Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Intensive therapy delayed microvascular complications in patients with type 2 diabetes mellitus and microalbuminuria

ACP J Club. 1999 July-Aug;131:1. doi:10.7326/ACPJC-1999-131-1-001


Source Citation

Gaede P, Vedel P, Parving H-H, Pedersen O. Intensified multifactorial intervention in patients with type 2 diabetes mellitus and micro-albuminuria: the Steno type 2 randomized study. Lancet. 1999 Feb 20;353:617-22.


Abstract

Question

Does intensive multifactorial therapy slow the initiation and progression of microvascular disease in patients with type 2 diabetes mellitus and microalbuminuria?

Design

Randomized, unblinded trial with mean follow-up of 3.8 years.

Setting

Diabetes center in Denmark.

Patients

160 patients (mean age 55 y, 74% men) with diabetes and a urinary albumin excretion rate (UAER) between 30 and 300 mg/24 h. Exclusion criteria were age < 40 or > 65 years, stimulated serum C-peptide level < 600 pmol/L, pancreatic insufficiency or pancreatitis, alcohol abuse, nondiabetic kidney disease, cancer, or life-threatening disease. Follow-up was 93%.

Intervention

Patients were allocated to either intensive multifactorial intervention in a specialized diabetes center (n = 80) or standard treatment by a general practitioner (n = 80). The intensive intervention included a low-fat diet and exercise; smoking cessation (if needed); angiotensin-converting enzyme inhibitors; vitamins C and E; aspirin for ischemic cardiovascular disease; and stepwise pharmacologic therapy to reduce glucoselevels, blood pressure, and lipid levels.

Main outcome measures

Nephropathy (UAER > 300 mg/24 h), retinopathy, neuropathy, death, and macrovascular events.

Main results

Compared with patients in the standard group, those in the intensive group had reduced risks for nephropathy (P = 0.01), progression of retinopathy (P = 0.04), blindness in 1 eye (P = 0.03), autonomic neuropathy (P = 0.01), and the combined outcome of death and macrovascular events or signs (P = 0.03) (Table). Groups did not differ for the development of new retinopathy, maculopathy or proliferative retinopathy, or peripheral neuropathy.

Conclusion

Multifactorial therapy reduced development of nephropathy and progression of retinal and neuropathic complications in patients with type 2 diabetes mellitus and microalbuminuria.

Source of funding: No external funding.

For correspondence: Professor Oluf Pedersen, Steno Diabetes Center, Niels Steensens Vej 2, DK 2820 Gentofte, Copenhagen, Denmark. FAX 45-33-91-09-60.


Table. Intensive vs standard treatment in patients with type 2 diabetes mellitus and microalbuminuria at 4 years*

Outcomes Intensive Standard RRR (95% CI) NNT (CI)
Nephropathy 11% 25% 56% (9 to 79) 7 (4 to 59)
Progression of retinopathy 26% 43% 40% (6 to 63) 6 (3 to 49)
Blindness in 1 eye 1% 9% 85% (11 to 98) 3 (6 to 134)
Progression of autonomic neuropathy 11% 29% 62% (23 to 82) 6 (3 to 19)
Combined death and macrovascular events 34% 54% 37% (10 to 57) 5 (3 to 23)

*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article.


Commentary

Metabolic abnormalities, including hyperglycemia, obesity, hypertension, and dyslipidemia, are frequently present inpatients with type 2 diabetes and are risk factors for both microvascular and macrovascular disease. The risk is further increased in patients with microalbuminuria. Clinical trial evidence has shown that reducing plasma glucose levels, blood pressure, or both slows the development or progression of microvascular complications. Individual trials have focused on 1 or, at most, 2 interventions. However, in routine clinical practice, multifactorial interventions are often needed to improve the many possible metabolic derangements.

Gaede and colleagues' study shows the benefits of intensively managing type 2 diabetes. A major strength of the study is its pragmatic design that compares multifactorial interventions (similar to those recommended by the American Diabetes Association) in a diabetes center with routine care by primary care providers. An impressive reduction in the development of microvascular complications was found; a cumulative end point assessing cardiovascular disease morbidity and mortality was also improved. The intensively treated group gained weight during the study.

Delivery of this type of care should become standard practice for patients with type 2 diabetes. However, optimal chronic disease management presents many challenges to health care delivery systems. Several recent reports have examined methods that may facilitate optimal delivery of this type of care. These include a case management approach in a U.S. health maintenance organization (1), shared care between hospital and general practice in the United Kingdom (2), and the use of electronic management tools in the physician's office (3).

Sean F. Dinneen, MD
Mayo ClinicRochester, Minnesota, USA


References

1. Aubert RE, Herman WH, Waters J, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial. Ann Intern Med. 1998;129:605-12.

2. Griffin S. Diabetes care in general practice: meta-analysis of randomised control trials. BMJ. 1998;317:390-6.

3. Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. JAMA. 1998;280:1339-46.