Original Article
The Effect of Long-Term Intensified Insulin Treatment on the Development of Microvascular Complications of Diabetes Mellitus
N Engl J Med 1993; 329:304-309July 29, 1993
- Abstract
Background
A cause-and-effect relation between blood glucose concentrations and microvascular complications in patients with insulin-dependent diabetes mellitus has not been established.
Methods
We randomly assigned 102 patients with insulin-dependent diabetes mellitus, nonproliferative retinopathy, normal serum creatinine concentrations, and unsatisfactory blood glucose control to intensified insulin treatment (48 patients) or standard insulin treatment (54 patients). We then evaluated them for microvascular complications after 18 months and 3, 5, and 7.5 years.
Results
Mean (±SD) glycosylated hemoglobin values were reduced from 9.5 ±1.3 percent to 7.1 ±0.7 percent in the group receiving intensified treatment and from 9.4 ±1.4 percent to 8.5 ±0.7 percent in the group receiving standard treatment (P = 0.001). In 12 of the patients receiving intensified treatment (27 percent of those included in the analysis) and 27 of those receiving standard treatment (52 percent), serious retinopathy requiring photocoagulation developed (P = 0.01). Visual acuity decreased in 6 patients receiving intensified treatment (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 the group receiving intensified treatment, as compared with nine patients in the group receiving standard treatment (P = 0.01). No patient in the intensified-treatment group had nephropathy with subnormal glomerular filtration rates, as compared with six patients in the standard-treatment group (P = 0.02). The conduction velocities of the ulnar, tibial, peroneal, and sural nerves decreased significantly more in the standard-treatment group than in the intensified-treatment group. The odds ratio for serious retinopathy was 0.4 (95 percent confidence interval, 0.2 to 1.0; P = 0.04) in the intensified-treatment group as compared with the standard-treatment group. The corresponding odds ratio for nephropathy was 0.1 (95 percent confidence interval, 0 to 0.8; P = 0.04).
Conclusions
Long-term intensified insulin treatment, as compared with standard treatment, retards the development of microvascular complications in patients with insulin-dependent diabetes mellitus.
Media in This Article
Figure 1
Mean (±SE) Proportions of Patients in the Intensified-Treatment and Standard-Treatment Groups without Serious Retinopathy, According to Life-Table Analysis.Figure 2
Mean (±SE) Proportions of Patients in the Intensified-Treatment and Standard-Treatment Groups without Nephropathy, According to Life-Table Analysis.Article Activity
- Article
Microvascular complications develop in many patients with insulin-dependent diabetes mellitus, and the effect of intensified insulin treatment on these complications has not been established. Some prospective, randomized studies have indicated that lower blood glucose concentrations retard the progression of nephropathy1-6 and neuropathy,5,7 but not that of retinopathy3,8-11. The Stockholm Diabetes Intervention Study was initiated in 1982 to compare the effects of intensified insulin treatment and standard insulin treatment on these complications. The results of this study after 18 months,12 3 years,13,14 and 5 years15-17 have been published. They show that albuminuria, the deterioration of nerve conduction velocities, and the progression of nonproliferative retinopathy were retarded in the patients who received intensified treatment, whereas the development of serious retinopathy requiring photocoagulation was not. This paper describes the results after almost eight years of follow-up.
Methods
Study Protocol and Patients
The study protocol was approved by the ethics committee of the Karolinska Institute, Stockholm, and all the patients gave informed consent before they entered the study. The patients enrolled had insulin-dependent diabetes mellitus, nonproliferative retinopathy, normal serum creatinine concentrations, and unsatisfactory blood glucose control (high blood glucose concentrations), according to their personal physicians12. Patients with albuminuria were not excluded. One patient in the standard-treatment group was treated with a beta-blocking agent for hypertension before entering the study. Ninety-one percent of the patients who were asked to participate accepted. Initially, 102 patients were randomly assigned to receive either intensified insulin treatment (48 patients) or standard insulin treatment (54 patients). During the study seven patients died (four in the intensified-treatment group and three in the standard-treatment group). Two patients in the intensified-treatment group and four in the standard-treatment group moved away from Stockholm, and their follow-up was only partial. They were therefore excluded from some of the analyses of results after 7.5 years. The base-line characteristics of the patients in the two treatment groups are shown in Table 1Table 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 groups were similar with regard to diastolic blood pressure, post-pubertal duration of diabetes, smoking habits (50 percent were smokers), and reported alcohol consumption. During the study two patients from each treatment group had an episode of diabetic ketoacidosis, and there were eight pregnancies in each group (seven women in the intensified-treatment group and six in the standard-treatment group completed their pregnancies).The treatment regimen of the intensified-treatment group consisted of individual education and then continuous tutoring with frequent face-to-face and telephone contact, initially every second week and then at greater intervals. Education concerned the action of 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 correctable by injection treatment was reinforced. During tutoring the patients tried in daily life to use the knowledge achieved, and then discussed their experiences with the physician-tutor. Most of the patients (82 percent) took at least three insulin injections daily.
