BeginningArticles Results of research of scientists throw down a challenge to ideas of treatment of a diabetes mellitus
Results of research of scientists throw down a challenge to ideas of treatment of a diabetes mellitus
Results of research of the American scientists - a call to traditional ideas of treatment of a diabetes mellitus
This article is intended for all of us whose activity is connected with a diabetes mellitus problem, that is treatment, financing, medical and social care of patients with a diabetes mellitus in the broadest sense.
The short overview of research (DCCT), the received results and the encouraging perspectives of their practical application is provided in article. DCCT is deciphered as Diabetes Control and Complications Trial (Research on control of diabetes and its complications).
These researches are one of the largest and the most important in the history of studying of a diabetes mellitus, and the received results can change radically traditional views of treatment of this disease.
Results of research open wide perspectives of considerable improvement of health and quality of life of the people suffering from a diabetes mellitus.
These results will also help to look in a new way at a diabetes problem to all interested specialists - from ordinary doctors-endocrinologists to the top officials of the state defining policy in the field of health care.
Shortly about the research DCCT
The research DCCT was conducted from 1982 to 1993 and was devoted to studying of influence of various modes of treatment of a diabetes mellitus on frequency and severity of late complications. 29 various centers of the USA and Canada with the assistance of 600 doctors and other specialists were involved in research. The cost of this research made 168 million US dollars. It is the largest of ever the conducted researches of a diabetes mellitus. But not only its scales were the main distinctive features. Thanks to original structure of research and care with which it was carried out this research became the turning point which opened the new horizons in treatment of an insulin-dependent diabetes mellitus.
To study efficiency of an intensive insulin therapy at a diabetes mellitus.
To find out influence of maintenance of level of glucose of blood in the limits as close as possible to normal level, on decrease in frequency and weight of late complications at an insulin-dependent diabetes mellitus.
To study a possibility of the prevention of development and the subsequent progressing of a retinopathy as most widespread complication at patients with diabetes.
Structure of research
The second group included 715 patients with symptoms of a retinopathy (group of secondary prevention).
The structure of research is provided in table 1.
Clinical wellbeing - lack of symptoms hyper - or a hypoglycemia was the purpose of traditional therapy. Only one or two injections of insulin a day, daily self-checking, training in the principles of a dietotherapy and physiotherapy exercises were for this purpose used. Routine inspection of these patients was performed quarterly.
At an intensive care the same clinical aims were pursued, as at traditional therapy, but also maintenance of a glycemia as close as possible to level which is observed at the healthy person (see table 2).
In 1 hour after food
In 3 hours after food
3,9-6,7 mmol/l (70-120 mg/dl)
10 mmol/l (180 mg/dl)
4,0 mmol/l (65 mg/dl)
The intensive care included at least three injections of insulin a day or use of an insulin pomp (pump), frequent measurement of content of glucose in blood (from four and more times a day), hospitalization to start an insulin therapy, frequent consultations and training in a dietotherapy, monthly clinical examination.
In both groups regular tests for identification of a microalbuminuria, proteinuria, and also symptoms of a retinopathy, neuropathy and a nephropathy were carried out. The age of the patients participating in research, duration of their disease of a diabetes mellitus, and also initial levels of glikozilirovanny hemoglobin were provided with the broadest range (see table 3).
Primary prevention (726 patients)
Secondary prevention (715 patients)
Prescription of diabetes (Wednesdays.)
With symptoms of a retinopathy
Initial stage of NPDR (Not proliferative diabetic retinopathy)
The average duration of supervision over patients made 6,5 years. Initially research was planned on 10 flyings. However, it was complete earlier planned term in connection with receiving statistically reliable results showing superiority of an intensive insulin therapy over standard.
Results of research
At patients without diabetic retinopathy (group of primary prevention) the intensive care at frequent measurement of content of glucose in blood reduced risk of development of this complication at least by 34%, and as much as possible - for 76% depending on ways of detection of initial weight of a diabetes mellitus (see fig. 1).
Figure 1. Frequency of developing of a retinopathy at the patients who did not have it at the beginning of research
Results of research showed that intensive treatment of diabetes reduces the frequency of an initial or proliferative retinopathy and diseases of the organs of sight demanding carrying out laser intervention by 45%. When carrying out intensive treatment in group of primary prevention the frequency of emergence of the first symptoms of a retinopathy decreased by 27%.
The intensive care also made favorable impact on patients, with symptoms of a retinopathy at the beginning of research: at the patients who are on an intensive care, progressing of a retinopathy came to light for 54% less than at the patients receiving traditional therapy (see fig. 2).
