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Am Fam Physician. 2002;65(4):707-708

Strict control of blood glucose levels in patients newly diagnosed with type 2 diabetes can result in a reduction of 25 percent in microvascular complications. Although data have not yet proved a reduction in mortality, insulin therapy is recommended for an increasing number of type 2 diabetic patients because of the accumulating evidence of benefit from strict glycemic control. Conversely, many patients are reported to dislike the repeated injections and blood glucose monitoring required in insulin therapy and to be particularly afraid of possible hypoglycemic episodes. These fears, plus the sense of failure felt by many patients because they require insulin therapy, have led to insulin treatment being associated with a decrease in quality of life in diabetic patients and their families. De Grauw and colleagues studied glycemic complications, hypoglycemic events, and quality of life in 38 Dutch patients changing from oral to insulin therapy for poorly controlled type 2 diabetes.

Patients were recruited from 10 general practices in which diabetic management was based on the guidelines of the Dutch College of General Practitioners. Patients with poor glycemic control despite optimal oral medication were eligible for the study if average glycosylated hemoglobin (HbA1c) levels were 8 percent or higher, or if blood glucose levels were persistently elevated. The change to insulin was made in two different ways to evaluate possible effects of the referral process and the extra attention provided to patients during the transition process. Group A patients had a 12-week period of enhanced care by a primary care physician and a dietitian to optimize noninsulin therapy in combination with diet and oral medications. Group B patients were immediately referred to a subspecialist for institution of insulin therapy. Over a nine-month period, glycemic control was monitored. Patients were also formally assessed using standardized protocols for medical history, cardiovascular risk factors and events, complications of diabetes, and other morbidities. Blood samples were taken for lipid and creatinine measurements, as well as to monitor glycemic control. Quality of life was assessed using two questionnaires of general functioning plus a validated diabetes symptom checklist.

Of the 38 patients, seven did not transition to insulin therapy because of marked improvement in glycemic control after entry in the study. In addition, four patients withdrew or were removed from the study. Mean HbA1c and fasting blood glucose levels fell significantly in the remaining 27 patients, who reported a statistically significant decrease in symptoms associated with hyperglycemia. Mean body weight and body mass index increased significantly, but blood pressure and lipid profiles showed a trend toward improvement. No increase in hypoglycemic symptoms was noted. No significant changes were found in any of the quality-of-life measurements, and there was a trend toward significant improvement in perceived health. By the end of the study, patients in groups A and B showed no significant differences in HbA1c changes and quality-of-life scores.

The authors conclude that patients with poorly controlled type 2 diabetes can be switched to insulin therapy without an increase in hypoglycemic episodes or deterioration in quality of life. Insulin therapy results in significant clinical and statistical improvements in glycemic control.

editor's note: Family physicians are in a time of great change in the management of diabetic patients. We are keenly aware of the guilt and emotional havoc that can result when overzealous “strict control” is forced on our patients, yet we know only too well the consequences for them and their families if diabetes is allowed to steadily work its mischief on their bodies. Part of the problem has been that patients perceive “having to go on insulin” as a personal failure. We even sometimes use it as a threat. This study challenges us to change our attitudes and think about using insulin earlier and more positively. The patients who transferred to insulin achieved better glycemic control, had no hypoglycemic episodes, and reported no decline in quality of life. Note that seven of the patients improved significantly just by being in the study. Could the extra explanations and attention be responsible?—a.d.w.

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