The patients in the standard-treatment group continued with routine 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 visits and were then used to improve treatment (to reduce blood glucose concentrations without increasing the frequency of hypoglycemia). During the first 5 years of the study a majority of the patients in the standard-treatment group took two daily insulin injections, but thereafter more of them took at least three injections a day (more than 60 percent after 7.5 years). No effort was made to alter the dietary intake of the patients, including those in whom renal disease developed. All the study patients saw the same physician, and this physician made the evaluations together with a diabetes nurse. The other investigators (the ophthalmologist, clinical neurophysiologist, and others) were unaware of the patients' treatment assignments.
Follow-up Studies
Blood Glucose Control
Glycosylated hemoglobin (normal range, 3.9 to 5.7 percent) was measured at entry, after six months, and then approximately every four months as previously described12,15. Blood glucose was not measured at clinic visits.
Retinopathy
During the first five years of follow-up, retinopathy was evaluated by color fundus photography and funduscopy12,15,16. Thereafter, an annual biomicroscopical examination through dilated pupils was performed by an ophthalmologist. The results of the last examination were used to determine whether serious retinopathy (proliferative retinopathy or clinically important macular edema requiring immediate photocoagulation) had developed. For such an analysis direct examination and fundus photography yield similar results18,19. This examination took place at different times after entry because the patients were enrolled in the study two at a time over a period of 18 months. In the multivariable analyses the initial extent of retinopathy was graded with the use 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 defined as months to the diagnosis of serious retinopathy, withdrawal from the study, or last examination without serious retinopathy. All 102 patients were included. The analysis stretches to 100 months, since follow-up was longer than 90 months in many patients. Visual acuity was assessed by the same ophthalmologist with standard Monoyer-Granstrom charts. A loss of two lines in one eye (e.g., a decrease from 1.0 to 0.8 in visual acuity) was considered to be a change.
Nephropathy
The 24-hour urinary excretion of albumin was measured at base line and after 7.5 years of follow-up as previously described13,15. Depending on the degree of albuminuria, the renal status of each patient was classified in the following way20: urinary albumin excretion of <20 μg per minute was considered to indicate normoalbuminuria, urinary albumin excretion of 20 to 200 μg per minute to indicate microalbuminuria, and urinary albumin excretion of >200 μg per minute to indicate nephropathy. Two patients in the standard-treatment group were excluded from the analyses of albuminuria and renal function because they had proteinuria for reasons unrelated to diabetes; proteinuria of unknown cause developed in one soon after the diagnosis of diabetes at the age of 10 years, and the other had had repeated episodes of pyelonephritis12.
The glomerular filtration rate was determined by measuring the clearance of EDTA labeled with chromium-5121 (normal range, 77 to 127 ml per minute). Blood pressure was measured with a standard sphygmomanometer with the patient in the supine position. Patients with two consecutive blood-pressure values above 140/90 mm Hg were treated, primarily with angiotensin-converting-enzyme (ACE) inhibitors, but sometimes with a loop diuretic and a calcium-channel-blocking drug. The total dietary protein intake was measured at base line and after five years with a 48-hour dietary recall, a modification of the 24-hour recall22.
In a life-table analysis the patients who had nephropathy at base line (two in the intensified-treatment group and three in the standard-treatment group) were excluded. Time to event was defined as the number of months to the diagnosis of nephropathy, the number of months to withdrawal from the study, or follow-up for 90 months without nephropathy.
Neuropathy
Peripheral neuropathy was assessed at base line and after 7.5 years by questioning the patients about symptoms of neuropathy, including paresthesia, dulled sensation, and pain in the legs and feet. Hand and arm symptoms were not assessed because of the possibility that they were caused by median-nerve compression. We also measured the conduction velocities of the ulnar (motor and sensory), tibial, peroneal, and sural nerves23 and sensory thresholds (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 considered to indicate statistical significance. We compared results that were approximately normally distributed using Student's t-test. The difference between means and the 95 percent confidence interval of the difference were calculated when indicated26. Results that were not normally distributed were compared with use of Wilcoxon's sign-rank test (for paired data) or the Mann-Whitney U test (for unpaired data). Contingency tables were analyzed with the chi-square test, and the differences between proportions (with 95 percent confidence intervals) were calculated27. Multivariable analyses were carried out with forward stepwise logistic regression, with the calculation of the odds ratio and its 95 percent confidence interval when the independent variable changed by one unit28 (e.g., by one percentage point for glycosylated hemoglobin). The proportion (±SE) of patients from each treatment group who survived without serious retinopathy or nephropathy was calculated by life-table analysis29.
