Background A cause-and-effect relation between blood glucoseconcentrations and microvascular complications in patients withinsulin-dependent diabetes mellitus has not been established.
Methods We randomly assigned 102 patients with insulin-dependentdiabetes mellitus, nonproliferative retinopathy, normal serumcreatinine concentrations, and unsatisfactory blood glucosecontrol to intensified insulin treatment (48 patients) or standardinsulin treatment (54 patients). We then evaluated them formicrovascular complications after 18 months and 3, 5, and 7.5years.
Results Mean (±SD) glycosylated hemoglobin values werereduced from 9.5 ±1.3 percent to 7.1 ±0.7 percentin the group receiving intensified treatment and from 9.4 ±1.4percent to 8.5 ±0.7 percent in the group receiving standardtreatment (P = 0.001). In 12 of the patients receiving intensifiedtreatment (27 percent of those included in the analysis) and27 of those receiving standard treatment (52 percent), seriousretinopathy requiring photocoagulation developed (P = 0.01).Visual acuity decreased in 6 patients receiving intensifiedtreatment (14 percent) and in 18 receiving standard treatment(35 percent) (P = 0.02). Nephropathy (urinary albumin excretion,>200 µg per minute) developed in one patient in thegroup receiving intensified treatment, as compared with ninepatients in the group receiving standard treatment (P = 0.01).No patient in the intensified-treatment group had nephropathywith subnormal glomerular filtration rates, as compared withsix patients in the standard-treatment group (P = 0.02). Theconduction velocities of the ulnar, tibial, peroneal, and suralnerves decreased significantly more in the standard-treatmentgroup than in the intensified-treatment group. The odds ratiofor serious retinopathy was 0.4 (95 percent confidence interval,0.2 to 1.0; P = 0.04) in the intensified-treatment group ascompared with the standard-treatment group. The correspondingodds ratio for nephropathy was 0.1 (95 percent confidence interval,0 to 0.8; P = 0.04).
Conclusions Long-term intensified insulin treatment, as comparedwith standard treatment, retards the development of microvascularcomplications in patients with insulin-dependent diabetes mellitus.
Microvascular complications develop in many patients with insulin-dependentdiabetes mellitus, and the effect of intensified insulin treatmenton these complications has not been established. Some prospective,randomized studies have indicated that lower blood glucose concentrationsretard the progression of nephropathy1,2,3,4,5,6 and neuropathy,5,7but not that of retinopathy3,8,9,10,11. The Stockholm DiabetesIntervention Study was initiated in 1982 to compare the effectsof intensified insulin treatment and standard insulin treatmenton these complications. The results of this study after 18 months,123 years,13,14 and 5 years15,16,17 have been published. Theyshow that albuminuria, the deterioration of nerve conductionvelocities, and the progression of nonproliferative retinopathywere retarded in the patients who received intensified treatment,whereas the development of serious retinopathy requiring photocoagulationwas not. This paper describes the results after almost eightyears of follow-up.
Methods
Study Protocol and Patients
The study protocol was approved by the ethics committee of theKarolinska Institute, Stockholm, and all the patients gave informedconsent before they entered the study. The patients enrolledhad insulin-dependent diabetes mellitus, nonproliferative retinopathy,normal serum creatinine concentrations, and unsatisfactory bloodglucose control (high blood glucose concentrations), accordingto their personal physicians12. Patients with albuminuria werenot excluded. One patient in the standard-treatment group wastreated with a beta-blocking agent for hypertension before enteringthe study. Ninety-one percent of the patients who were askedto participate accepted. Initially, 102 patients were randomlyassigned to receive either intensified insulin treatment (48patients) or standard insulin treatment (54 patients). Duringthe study seven patients died (four in the intensified-treatmentgroup and three in the standard-treatment group). Two patientsin the intensified-treatment group and four in the standard-treatmentgroup moved away from Stockholm, and their follow-up was onlypartial. They were therefore excluded from some of the analysesof results after 7.5 years. The base-line characteristics ofthe patients in the two treatment groups are shown in Table 1.The groups were similar with regard to diastolic blood pressure,post-pubertal duration of diabetes, smoking habits (50 percentwere smokers), and reported alcohol consumption. During thestudy two patients from each treatment group had an episodeof diabetic ketoacidosis, and there were eight pregnancies ineach group (seven women in the intensified-treatment group andsix in the standard-treatment group completed their pregnancies).
