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

Robert R. Henry, MD; and Saul Genuth, MD
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From the Department of Medicine, University of California, San Diego; the Veterans Affairs Medical Center, San Diego, California; the Department of Medicine, Case Western Reserve University, and Mt. Sinai Medical Center, Cleveland, Ohio. Note: This article is one of a series of articles comprising an Annals of Internal Medicine supplement entitled “Risks and Benefits of Intensive Management in Non-Insulin-dependent Diabetes Mellitus: The Fifth Regenstrief Conference.” To view a complete list of the articles included in this supplement, please view its Table of Contents. Acknowledgments: The authors thank Drs. Charles Clark and Ted Ganiats for their constructive comments and advice. Grant Support: By the Medical Research Service, Department of Veterans Affairs, the Veterans Affairs Medical Center, San Diego. California, and by the Saltzman Institute for Clinical Investigation, Mt. Sinai Medical Center, Cleveland, Ohio. Requests for Reprints: Robert R. Henry, MD, Veterans Affairs Medical Center, San Diego (V-111G), 3350 La Jolla Village Drive, San Diego, CA 92161. Current Author Addresses: Dr. Genuth: Chief, Endocrinology, Mt. Sinai Medical Center, One Mt. Sinai Drive, Cleveland, OH 44106-4198.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1996;124(1_Part_2):175-177. doi:10.7326/0003-4819-124-1_Part_2-199601011-00019
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Purpose: To review issues about intensive management of non–insulin-dependent diabetes mellitus (NIDDM) and to formulate recommendations for goals and general approaches to implementation of intensive management.

Method: A panel of clinical scientists and practitioners specializing in diabetes initially used a formal nominal process to identify the points of agreement on major issues. These points were further refined in a general conference discussion.

Conclusions: 1) On the basis of data from intervention trials in IDDM that prove that intensive glycemic control reduces microvascular and neuropathic complications, coupled with epidemiologic and basic scientific data that support the strong likelihood of a similar benefit in NIDDM, the goal of treatment in NIDDM should be near-normal glycemia [glycohemoglobin level no higher than 1.0% above the upper normal limit]; 2) glycemic targets should be adjusted individually according to clinical factors such as increased risk for hypoglycemia, advanced age, or reduced life expectancy from comorbid conditions; 3) some degree of comprehensive and repetitive instruction about diet and exercise and the use of blood glucose self-monitoring for all patients is essential to achieve the chosen targets; 4) intensive management of hyperglycemia should be instituted early and should initially emphasize diet and exercise therapy; staged introduction of oral hypoglycemic agents and finally insulin regimens of increasing complexity are recommended as needed to achieve glycemic targets; 5) comprehensive care must also include aggressive attempts to reduce cardiovascular risk factors [particularly hypertension, smoking, dyslipidemia, and obesity] as well as prevention of nephropathy and neuropathy; 6) the complex interaction among treatment regimens for hyperglycemia, dyslipidemia, obesity, and hypertension ideally requires a team approach, using a physician, diabetes educator, nurse, dietitian, and other health professionals; health insurers should make these resources available to generalists who currently care for most diabetic patients.





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