Results
Blood Glucose Control
At entry, glycosylated hemoglobin was 9.5 ±1.3 percent in the intensified-treatment group and 9.4 ±1.4 percent in the standard-treatment group. During the first 60 months (14 measurements), it was 7.2 ±0.6 percent in the intensified-treatment group and 8.7 ±1.1 percent in the standard-treatment group (P = 0.001). The mean value for the whole study (22 measurements during a period of 6 to 90 months) was 7.1 ±0.7 in the intensified-treatment group and 8.5 ±0.7 in the standard-treatment group (P = 0.001). There were 1.1 episodes of serious hypoglycemia (requiring help from someone else) per patient-year in the intensified-treatment group, and 0.4 such episodes per patient-year in the standard-treatment group.
Retinopathy
The last eye examination took place after a median of 94 months (range, 58 to 109), a period that did not differ between study groups (P = 0.82). The patients who died or moved before year 5 were not included. In the intensified-treatment group serious retinopathy developed in 12 patients (27 percent), as compared with 27 patients (52 percent) in the standard-treatment group. The difference between proportions was 25 percent (95 percent confidence interval, 6 to 44; P = 0.01). Five patients in the standard-treatment group and one in the intensified-treatment group needed vitreous surgery during follow-up. Visual acuity decreased in 6 patients (14 percent) in the intensified-treatment group and in 18 patients (35 percent) in the standard-treatment group (difference between proportions, 21 percent; 95 percent confidence interval, 5 to 37; P = 0.02).
In the multivariable analysis the development of serious retinopathy at any time during follow-up was related to the percentage of glycosylated hemoglobin at base line and during the first 6 to 60 months of follow-up, the extent of retinopathy at base line, and the dose of insulin at base line (Table 2Table 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.), but not to 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 development of visual deterioration at any time during follow-up correlated with the percentage of glycosylated hemoglobin during the first 6 to 60 months, the initial extent of retinopathy, and diastolic blood pressure (Table 2).When the extent of retinopathy at base line and treatment group were entered together into a logistic-regression analysis with serious retinopathy as the dependent variable, the effect of assignment 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 are shown in Figure 1Figure 1
Mean (±SE) Proportions of Patients in the Intensified-Treatment and Standard-Treatment Groups without Serious Retinopathy, According to Life-Table Analysis.. During the period after 90 months, the number of patients with serious retinopathy increased steeply only in the standard-treatment group.Nephropathy
During the 7.5-year period, nephropathy developed in nine patients in the standard-treatment group and in one in the intensified-treatment group (difference between proportions, 16 percent; 95 percent confidence interval, 4 to 27; P = 0.01) (Table 3Table 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 excretion rate 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 μg per minute at base line and 45 ±110 μg per minute after 7.5 years (P = 0.04 for the difference between groups). There was a mean decrease of 11 ±130 μg per minute in 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 evaluations after 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. The presence of nephropathy after 7.5 years was independently related to the mean glycosylated hemoglobin value from month 6 to month 90 (odds ratio, 5.9; 95 percent confidence interval, 1.9 to 16.8; P = 0.001) and the initial extent of retinopathy (odds ratio, 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 initial extent of retinopathy, assignment to the intensified-treatment group was significantly and independently related to the avoidance of 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 the number of patients in the standard-treatment group in whom nephropathy developed, but not in the intensified-treatment group (Figure 2Figure 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 ±19 to 109 ±19 ml per minute in the intensified-treatment group and from 126 ±21 to 110 ±27 ml per minute in the standard-treatment group during the 7.5-year period (P = 0.73). During this follow-up period, nephropathy (with a glomerular filtration rate below the normal range) developed in six of the patients in the standard-treatment group but in none of those in the intensified-treatment group (P = 0.02).
Eleven patients in the intensified-treatment group (10 of whom were treated with ACE inhibitors) and 17 patients in the standard-treatment group (14 treated with ACE inhibitors) were treated for high blood pressure during the study. The groups were similar with regard to blood pressure (at base line and 7.5 years) and dietary protein intake (at base line and 5 years).
