Q J Med 2000; 93: 369-374
© 2000 Association of Physicians
Commentary |
Poor glycaemic control in type 2 diabetes: a conspiracy of disease, suboptimal therapy and attitude
From the Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Infirmary, Oxford, UK
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Introduction |
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Glycaemia in type 2 diabetes is difficult to manage long-term, and despite a wealth of epidemiological evidence, there continued to be doubts, until recently, as to whether intensive glucose control was beneficial. The publication of robust prospective evidence from the United Kingdom Prospective Diabetes Study1 in September 1998 marked a seminal change.
In type 2 diabetes, there was extensive epidemiological data suggesting that complications were linked to glycaemic exposure,2 but the UGDP (University Group Diabetes Program)3 trial had raised doubts about the safety of sulphonylureas in reducing plasma glucose. The DCCT4 showed in 1993 that tight glycaemic control reduced microvascular complications in type 1 diabetes. The UKPDS provided evidence that tight control was beneficial in type 2 diabetes: patients in an intensively treated group achieved a median HbA1c of 7.0% at 10 years compared to 7.9% in those in a conventionally treated group. This improvement in glycaemic control was associated
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Progressive decline of ß-cell function |
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Attempting to avoid polypharmacy or insulin treatment |
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Avoiding hypoglycaemia |
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Concern over the possibility of increased macrovascular risk |
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Concern over the risk of atherogenicity due to high doses of insulin
Concern over adverse cardiovascular effects from sulphonylureas
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Imprecise guidelines |
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Weight gain |
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Limitations of current technology |
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The elderly |
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Unintentional non-compliance
Physical factors/impediments
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Resources |
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Conclusion |
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Notes |
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References |
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