Table 1. Characteristics of the Patients with IDDM Who Entered the Study and of Those Who Remained in the Study after 5 Years and after 7.5 Years.
The treatment regimen of the intensified-treatment group consistedof individual education and then continuous tutoring with frequentface-to-face and telephone contact, initially every second weekand then at greater intervals. Education concerned the actionof insulin, intermediary metabolism, home glucose monitoring,and how to interpret blood glucose tests to modify treatment.The notion of diabetes as a shortage of insulin correctableby injection treatment was reinforced. During tutoring the patientstried in daily life to use the knowledge achieved, and thendiscussed their experiences with the physician-tutor. Most ofthe patients (82 percent) took at least three insulin injectionsdaily.
The patients in the standard-treatment group continued withroutine diabetes care, visiting the physician every four months.They were advised to measure their blood glucose concentrations,but their test results were discussed only at regular visitsand were then used to improve treatment (to reduce blood glucoseconcentrations without increasing the frequency of hypoglycemia).During the first 5 years of the study a majority of the patientsin the standard-treatment group took two daily insulin injections,but thereafter more of them took at least three injections aday (more than 60 percent after 7.5 years). No effort was madeto alter the dietary intake of the patients, including thosein whom renal disease developed. All the study patients sawthe same physician, and this physician made the evaluationstogether with a diabetes nurse. The other investigators (theophthalmologist, clinical neurophysiologist, and others) wereunaware of the patients' treatment assignments.
Follow-up Studies
Blood Glucose Control
Glycosylated hemoglobin (normal range, 3.9 to 5.7 percent) wasmeasured at entry, after six months, and then approximatelyevery four months as previously described12,15. Blood glucosewas not measured at clinic visits.
Retinopathy
During the first five years of follow-up, retinopathy was evaluatedby color fundus photography and funduscopy12,15,16. Thereafter,an annual biomicroscopical examination through dilated pupilswas performed by an ophthalmologist. The results of the lastexamination were used to determine whether serious retinopathy(proliferative retinopathy or clinically important macular edemarequiring immediate photocoagulation) had developed. For suchan analysis direct examination and fundus photography yieldsimilar results18,19. This examination took place at differenttimes after entry because the patients were enrolled in thestudy two at a time over a period of 18 months. In the multivariableanalyses the initial extent of retinopathy was graded with theuse of fundus photographs on a 12-grade scale (from 0.5 to 6.0)12,16.In the life-table analysis the time to an event was definedas months to the diagnosis of serious retinopathy, withdrawalfrom the study, or last examination without serious retinopathy.All 102 patients were included. The analysis stretches to 100months, since follow-up was longer than 90 months in many patients.Visual acuity was assessed by the same ophthalmologist withstandard Monoyer-Granstrom charts. A loss of two lines in oneeye (e.g., a decrease from 1.0 to 0.8 in visual acuity) wasconsidered to be a change.
Nephropathy
The 24-hour urinary excretion of albumin was measured at baseline and after 7.5 years of follow-up as previously described13,15.Depending on the degree of albuminuria, the renal status ofeach patient was classified in the following way20: urinaryalbumin excretion of <20 µg per minute was consideredto indicate normoalbuminuria, urinary albumin excretion of 20to 200 µg per minute to indicate microalbuminuria, andurinary albumin excretion of >200 µg per minute toindicate nephropathy. Two patients in the standard-treatmentgroup were excluded from the analyses of albuminuria and renalfunction because they had proteinuria for reasons unrelatedto diabetes; proteinuria of unknown cause developed in one soonafter the diagnosis of diabetes at the age of 10 years, andthe other had had repeated episodes of pyelonephritis12.
The glomerular filtration rate was determined by measuring theclearance of EDTA labeled with chromium-5121 (normal range,77 to 127 ml per minute). Blood pressure was measured with astandard sphygmomanometer with the patient in the supine position.Patients with two consecutive blood-pressure values above 140/90mm Hg were treated, primarily with angiotensin-converting-enzyme(ACE) inhibitors, but sometimes with a loop diuretic and a calcium-channel-blockingdrug. The total dietary protein intake was measured at baseline and after five years with a 48-hour dietary recall, a modificationof the 24-hour recall22.
In a life-table analysis the patients who had nephropathy atbase line (two in the intensified-treatment group and threein the standard-treatment group) were excluded. Time to eventwas defined as the number of months to the diagnosis of nephropathy,the number of months to withdrawal from the study, or follow-upfor 90 months without nephropathy.
