occurrence and severity of large blood vessel diseases. Aggressive control with intensive therapy means achieving fasting glucose levels between 70-120 mg/dl; glucose levels of less than 160 mg/dl after meals; and a near normal hemoglobin A1C levels (see below).

Studies in type 1 patients have shown that in intensively treated patients, diabetic eye disease decreased by 76%, kidney disease decreased by 54%, and nerve disease decreased by 60%. More recently the EDIC trial has shown that type 1 diabetes is also associated with increased heart disease, similar to type 2 diabetes. However, the price for aggressive blood sugar control is a two to three fold increase in the incidence of abnormally low blood sugar levels (caused by the diabetes medications). For this reason, tight control of diabetes to achieve glucose levels between 70-120 mg/dl is not recommended for children under 13 years of age, patients with severe recurrent hypoglycemia, patients unaware of their hypoglycemia, and patients with far advanced diabetes complications. To achieve optimal glucose control without an undue risk of abnormally lowering blood sugar levels, patients with type 1 diabetes must monitor their blood glucose at least four times a day and administer insulin at least three times per day. In patients with type 2 diabetes, aggressive blood sugar control has similar beneficial effects on the eyes, kidneys, nerves and blood vessels.


How is diabetes treated?

Please see the Diabetes Treatment article.

Diabetes At A Glance
Diabetes is a chronic condition associated with abnormally high levels of sugar (glucose) in the blood.
Insulin produced by the pancreas lowers blood glucose.
Absence or insufficient production of insulin causes diabetes.
The two types of diabetes are referred to as type 1 (insulin dependent) and type 2 (non-insulin dependent).
Symptoms of diabetes include increased urine output, thirst and hunger as well as fatigue.
Diabetes is diagnosed by blood sugar (glucose) testing.
The major complications of diabetes are both acute and chronic.
Acutely: dangerously elevated blood sugar, abnormally low blood sugar due to diabetes medications may occur.
Chronically: disease of the blood vessels (both small and large) which can damage the eye, kidneys, nerves, and heart may occur
Diabetes treatment depends on the type and severity of the diabetes. Type 1 diabetes is treated with insulin, exercise, and a diabetic diet. Type 2 diabetes is first treated with weight reduction, a diabetic diet, and exercise. When these measures fail to control the elevated blood sugars, oral medications are used. If oral medications are still insufficient, insulin medications are considered.

[Jan B]

Regarding tight control not recommended for:
patients with severe recurrent hypoglycemia, patients unaware of their hypoglycemia --

This part sounds like good advice for a few weeks to a month or so, until the patient regains awareness of their hypos. (You, John, may not argue with this point, as long as it's temporary.)

[Injecto]

"and patients with far advanced diabetes complications."

This one comment alone bothers me, and frankly, makes NO sense at all. So if you have had your foot amputated (due to an obviously severe complication) you should avoid tight control thereafter? Why? So you can just go blind next? It makes no logical sense. Tight control has been experienced by many to "regain" health, even after complications. You obviously can't get your foot back, but you sure as **** can stop the next one from the same fate, so why avoid tight control (as one and only one example).

[xMenace]

Regarding tight control not recommended for:
patients with severe recurrent hypoglycemia, patients unaware of their hypoglycemia --

This part sounds like good advice for a few weeks to a month or so, until the patient regains awareness of their hypos. (You, John, may not argue with this point, as long as it's temporary.)

I argue about regaining awareness. I am fairly aware of my symptoms while awake, but while sleeping is a hopeless cause. I would say temporarily while learning effective techniqies to control BGs, recognize hypos, and prevent hypos. I spend a couple minutes every night before bed assessing my BGs and likelyhood of bottoming out. This simple exercise has saved my *** a few times. It's even more effective with a partner.

[xMenace]

"and patients with far advanced diabetes complications."

This one comment alone bothers me, and frankly, makes NO sense at all. So if you have had your foot amputated (due to an obviously severe complication) you should avoid tight control thereafter? Why? So you can just go blind next? It makes no logical sense. Tight control has been experienced by many to "regain" health, even after complications. You obviously can't get your foot back, but you sure as **** can stop the next one from the same fate, so why avoid tight control (as one and only one example).

A guy in my group, a brother of a co-worker, who I met in the hospital as he was unconcious and struggling for his life due to an internal infection, who previously lost two toes, now is 6.5% and doing great! I never helped him BTW, he was already on the right path.

[Mich]

Hey X,

(I like the Slinky quote, by the way... )

Perhaps they made that statement about control considering the newly available info on links between sudden tight control and eye problems. They don't know much about it, but there has been evidence that when people go from high A1C to suddenly good ones, some diabetic complications seem to worsen for a while. (Google to verify this.)

I don't know if it was coincidence, but my eye problems appeared within a month of getting my pump. This would be after many years of eye status quo with MDI. Interesting. I still think the infusion basal insulin is very worth it.