Figure 2. Frequency of emergence of retinopatichesky changes at patients with symptoms of a retinopathy at the beginning of research
Advantages of an intensive care were not limited to prevention or decrease in progressing of a retinopathy. As a result of an intensive care the frequency of damage of kidneys which was estimated on microalbuminuria level, in all studied group was reduced by 35%. The intensive care also reduced clinically significant microalbuminuria in group in general by 56%.
Intensive treatment reduces risk of development of clinically significant neuropathy by 60% (in group in general). In group of primary prevention this risk decreased by 70%.
The table given below shows decrease in frequency of development of a nephropathy and neuropathy at an intensive insulin therapy in comparison with traditional at patients of both groups (see table 4).
During intensive treatment levels of glikozilirovanny hemoglobin at patients were much lower, than at usual therapy though only at small percent of patients this level reached the values characteristic of persons without diabetes mellitus.
Research showed a steady tendency to reduction of complications from large vessels in process of decrease in level of sugar of blood. Rather low number of cases of damage of heart was noted that can be connected with rather young age of the studied group of patients (middle age - 27 years).
Decrease in risk
Microproteinuria (release of proteins with urine of 40 mg/days)
Proteinuria (release of proteins with urine more than 300 mg/days)
Research showed decrease at intensive treatment of level of the general cholesterol, but not cholesterol of lipoproteids of high density.
Researchers came to a conclusion that intensive treatment does not cause progressing of complications from large vessels.
Triple increase in frequency of development of a hypoglycemia was the most essential risk connected with intensive treatment. However, only several patients needed correction of this state, and authors of this research consider that advantages of decrease in complications considerably exceed risk of development of a hypoglycemia at an intensive care. And modern control methods of a glycemia by means of portable devices in addition reduce this risk.
Patients at intensive treatment gain weight also quicker, than at usual treatment.
Control of content of glucose in blood
For successful results of an intensive care precision and frequent measurement of content of glucose in blood is extremely important. At least, patients have to carry out blood sugar control before each injection or bolyusny infusion from the wearable doser to define how many insulin units are required to them. Respectively, measurement of content of glucose in blood should be performed before each meal and before going to bed. Also it is recommended to hold testing in two-three hours after food, especially in cases when patients are in a stage of definition of an insulin dose necessary for them. But still it is not enough carrying out the test: patients have to know also how to interpret the received results, and, in case of need, respectively to change the accepted insulin dose.
As the patient needs to see to seven measurements of content of glucose in blood in day, for it it is necessary glyukometr - compact, reliable, easy in use and quickly yielding exact results.
What means the research DCCT for treatment of a diabetes mellitus
Research showed that the intensive insulin therapy allows to reach close to normal the level of compensation of a diabetes mellitus and, as a result, considerably to reduce risk of development and severity of complications.
DCCT and non-insulin-dependent diabetes
The research DCCT did not include studying of patients with diabetes of the II type. However, does not raise doubts that strict control of glucose in blood can be also useful also to these patients for the purpose of decrease in risk of complications which arise at them also often, as well as at patients with diabetes of the I type. At the same time the tableted glucose-lowering drugs, the observance of a diet, regulations of exercise stresses applied with the same purpose as for insulin-dependent patients - maintenance of a glycemia at the level as close as possible to norm can be the fixed therapeutic assets for them.
To most of the people sick with an insulin-dependent diabetes mellitus, the intensive insulin therapy setting as the purpose achievement of the level of a glycemia as close as possible to the level of the healthy person is shown. Conditions of implementation of the principle of an intensive insulin therapy:
Motivation of the patient to active management of a diabetes mellitus
Complex training of the patient
Individual selection of the scheme of an insulin therapy and size of the entered insulin doses
Frequent control of a glycemia (to 7 times a day)
Observance of a diet and the program of exercise stresses according to the scheme of an insulin therapy
Psychological support of the patient
The conducted research confirmed that the intensive insulin therapy really prevents development of complications at diabetes which can lead to such serious consequences as a blindness, damage of kidneys, amputation of extremities, diseases of cardiovascular system, strokes.
As it is emphasized in conclusions of group of the researchers who were carrying out DCCT, this research confers moral responsibility on doctors, nurses, nutritionists and psychologists for that they convinced patients of need to support the content of glucose in blood at the levels as it is possible closer to normal.
Any research did not show so convincingly advantage of an intensive insulin therapy in comparison with other methods of treatment yet. Therefore all specialists participating in the research DCCT and their many colleagues in the different countries who got acquainted with results of this research agreed in opinion on expediency of universal implementation of a method of an intensive insulin therapy in combination with frequent control of level of glucose in blood.