Neuropathy
In the intensified-treatment group the number of patients with symptoms of peripheral neuropathy increased from five (12 percent) to six (14 percent) during the 7.5-year follow-up period. The corresponding numbers in the standard-treatment group were 8 (17 percent) and 13 (28 percent) (P = 0.1 for the difference between groups). The conduction velocities of the ulnar nerve and the sensory thresholds are shown in Table 4Table 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., and the nerve conduction velocities in the legs are shown in Figure 3Figure 3
Mean (±SE) Conduction Velocities of the Tibial, Peroneal, and Sural Nerves in the Intensified-Treatment and Standard-Treatment Groups.. During the 7.5-year period the deterioration in nerve conduction velocities was greater in the standard-treatment group (P = 0.003 for the tibial nerve, P = 0.007 for the peroneal nerve, and P = 0.02 for the sural nerve). Neuropathic foot ulcers developed in three patients in the standard-treatment group and in none in the intensified-treatment group.Discussion
The patients who participated in this trial were selected because their physicians thought that they had unsatisfactory blood glucose control. In the group following our program of intensified treatment, without insulin pumps, blood glucose control improved significantly more than in the standard-treatment group. After five years of intensified treatment, nonproliferative retinopathy was retarded15,16. At that time, however, serious retinopathy requiring photocoagulation treatment was equally common in both treatment groups15. Although the progression of nonproliferative retinopathy was related to the glycosylated hemoglobin values during the study, the appearance of serious retinopathy was not15,17. After 94 months, serious retinopathy was more common in the standard-treatment group, and its appearance was related to the glycosylated hemoglobin values during the first 5 years of the study. There thus seems to be a lag between high blood glucose concentrations and the appearance of serious retinopathy. Serious retinopathy also appeared more often in the patients who had more advanced nonproliferative retinopathy at base line. Treatment group, however, was significantly related to outcome when the effect of the initial extent of retinopathy was eliminated in a multivariable analysis.
The ultimate goal in patients with retinopathy is to prevent decreased visual acuity. This was achieved in the intensified-treatment group. Treatment with photocoagulation probably explains some of the difference between the groups. The lower blood glucose concentrations achieved by the patients in the intensified-treatment group clearly reduced the need for such treatment.
Nephropathy developed in nine patients in the standard-treatment group but in only one patient in the intensified-treatment group during the study, and the glomerular filtration rate dropped below the normal range in six patients in the standard-treatment group. After adjustment for retinopathy at base line in the multivariable analysis, we found that the patients in the intensified-treatment group were still at lower risk for nephropathy than those in the standard-treatment group. Blood pressure and dietary protein intake were similar in the two groups and did not change in either, so these factors did not cause the difference in albumin excretion between the groups.
The differences between the groups with regard to nerve conduction velocities were so large that they should have been clinically important, according to Dyck and O'Brien30. Clinical subjective symptoms of neuropathy, however, differed only slightly between groups.
Can the advanced complications leading to long-term disability also be retarded or avoided by intensified insulin treatment? Our study has not continued long enough and does not have the statistical power to answer that question. Neuropathic ulceration and glomerular filtration rates below the normal range occurred only in patients in the standard-treatment group. Among the seven patients who were treated with photocoagulation but who could still be evaluated with fluorescein angiography after five years, the four in the standard-treatment group had increased capillary 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 vitreous surgery, as compared with only one in the intensified-treatment group. All these numbers are small, but they point in the same direction.
Our study shows that lower blood glucose concentrations retard the development of microvascular complications in patients with insulin-dependent diabetes mellitus, even when retinopathy has begun to develop. This confirms our 5-year findings about nephropathy and neuropathy, and the effects were accentuated after 7.5 years of intensified insulin treatment. We now show that visual deterioration and serious retinopathy requiring immediate photocoagulation are also influenced by the lower blood glucose concentrations, and that patients receiving intensified treatment less often have reduced renal function. The development of nephropathy and neuropathy was retarded after a few years of intensified insulin treatment; it took longer to retard the development of serious retinopathy.
The patients in the intensified-treatment group had a mean glycosylated hemoglobin value of slightly more than 7 percent, which is higher than normal. Intensified insulin treatment, with blood glucose concentrations closer to, but still above, the normal range, retards both mild and advanced microvascular complications in patients with insulin-dependent diabetes mellitus and nonproliferative retinopathy.
Supported by grants from the Swedish Division of NOVO-Nordisk, Boehringer-Mannheim Scandinavia, and the Swedish Medical Research Council (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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