Am Fam Physician. 1999;60(7):1914-1921
The management of patients with type 1 diabetes mellitus (formerly known as juvenile-onset or insulin-dependent diabetes mellitus) poses a number of challenges to the practicing physician. These challenges include helping patients maintain optimal blood glucose control, implementing a monitoring schedule to screen for micro- and macrovascular complications, providing primary and secondary interventions to prevent or ameliorate these complications, and screening for and managing comorbid conditions (e.g., hypertension and hyperlipidemia). Reasonable targets for tight control have been defined as a mean blood glucose level of 155 mg per dL (8.6 mmol per L) and a glycosylated hemoglobin (HbA1c) level of approximately 7 percent.1 An important question is whether the efforts necessary to achieve tight control are worthwhile.
The Diabetes Control and Complications Trial (DCCT)2 was a landmark multicenter trial designed to assess the impact of tight blood glucose control on patients with type 1 diabetes. The study included two groups of patients: the first group was treated conventionally (typically a two-injections-daily regimen of short- and intermediate-acting insulin). The second group was treated with an intensive multi-injection or pump regimen that used a multidisciplinary health care team to help the patient achieve tighter control.
The significant finding of the DCCT2 was that, while normalization of glucose values (HbA1c level less than 6 percent) was not achieved in the intensively treated cohort over the seven-year study period, a 60 percent reduction was achieved in the development of diabetic retinopathy, nephropathy and neuropathy. This benefit was achieved most dramatically in patients who could achieve and maintain a HbA1c level of approximately 7 percent, which, while not normal, was adequate for the reduction of complications.2,3
In this issue of American Family Physician, Havas4 presents a summary of patient-centered educational guidelines to help patients achieve tight control. These guidelines are based on the author's unique experience as an internist, a subspecialist in preventive medicine, and a patient with diabetes who has practiced tight control for more than 40 years. We agree with the author that the special relationship between the family physician and the patient is integral to achieving optimal control. However, to meet the challenge of providing services that patients need to achieve such control, the physician is likely to require assistance from outside providers. We endorse the statement from the American Diabetes Association1 that “people with diabetes should receive their treatment and care from a physician-coordinated team. Such teams include, but are not limited to, physicians, nurses, dietitians, and mental health professionals with expertise and a special interest in diabetes.”
The time commitment and the expertise needed to help a patient achieve tight control can be considerable. For example, in the DCCT study,2 the patient population was young, relatively healthy and highly motivated. The professional personnel conducting the study included endocrinologists, diabetes educators, dietitians and social workers. The intensive-treatment group received far more attention and medical services than are routinely available in clinical practice. In our opinion, a successful intensive regimen will require a highly motivated patient using the resources available from a family physician, diabetes educator, dietitian, social worker and, occasionally, a psychologist. The “diabetes team” ideally includes an endocrinologist serving as consultant to the family physician and providing ongoing education to other members of the team.
Tight glucose control has an associated high monetary cost. Appointments with a nurse educator and nutritionist are typically poorly reimbursed by traditional fee-for-service insurance. The costs of nonphysician personnel under capitation are closely watched and often considered unnecessary. This, along with the added supply costs (e.g., additional glucose strips that cost 75 cents each and are used multiple times a day), may result in an expense to the patient that is burdensome.
We feel that the genuine risks of tight control are understated. Tight control of blood glucose can be inconvenient and occasionally dangerous.3 The major danger is hypoglycemia. Serious hypoglycemia may result in altered consciousness, coma or convulsions resulting in injury to the patient or others. Hypoglycemia contributing to a motor vehicle collision typically results in forfeiture of the patient's driver's license. Older patients with macrovascular disease may be vulnerable to an ischemic event (myocardial infarction or stroke) as the result of the hypoglycemic event. Tight control should not be attempted by patients who are unable or unwilling to participate actively in their glucose management.3
As described by Havas,4 the risk of hypoglycemia is clearly reduced by frequent monitoring of blood glucose levels, adjustments in insulin dosing, alterations in timing and content of meals, and change in activity patterns. Even with these behavior modifications, episodes of severe hypoglycemia may occur. In a study by Clarke and colleagues5 involving 93 adults with type 1 diabetes, patients with a history of episodes of severe hypoglycemia did not show objective evidence of managing their diabetes differently from those without a history of hypoglycemic episodes. Specifically, when low blood glucose levels occurred, the preceding management behaviors were not different. Again, it is our opinion that an understanding of these issues will require comprehensive “team” management.
In summary, we share the goals of providing family physicians with practical information needed to help patients achieve optimal control. Improvement in control sustained over many years has been associated with striking reductions in rates of complications associated with diabetes. It is important that family physicians stay actively involved with their patients with type 1 diabetes and maintain an optimistic outlook that these patients can achieve better control. It is also important that the patient share this belief. However, the treatment plan must include all of the financial and time costs to the patient and the physician that are associated with this endeavor, as well as considering the resources necessary to reach the objective and the potential risks of tight control.