Mich

[xMenace]

Hey X,

(I like the Slinky quote, by the way... )

Replace the words 'some people' with 'most doctors'

Perhaps they made that statement about control considering the newly available info on links between sudden tight control and eye problems. They don't know much about it, but there has been evidence that when people go from high A1C to suddenly good ones, some diabetic complications seem to worsen for a while. (Google to verify this.)

I don't know if it was coincidence, but my eye problems appeared within a month of getting my pump. This would be after many years of eye status quo with MDI. Interesting. I still think the infusion basal insulin is very worth it.

Mich

I experienced the same. 6 weeks after pumping, the eye went nuts. My optho said there's noe relationship, but I've heard too many stories to not suspect it. I think this has been the policy for a long time.

[xMenace]

Log In Problems
Implications of the Diabetes Control and Complications Trial
from Diabetes Care

The American Diabetes Association Response To The DCCT
Are the results of the DCCT significant and reliable? The DCCT was well designed and efficiently carried out. The results are statistically significant and are of major clinical importance. They convincingly demonstrate that blood glucose control significantly influences development of complications in subjects with type 1 diabetes. The study does not appear to have major flaws. As in all clinical trials, not every variable could be studied. In the DCCT, the age range of the study subjects was rather narrow and relatively few minority patients participated, but there is no reason to believe that the results would not apply to all people with type 1 diabetes.

What level of glucose control should be sought? It appears that there is a direct relationship between blood glucose level and the risk of complications. However, there are other factors, such as genetics, that influence complications. Nevertheless, patients should aim for the best level of glucose control they can achieve without placing themselves at undue risk for hypoglycemia or other hazards associated with tight control (see question 3). Any improvement in blood glucose control has been shown to slow the development and progression of microvascular complications.
As has always been the case, therapy for diabetes must be individualized in consultation between patient and primary health care provider. If the type 1 patient is intellectually, emotionally, physically, and financially able to attempt tight control, and if a health care team is available to provide resources, guidance, and support, a reasonable goal is the mean plasma glucose and HbA1c levels achieved in the intensive treatment group of the trial (i.e., mean blood glucose of 155 mg/dl [8.6 mmol/l] and HbA1c of ~7.2%; normal average blood glucose is ~110 mg/dl [6.1 mmol/l] and HbA1c is <=6.05%).


Is tight control of blood glucose dangerous? It can be. The major danger is hypoglycemia, especially in people with type 1 diabetes. Serious hypoglycemia may result in altered consciousness, coma, or convulsions resulting in injury to the patient or others. Hypoglycemia may also have harmful effects on neuropsychological and intellectual function in children, although in DCCT participants, these adverse effects were not observed. In older people, low blood glucose may lead to strokes or heart attacks. The intensive treatment group in the DCCT had a threefold greater risk of severe hypoglycemia than did the standard treatment group.
The risk of hypoglycemia must be taken into consideration, although the danger may be reduced by frequent blood glucose monitoring; adjustment of insulin dosage; alteration of the timing, frequency, and content of meals; and change in exercise/activity patterns. Thus, comprehensive self-management training is essential.

The intensive treatment group also experienced significant weight gain, which can have adverse medical and emotional consequences.


Do the results of the DCCT apply to people with type 2 diabetes? Patients with type 2 diabetes were not studied in the DCCT. However, the largest and longest study on patients with type 2 diabetes, the United Kingdom Prospective Diabetes Study (UKPDS), conclusively demonstrated that improved blood glucose control in these patients reduces the risk of developing retinopathy and nephropathy and possibly reduces neuropathy. The overall microvascular complications rate was decreased by 25% in patients receiving intensive therapy versus conventional therapy. Epidemiological analysis of the UKPDS data showed a continuous relationship between the risk of microvascular complications and glycemia, such that for every percentage point decrease in HbA1c (e.g., 9 to 8%), there was a 35% reduction in the risk of microvascular complications. These results confirm in type 2 diabetes that lowering blood glucose is beneficial. The UKPDS also showed that aggressive control of blood pressure, consistent with American Diabetes Association recommendations, significantly reduced strokes, diabetes-related deaths, heart failure, microvascular complications, and visual loss.
Several observational studies, including the results of the epidemiologic analysis of UKPDS data, have shown strong and statistically significant associations between blood glucose control and the risk of cardiovascular disease morbidity and mortality. The UKPDS showed a 16% reduction (not statistically significant, P = 0.052) in the risk of combined fatal or nonfatal myocardial infarction and sudden death in the intensively treated group.

For further discussion, see the American Diabetes Association's position statement "Implications of the United Kingdom Prospective Diabetes Study."


