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What Prevents the Risk of Diabetes Complications? Intensive Therapy and the Means to Sustain It.


28 July 2009

What Prevents the Risk of Diabetes Complications? Intensive Therapy and the Means to Sustain It.

I must admit I am perplexed by the new study findings from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Research Group which comes on the heels of the DCCT Study. I am perplexed for two reasons.

This study set out to understand the LONG-TERM effects of intensive therapy for Type1 DM over a 30 year period versus the older DCCT study which looked at intensive therapy (maintaining a HbA1C not >6 or as close as possible) for ten years 1983-1993. The new study concluded that frequencies of serious complications in patients with T1DM, especially when treated intensively, are lower than that reported historically.

Firstly, I find it puzzling that EVEN with meticulous care, people who have Type 1 diabetes for 30+ years will suffer from complications; 22% of patients have proliferative retinopathy* (roughly 1600 patients in the study, gives a number of about 350.)

Here is what the Archives of Internal Medicine reported yesterday:

This study describes the current-day outcomes that patients with type 1 diabetes can expect with conventional therapy and intensive therapy.After 30 years of diabetes, 22%, 9%, and 9% of intensively treated patients developed proliferative retinopathy, advanced nephropathy, and cardiovascular disease, respectively. Fewer than 1% lost vision (<20/200), required a kidney transplant or dialysis, or had an amputation because of their diabetes. The remarkable improvement in long-term outcomes should inform clinicians and patients alike to implement intensive diabetes therapy as early in the course of diabetes as possible.

I would expect the outcomes to be a little bit better. This perplexes me. (I am a type 1 in my 34th year without complications; I manage by intensive pump therapy but for 20 years I was managing with 1 or 2 shots a day in the 1970s and 80s).

But I get the essential public service message. There is a lot of work to be done to help patients AND doctors (endocrinologists specifically) understand the importance of intensive therapy. What is intensive therapy? It is either pump therapy or multiple injection therapy with analog insulins and testing blood sugars at wake-up, bedtime and before each meal, scheduling doctor's visits at minimum 3-4 times a year, and having an HBA1c test coinciding with visits. There is a lot of mindful work involved, a lot of supplies, a lot of visits to doctors (including an opthalmologist) and most importantly, a lot of money to cover the therapy. This last item concerns me. Does every child or adult with T1DM have insurance coverage or cash/credit to cover the expenses? Probably not. But the study tells us to implement intensive therapy as early as possible for any chance of success.

What really perplexes me is that a great deal of money (even if one has good medical coverage) is required to sustain the recommended intensive care. I find that the study outcome is not surprising. It is perfectly clear that intensive therapy is the best route if you have T1DM and would like to live a long life with the lowest risk of diabetic complications possible. That was made very clear by the first DCCT. Since then analog insulins have been introduced, pump therapy has become mainstream and blood glucose monitors and other technical gadgets (CGMS) are superior and have become more and more sophisticated. So much so, that I am always reluctant to buy the latest diabetes gadget thinking I should wait until something better comes along ... just how I feel when I buy a computer or a mobile phone.

And just like updating my digital home office or child tech goods/games, it all costs a great deal. Here is what it would cost anyone newly diagnosed at entry point and for 3 month supplies to manage intensive PUMP therapy or multiple insulin injection therapy (in cash).

Pump $6000 (one time cost) under warrenty for 4 years
GGMS 650 (one time cost) lasts for one year

Blood Glucose Monitor 100 (good for 2 years)

Sensors for CGMS $1050 for 10 (350x 3 for 3 month supply)
Insulin (rapid) 400
Infusion sets for pumps $400
reservoirs 150

glucose test strips 450
Lancets 20
alcohol pads 15
batteries 20

Syringes (4-5 times per day) 280 $150
Long acting insulin 300

PUMP Therapy
One time costs (1 - 4 year(s)) $6750
3 monthly supply $2505 (minimally)

Multiple Injections
One time cost (BG monitor) 100
3 monthly supply $1400 (minimally)

Doctors and patient organizations rant and rave about the importance of intensive care but at what a cost! I think we have all acknowledged the 10-30 year studies. Now all we have to do is work together to ensure that intensive therapy is available to all - not just to the lucky who either have medical coverage or the means to sustain it.

The US News and World Report article on the study's findings ends with Barbara Araneo, director of diabetic complications for the Juvenile Diabetes Research Foundation:

'The bottom line, she said, "is that there's always something you can do about diabetes. It's not hopeless.'

I veer away from double negatives to reach an affirmation. There is always hope (for everyone) sounds much better to me.

*What are the stages of diabetic retinopathy?
Diabetic retinopathy has four stages:

1.Mild Nonproliferative Retinopathy. At this earliest stage, microaneurysms occur. They are small areas of balloon-like swelling in the retina's tiny blood vessels.
2.Moderate Nonproliferative Retinopathy. As the disease progresses, some blood vessels that nourish the retina are blocked.
3.Severe Nonproliferative Retinopathy. Many more blood vessels are blocked, depriving several areas of the retina with their blood supply. These areas of the retina send signals to the body to grow new blood vessels for nourishment.
4.Proliferative Retinopathy. At this advanced stage, the signals sent by the retina for nourishment trigger the growth of new blood vessels. This condition is called proliferative retinopathy. These new blood vessels are abnormal and fragile. They grow along the retina and along the surface of the clear, vitreous gel that fills the inside of the eye. By themselves, these blood vessels do not cause symptoms or vision loss. However, they have thin, fragile walls. If they leak blood, severe vision loss and even blindness can result.


Blogger Lyrehca said...

Great questions about the economic costs of intensive management of type 1.

8:13 PM  
Blogger Bethanne said...

I like your positive outlook better, too. The costs boggle my mind. I just got my CGMS, and I'm blessed to have insurance. The studies are good, though because they are continuing to prove that technology is and will continue to better our lives. Without the studies, no one would approve the CGMS or the pump. I hope they keep doing them.

like you, i'm surprised, too. i'm going on 21 years with no complications. :)

2:58 AM  

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