What were some of the unexpected findings?

In the first place, it was clearly shown that diet and exercise alone is very ineffective over the long term unless other treatments are added. Only 3% of the entire group were able to hold glucose levels down to the necessary degree using diet alone.

Secondly, it was shown that, with the medication we currently have available, we are able to lower glucose levels adequately but not by using one medication alone. While one medication may work for a few years, most people will need a second medication within five years, and a third medication within ten years. Insulin will have to be given in much higher doses than was used in this large trial, in order to achieve long-term success.

Thirdly, some of the newer medications will have to be used if success is to be achieved. While three classes of drugs were used in this large study, sulfonylurea agents (including glyburide), metformin, and insulin, other agents such as thiazolidinediones will be required in some people. New insulin forms such as Lispro insulin (Humalog) will have a needed role. Currently neither of these is approved for use in the pharmacare program in British Columbia due principally to their cost. We will have to lobby the government to approve such medications to enhance our ability to treat all people to the optimal level.

Fourthly, one of the most impressive findings in this research was that blood pressure control turned out to be even more important than blood glucose control in preventing the complications of type 2 diabetes. Formerly we knew that the goal level of blood pressure control was less than 140/90, but this study showed major reductions in heart attacks, strokes and eye and kidney complications were achieved if the blood pressure was reduced to an average of 144/82. To effect this, once again several medications were required. The unfortunate truth is that prevention of the complications of diabetes will require polypharmacy both in glucose lowering and blood pressure lowering drugs. On the positive side, it was shown that successful outcomes can be achieved if we can encourage the person with diabetes and the entire medical team to persist until goal levels are reached - when this is done, complications will be avoided.

There were many detailed findings in these studies, which cannot be reported here. They are findings that must be transmitted not only to physicians and nurses treating people with diabetes, but more importantly to the people who have the disease. Patients can participate in their own care, understand why it is vital that they understand the importance of achieving these goals, and how to do it.

Dr. Keith Dawson is an active researcher and educator in diabetes and maintains a busy practice treating individuals with diabetes.

References

1. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33) The Lancet, 1998, Vol. 352; pg. 837-853.
2. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34) The Lancet, 1998, Vol. 352; pg. 853-865.