Is tight control contraindicated in any group of patients? Tight control should not be attempted by patients unable or unwilling to participate actively in their glucose management. Tight control is contraindicated in infants <2 years old. It should be undertaken with extreme caution in children between the ages of 2 and 7 years because hypoglycemia may impair normal brain development, which is not complete until 7 years of age. The danger of hypoglycemia is greater in infants and children because food intake, activity, and adherence to treatment schedules are less predictable than in adults. Because preadolescents appear to be relatively protected from microvascular complications, the need for tight control might be less than in postpubertal subjects. Older patients with significant atherosclerosis may be vulnerable to permanent injury from hypoglycemia. Although there are few absolute contraindications to tight control, relative contraindications will be more frequent. Clinical judgment and common sense will be required in decision making under the latter circumstance. Given the above caveats, multiple insulin injections and frequent blood glucose monitoring from the onset of type 1 diabetes should be standard therapy.

Should tight control be the goal of therapy for patients with established complications? Again, clinical judgment is required. Unless patients have advanced, severe complications, the answer would often be yes. Tight control may not be indicated for patients who already have marked visual loss or end-stage renal disease. Patients with advanced complications were not entered into the trial, so no direct evidence is available to indicate that tight control in such patients is beneficial.

Should intensive therapy be offered to patients with long-standing diabetes and no evidence of microvascular complications? If a person has had diabetes for 20–25 years following puberty without signs of retinal, nerve, or kidney disease or if complications are minimal (e.g., one or two microaneurysms in the retina), tight control might not be necessary.

Will tight control prevent macrovascular complications? Atherosclerosis occurs earlier in people with diabetes than it does in those without elevated blood glucose levels. The DCCT was reassuring in demonstrating that there was no increase in cardiovascular disease in the setting of intensive therapy.

Is there any way to predict genetic susceptibility to diabetic complications? As was mentioned earlier, susceptibility to complications and damage from elevated blood glucose levels is influenced by one's genes. Unfortunately, we have not identified markers of susceptibility.

For those choosing tight control, is lifelong intensive treatment required? In general, tight control for people beyond puberty should be maintained for life. Alteration of therapy may be required because of advanced age or other changes in clinical circumstances, e.g., after a stroke or heart attack, signaling more serious risks from hypoglycemia.

[xMenace]

Are the results of the DCCT achievable for most people with diabetes? In theory, the answer is yes. However, in the real world, great effort will be required to reproduce the results of the DCCT. It must be recognized that the study group was young, generally healthy, and highly motivated. The professional personnel conducting the study were trained endocrinologists and diabetes educators in academic centers who were highly motivated and meticulous in their management of the study subjects. The intensively treated group received far more attention and medical services than are routinely available in clinical practice. In many cases, participants and professionals became "family." Broad implementation of intensive therapy will require expanded health care teams (knowledgeable physicians, diabetes educators, nutritionists, and social workers), major professional and patient educational efforts, and an enhanced partnership between specialists and primary care providers. The costs of these services and reimbursement mechanisms will have to be addressed (see question 13). Even if the DCCT results are not achieved, any improvement in blood glucose control has been shown to slow the development and progression of microvascular complications.

What form of intensive treatment is recommended? Improved glucose control in type 1 diabetes had beneficial effects whether delivered by multiple daily injections or programmable insulin-infusion pumps. The choice of treatment depends on the wishes of the individual patient and the comfort/competence of the health care team with a given technique.

Will the postulated benefits of better control be worth the increased costs? It is recognized that there will be substantially increased costs of widely applying the recommendations of this study in the U.S. There will also need to be additional efforts to ensure professional education, so that health practitioners are able to effectively and safely implement the therapy employed in the DCCT. It is hoped that the long-term benefits of healthier, more productive lives with fewer complications will offset the costs of tight control. The cost-benefit ratio for intensive therapy is in a range similar to other commonly accepted treatments in the U.S.

[peej07]

The funny thing is I've had many optos and retina specialists tell me that in some patients they have seen eye problems as well as kidney problems reversed when getting under tight control with a pump.

[cheryl]

I totally agree with under 13 years of age, and all, because children are very very very active....My target as a 12 year old was 100-180, now, they were fine if I was 80 but no lower if any lower than that I had to treat it and treat it fast....I was of course on Regular and NPH....and all that....I also agree that while going thru puberty, no child or teenager should even expect to have the greatest of levels.....especially us girls, there is just no way it is too too hard....and then on top of that trying to be normal it is very very very hard...

There are some people who's hypoglycemic awarness, does not go away even after running higher for a month or two....so they have to run higher....people with complications, I don't get this one unless they go about it too fast, I think if someone is suffering complications, and they run higher, they have to slowly get them down to tight control, not oh one day running 250 all the time, and then running below 100 then next day then there after that is not healthy...that is how I feel on that one....It is hard for some people to have tight control no matter what they do, I don't have tight control, I have good control, I am very insulin sensitive....unless it's my insulin, I can't level off in the 80's at all, no matter what an 80 means a drop....but I can at 100...so I dunno.....

Cheryl