Diabetes mellitus. Control and complications

Long-term complications now account for the bulk of morbidity and mortality attributable to diabetes. Although the linkage is not yet clear, it is quite likeley that metabolic abnormalities are the important determinant. Some evidence suggests that people with diabetes who have good blood glucose control have fewer complications than those with poorly controlled disease, but many other factors may be important as well. Whether deliberate intervention designed to achieve near normoglycemia can alter the initial development of complications or the prognosis of established complications is controversial. The ongoing Diabetes Control and Complications Trial should definitively answer this question. Specific and definitive guidelines for treatment cannot be given at present. Certainly, the basic goal is clinical well-being (elimination of fatigue, polyuria, nocturia, thirst, blurred vision, and undesired weight loss). These clinical goals can usually be achieved by maintaining blood glucose level under 200 to 250 mg/dl. More stringent blood glucose goals should be set only after careful discussion with the patient about the possible benefits of control, the risks of hypoglycemia, and the demands of a particular insulin regimen. Intensive insulin therapy can clearly be demanding, and the positives and negatives of such therapy must be weighed carefully. Whenever severe hypoglycemia is encountered with any treatment regimen, careful consideration should be given to resetting blood glucose goals upward.