Practical steps to improving the management of type 1 diabetes: recommendations from the Global Partnership for Effective Diabetes Management

Abstract

The Diabetes Control and Complications Trial (DCCT) led to considerable improvements in the management of type 1 diabetes, with the wider adoption of intensive insulin therapy to reduce the risk of complications. However, a large gap between evidence and practice remains, as recently shown by the Pittsburgh Epidemiology of Diabetes Complications (EDC) study, in which 30-year rates of microvascular complications in the 'real world' EDC patients were twice that of DCCT patients who received intensive insulin therapy. This gap may be attributed to the many challenges that patients and practitioners face in the day-to-day management of the disease. These barriers include reaching glycaemic goals, overcoming the reality and fear of hypoglycaemia, and appropriate insulin therapy and dose adjustment. As practitioners, the question remains: how do we help patients with type 1 diabetes manage glycaemia while overcoming barriers? In this article, the Global Partnership for Effective Diabetes Management provides practical recommendations to help improve the care of patients with type 1 diabetes.

Figure 1

DCCT/EDIC: Cumulative incidence of any CVD event with intensive vs. conventional insulin treatment in patients with type 1 diabetes (n= 1397) (8). MI, myocardial infarction. *Intensive vs. conventional treatment. Copyright © 2005 Massachusetts Medical Society. All rights reserved.

Figure 2

EDIC study: (A) Cumulative incidence of retinopathy (n= 1349) and (B) HbA_1c values (n= 1211) over 10 years after the DCCT trial in which patients with type 1 diabetes were treated with intensive vs. conventional insulin therapy (9). (A) Error bars are 95% confidence intervals. (B) Box presents quartiles of distribution; vertical lines show the 95th and 5th percentiles; horizontal line is median; + indicates mean. Copyright © 2008 American Medical Association. All rights reserved.

Figure 3

Cumulative incidences of (A) proliferative retinopathy or worse, (B) nephropathy and (C) CVD over time in the DCCT intensive therapy group, DCCT conventional therapy group and EDC cohort (2). Nephropathy was defined as albumin excretion rate ≥ 300 mg/24 h, serum creatinine ≥ 2 mg/dl, or dialysis or renal transplant. CVD was defined as: non-fatal myocardial infarction or stroke, CVD death, subclinical myocardial infarction, angina, angioplasty or coronary artery bypass. Copyright © 2009 American Medical Association. All rights reserved.

Figure 4

Risk of severe hypoglycaemia vs. HbA_1c in the intensive (•) and conventional (○) groups during the DCCT (n= 1441) (53). Copyright © 1997 American Diabetes Association. Reprinted with permission from The American Diabetes Association.