Neuropathy
Peripheral neuropathy was assessed at base line and after 7.5years by questioning the patients about symptoms of neuropathy,including paresthesia, dulled sensation, and pain in the legsand feet. Hand and arm symptoms were not assessed because ofthe possibility that they were caused by median-nerve compression.We also measured the conduction velocities of the ulnar (motorand sensory), tibial, peroneal, and sural nerves23 and sensorythresholds (vibratory and thermal) on the feet and hands24,25.
Statistical Analysis
The results are given as means ±SD unless otherwise stated.A two-sided probability level of 0.05 or less was consideredto indicate statistical significance. We compared results thatwere approximately normally distributed using Student's t-test.The difference between means and the 95 percent confidence intervalof the difference were calculated when indicated26. Resultsthat were not normally distributed were compared with use ofWilcoxon's sign-rank test (for paired data) or the Mann-WhitneyU test (for unpaired data). Contingency tables were analyzedwith the chi-square test, and the differences between proportions(with 95 percent confidence intervals) were calculated27. Multivariableanalyses were carried out with forward stepwise logistic regression,with the calculation of the odds ratio and its 95 percent confidenceinterval when the independent variable changed by one unit28(e.g., by one percentage point for glycosylated hemoglobin).The proportion (±SE) of patients from each treatmentgroup who survived without serious retinopathy or nephropathywas calculated by life-table analysis29.
Results
Blood Glucose Control
At entry, glycosylated hemoglobin was 9.5 ±1.3 percentin the intensified-treatment group and 9.4 ±1.4 percentin the standard-treatment group. During the first 60 months(14 measurements), it was 7.2 ±0.6 percent in the intensified-treatmentgroup and 8.7 ±1.1 percent in the standard-treatmentgroup (P = 0.001). The mean value for the whole study (22 measurementsduring a period of 6 to 90 months) was 7.1 ±0.7 in theintensified-treatment group and 8.5 ±0.7 in the standard-treatmentgroup (P = 0.001). There were 1.1 episodes of serious hypoglycemia(requiring help from someone else) per patient-year in the intensified-treatmentgroup, and 0.4 such episodes per patient-year in the standard-treatmentgroup.
Retinopathy
The last eye examination took place after a median of 94 months(range, 58 to 109), a period that did not differ between studygroups (P = 0.82). The patients who died or moved before year5 were not included. In the intensified-treatment group seriousretinopathy developed in 12 patients (27 percent), as comparedwith 27 patients (52 percent) in the standard-treatment group.The difference between proportions was 25 percent (95 percentconfidence interval, 6 to 44; P = 0.01). Five patients in thestandard-treatment group and one in the intensified-treatmentgroup needed vitreous surgery during follow-up. Visual acuitydecreased in 6 patients (14 percent) in the intensified-treatmentgroup and in 18 patients (35 percent) in the standard-treatmentgroup (difference between proportions, 21 percent; 95 percentconfidence interval, 5 to 37; P = 0.02).
In the multivariable analysis the development of serious retinopathyat any time during follow-up was related to the percentage ofglycosylated hemoglobin at base line and during the first 6to 60 months of follow-up, the extent of retinopathy at baseline, and the dose of insulin at base line (Table 2), but notto the percentage of glycosylated hemoglobin after 60 months,the duration of diabetes, the initial diastolic blood pressure,albuminuria at base line, or smoking habits. The developmentof visual deterioration at any time during follow-up correlatedwith the percentage of glycosylated hemoglobin during the first6 to 60 months, the initial extent of retinopathy, and diastolicblood pressure (Table 2).
Table 2. Odds Ratios for Various Independent Variables in Relation to the Development of Serious Retinopathy during 94 Months of Follow-up, the Appearance of Serious Retinopathy after 5 Years (New Serious Retinopathy), and the Deterioration of Visual Acuity during 94 Months of Follow-up.
When the extent of retinopathy at base line and treatment groupwere entered together into a logistic-regression analysis withserious retinopathy as the dependent variable, the effect ofassignment to the intensified-treatment group remained significant(odds ratio, 0.4; 95 percent confidence interval, 0.2 to 1.0;P = 0.04).
The results of the life-table analysis of all 102 patients areshown in Figure 1. During the period after 90 months, the numberof patients with serious retinopathy increased steeply onlyin the standard-treatment group.
