[ Diabetes Type 2 ]

Evaluation of an intensified insulin treatment and teaching programme as routine management of type 1


The prospective, randomized FREEDOM (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes) trial found coronary artery bypass graft surgery (CABG) was associated with better clinical outcomes than percutaneous coronary intervention (PCI) in patients with diabetes and multivessel disease, managed with or without insulin. We examined the risk of severe hypoglycaemia, ketoacidosis, and death in a meta-analysis of randomized controlled trials. To examine the effects of insulin and improved glycemia on insulin sensitivity and intracellular lipids, we performed stepped (1, 2, and 4 mU x min(-1) x kg(-1)) hyperinsulinemic-euglycemic clamps in eight type 2 diabetic and six nondiabetic control subjects at baseline and after 12 and 67 h of insulin-mediated near-normoglycemia (118 +/- 7 mg/dl). Age- and sex-specific heart disease mortality rates and standardised mortality ratios were calculated. Streptozotocin (STZ) treatment of rats is known to induce a specific pancreatic beta cell necrosis, leading to an insulinopenia syndrome [34], similar to the immunologic induced beta cell necrosis in T1D human, except by the extension of the beta cell lack, which is more pronounced in humans. On the negative side, insulin carries a high risk of low blood sugar reactions if too much is used, and many people gain weight when treated with insulin. In bovine-insulin-treated patients blood glucose before the evening insulin injection was higher on BHI than on bovine insulin (11·6 vs 10·0 mmol/l).

We conclude that no increase in beta-cell insulin content could be demonstrated in newly diagnosed diabetic NOD mice after early high-dose insulin treatment, at least not in the presence of high blood glucose values. Incidence rates of ketoacidosis were 0.16 episodes per patient per year during standard treatment, 0.01 during intensified treatment (p less than 0.01) and 0.04 in group C (p less than 0.025). However, there has been little research about this, and there are no guidelines that recommend reducing insulin doses after dialysis. Frequency of severe hypoglycaemia was not significantly different between the three treatment regimens. Thus, under the condition that insulin treatment is based upon a structured and comprehensive training of the patient, intensified insulin injection therapy performed as routine treatment of Type 1 diabetes significantly lowers HbA1 levels without increasing the risk of severe hypoglycaemia.

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