Aggressive Early Diabetes Care Prevents Later Complications

NEW YORK CITY?The call for aggressive early treatment of diabetes is becoming louder with the spiraling prevalence of the disease and a new understanding that delayed therapy increases the risk of future complications.

At a recent symposium titled, "Speaking about Diabetes," Richard M. Bergenstal, MD, executive director, Inter?national Dia?betes Center, Minnea??polis, Minn, pointed to a November 2005 "upgrade" in the Centers for Disease Control and Prevention estimate of the number of Americans with diabetes to 20.8 million (or about 7% of the US population) from their earlier estimate of 18.8 million. However, more than one third (6.2 million) of those with diabetes remain undiagnosed. Dr Bergenstal noted that failure to treat patients aggressively at the outset may have a carryover effect, recently referred to as "metabolic memory" or "metabolic imprinting."

Dr Bergenstal described this effect to IMWR. "It appears that when you live for 10 years with high blood sugars, you do some irreparable damage, although present control may eventually lead to some turnaround," he said. Suspicion of such an effect was first aroused with the observation in large-scale trials that intensive glucose-lowering therapy reduced later complications.

Previous data suggest that 63% of patients with diabetes do not attain hemoglobin (Hb) A1c levels <7%, and thus, Dr Bergenstal suggests, qualify for insulin therapy. At his center, he added, after trying "2 or 3 oral agents for 3 months each," if the patient's HbA1c is >7%, they recommend insulin. Many other physicians wait 10 years to prescribe insulin, "and that's the problem."

Often, physicians and patients are resistant to starting insulin therapy when it becomes medically warranted. Physicians who dangle the threat of the need for insulin injections to spur compliance with diet, exercise, and oral medications may be sending the wrong message. Their own hesitancy may lie in their knowledge that educating patients about the use of injections "is a lot harder than giving a pill," Dr Bergenstal said.

A patient's fear of injections is another factor. And parents may be lenient with their diabetic children, unaware that ?complications go hand in hand with blood glucose levels in the early years of the disease.