Figure 1. Mean (±SE) Proportions of Patients in the Intensified-Treatment and Standard-Treatment Groups without Serious Retinopathy, According to Life-Table Analysis.
Nephropathy
During the 7.5-year period, nephropathy developed in nine patientsin the standard-treatment group and in one in the intensified-treatmentgroup (difference between proportions, 16 percent; 95 percentconfidence interval, 4 to 27; P = 0.01) (Table 3).
Table 3. Urinary Albumin Excretion at Base Line and after 7.5 Years in the Intensified-Treatment and Standard-Treatment Groups.
In the standard-treatment group, the urinary albumin excretionrate increased from 63 ±206 µg per minute to 119±219 µg per minute during the 7.5-year period;in the intensified-treatment group it was 56 ±175 µgper minute at base line and 45 ±110 µg per minuteafter 7.5 years (P = 0.04 for the difference between groups).There was a mean decrease of 11 ±130 µg per minutein the intensified-treatment group, and a mean increase of 55±240 µg per minute in the standard-treatment group(P = 0.37). Only the 91 patients who had complete evaluationsafter 7.5 years were included in this analysis.
In the multivariable analysis of risk factors for nephropathy,the patients who initially had nephropathy were excluded. Thepresence of nephropathy after 7.5 years was independently relatedto the mean glycosylated hemoglobin value from month 6 to month90 (odds ratio, 5.9; 95 percent confidence interval, 1.9 to16.8; P = 0.001) and the initial extent of retinopathy (oddsratio, 3.9; 95 percent confidence interval, 1.3 to 11.6; P =0.01). Other factors (urinary albumin excretion at base line,glycosylated hemoglobin value at base line, duration of diabetes,diastolic blood pressure at base line, smoking habits, age,age at diagnosis, and insulin dose) did not influence the outcome.When treatment group was analyzed together with the initialextent of retinopathy, assignment to the intensified-treatmentgroup was significantly and independently related to the avoidanceof nephropathy (odds ratio, 0.1; 95 percent confidence interval,0 to 0.8; P = 0.04).
In the life-table analysis, there was a steady increase in thenumber of patients in the standard-treatment group in whom nephropathydeveloped, but not in the intensified-treatment group (Figure 2).
Figure 2. Mean (±SE) Proportions of Patients in the Intensified-Treatment and Standard-Treatment Groups without Nephropathy, According to Life-Table Analysis.
The mean glomerular filtration rate decreased from 122 ±19to 109 ±19 ml per minute in the intensified-treatmentgroup and from 126 ±21 to 110 ±27 ml per minutein the standard-treatment group during the 7.5-year period (P= 0.73). During this follow-up period, nephropathy (with a glomerularfiltration rate below the normal range) developed in six ofthe patients in the standard-treatment group but in none ofthose in the intensified-treatment group (P = 0.02).
Eleven patients in the intensified-treatment group (10 of whomwere treated with ACE inhibitors) and 17 patients in the standard-treatmentgroup (14 treated with ACE inhibitors) were treated for highblood pressure during the study. The groups were similar withregard to blood pressure (at base line and 7.5 years) and dietaryprotein intake (at base line and 5 years).
Neuropathy
In the intensified-treatment group the number of patients withsymptoms of peripheral neuropathy increased from five (12 percent)to six (14 percent) during the 7.5-year follow-up period. Thecorresponding numbers in the standard-treatment group were 8(17 percent) and 13 (28 percent) (P = 0.1 for the differencebetween groups). The conduction velocities of the ulnar nerveand the sensory thresholds are shown in Table 4, and the nerveconduction velocities in the legs are shown in Figure 3. Duringthe 7.5-year period the deterioration in nerve conduction velocitieswas greater in the standard-treatment group (P = 0.003 for thetibial nerve, P = 0.007 for the peroneal nerve, and P = 0.02for the sural nerve). Neuropathic foot ulcers developed in threepatients in the standard-treatment group and in none in theintensified-treatment group.
Table 4. Conduction Velocities of the Ulnar Nerve, Vibration Thresholds, and Thermal Thresholds in the Intensified-Treatment and Standard-Treatment Groups at Base Line and Deterioration after 7.5 Years.
Figure 3. Mean (±SE) Conduction Velocities of the Tibial, Peroneal, and Sural Nerves in the Intensified-Treatment and Standard-Treatment Groups.
Discussion
The patients who participated in this trial were selected becausetheir physicians thought that they had unsatisfactory bloodglucose control. In the group following our program of intensifiedtreatment, without insulin pumps, blood glucose control improvedsignificantly more than in the standard-treatment group. Afterfive years of intensified treatment, nonproliferative retinopathywas retarded15,16. At that time, however, serious retinopathyrequiring photocoagulation treatment was equally common in bothtreatment groups15. Although the progression of nonproliferativeretinopathy was related to the glycosylated hemoglobin valuesduring the study, the appearance of serious retinopathy wasnot15,17. After 94 months, serious retinopathy was more commonin the standard-treatment group, and its appearance was relatedto the glycosylated hemoglobin values during the first 5 yearsof the study. There thus seems to be a lag between high bloodglucose concentrations and the appearance of serious retinopathy.Serious retinopathy also appeared more often in the patientswho had more advanced nonproliferative retinopathy at base line.Treatment group, however, was significantly related to outcomewhen the effect of the initial extent of retinopathy was eliminatedin a multivariable analysis.
The ultimate goal in patients with retinopathy is to preventdecreased visual acuity. This was achieved in the intensified-treatmentgroup. Treatment with photocoagulation probably explains someof the difference between the groups. The lower blood glucoseconcentrations achieved by the patients in the intensified-treatmentgroup clearly reduced the need for such treatment.
Nephropathy developed in nine patients in the standard-treatmentgroup but in only one patient in the intensified-treatment groupduring the study, and the glomerular filtration rate droppedbelow the normal range in six patients in the standard-treatmentgroup. After adjustment for retinopathy at base line in themultivariable analysis, we found that the patients in the intensified-treatmentgroup were still at lower risk for nephropathy than those inthe standard-treatment group. Blood pressure and dietary proteinintake were similar in the two groups and did not change ineither, so these factors did not cause the difference in albuminexcretion between the groups.
The differences between the groups with regard to nerve conductionvelocities were so large that they should have been clinicallyimportant, according to Dyck and O'Brien30. Clinical subjectivesymptoms of neuropathy, however, differed only slightly betweengroups.
Can the advanced complications leading to long-term disabilityalso be retarded or avoided by intensified insulin treatment?Our study has not continued long enough and does not have thestatistical power to answer that question. Neuropathic ulcerationand glomerular filtration rates below the normal range occurredonly in patients in the standard-treatment group. Among theseven patients who were treated with photocoagulation but whocould still be evaluated with fluorescein angiography afterfive years, the four in the standard-treatment group had increasedcapillary loss (areas with loss of capillaries on the angiogram),but not the three in the intensified-treatment group16. Altogether,five patients in the standard-treatment group needed vitreoussurgery, as compared with only one in the intensified-treatmentgroup. All these numbers are small, but they point in the samedirection.
Our study shows that lower blood glucose concentrations retardthe development of microvascular complications in patients withinsulin-dependent diabetes mellitus, even when retinopathy hasbegun to develop. This confirms our 5-year findings about nephropathyand neuropathy, and the effects were accentuated after 7.5 yearsof intensified insulin treatment. We now show that visual deteriorationand serious retinopathy requiring immediate photocoagulationare also influenced by the lower blood glucose concentrations,and that patients receiving intensified treatment less oftenhave reduced renal function. The development of nephropathyand neuropathy was retarded after a few years of intensifiedinsulin treatment; it took longer to retard the developmentof serious retinopathy.
The patients in the intensified-treatment group had a mean glycosylatedhemoglobin value of slightly more than 7 percent, which is higherthan normal. Intensified insulin treatment, with blood glucoseconcentrations closer to, but still above, the normal range,retards both mild and advanced microvascular complications inpatients with insulin-dependent diabetes mellitus and nonproliferativeretinopathy.
Supported by grants from the Swedish Division of NOVO-Nordisk,Boehringer-Mannheim Scandinavia, and the Swedish Medical ResearchCouncil (06615).
Source Information
From the Departments of Internal Medicine (P.R.) and Clinical Neurophysiology (B.-Y.N.), Sodersjukhuset, and the Stockholm County Council Teaching Center for Diabetes and Karolinska Sjukhuset (U.R.), all in Stockholm, Sweden.
Address reprint requests to Dr. Reichard at the Department of Internal Medicine, Sodersjukhuset, 118 83 Stockholm, Sweden.
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