Variabilidade do controle glicêmico de pacientes com diabetes tipo 1 e tipo 2 durante um ano de acompanhamento

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Abstract

Para verificar a variabilidade do controle glicêmico em um estudo não controlado de diabéticos durante um ano de acompanhamento, nós avaliamos retrospectivamente 113 pacientes diabéticos. Com os valores das HBA1c (hemoglobina glicada) dosadas em 1998 calculamos um índice de controle que foi associado à idade, duração do diabetes, IMC e dose de insulina. A HBA1c foi maior em pacientes DM1 do que DM2, respectivamente [7,9 (4,4-13,3) vs. 7,0 (4,4-13,4)%; p= 0,007]. Nos 90 pacientes com no mínimo duas HBA1c, 68 (75,6%) mantiveram o controle: 51 (76,1%) em bom, 8 (11,1%) em regular e 9 (11,9%) em péssimo controle. Nenhum manteve todas as HBA1c na faixa da normalidade, sendo que 26 pacientes (28,9%) tiveram pelo menos uma HBA1c normal. No grupo geral, 44 pacientes (48,9%) apresentaram aumento da HBA1c, 41 (45,6%) diminuição e 5 pacientes (5,6%) mantiveram o mesmo valor, sem diferença entre DM1 e DM2 (p= 0,77). Observamos diferença na HBA1c e tempo de duração de diabetes entre os pacientes com DM2 que tratavam com dieta, hipoglicemiante oral, terapia combinada e monoterapia com insulina, respectivamente (5,4±0,5 vs. 6,3±1,3 vs. 7,6±1,4 vs. 8,4±2,0%; p= 0,001) e (8,5±9,9 vs. 5,3±4,2 vs. 14,1±9,6 vs. 16,9±8,1 anos; p= 0,003). O coeficiente de variação intraindividual da HBA1c foi de 11,6±7,4% (p= 0,0000), sendo de 12,8±7,6% (p= 0,0000) em DM1 e 10,4±7,2% em DM2 (p= 0,0000) sem diferença entre ambos. Concluímos que em nossa amostra a maioria dos pacientes manteve um bom controle apesar da variabilidade intraindividual e da dificuldade em normalizar os níveis de HBA1c.

Translated abstract

To evaluate the variability of glicemic control in diabetic patients followed during one year, we conducted a retrospective study in which the record data of 113 diabetic patients were analyzed. The value of HBA1c (glycated hemoglobin) measured during a year were registered and an index of glicemic control was calculated. This index was associated with duration of diabetes, BMI and dose of insulin. HBA1c were higher in type 1 diabetes than type 2, respectively, [7.9 (4.4-13.3) vs. 7.0 (4.4-13.4)%; p= 0.007]. In 90 patients with at least two HBA1c measurements, 68 (75.6%) had no change in glicemic control: 51 (76.1%) had good, 8 (11.1%) regular and 9 (11.9%) poor control. None of them sustained all the HBA1c in the normal range: 26 (28.9%) had at least one normal HBA1c value. In general group, 44 patients (48.9%) showed increase, 41 (45.6%) decreased and 5 (5.6%) remained with the same level of HBA1c, without difference between DM1 and DM2 (p= 0,77). A difference in HBA1c and diabetes duration among patients with DM2 treated with diet, oral hipoglycemic agents, combined therapy and monotherapy with insulin, was noted respectively (5.4±0.5 vs. 6.3±1.3 vs. 7.6±1.4 vs. 8.4±2.0%; p= 0.001) and (8.5±9.9 vs. 5.3±4.2 vs. 14.1±9.6 vs. 16.9±8.1 years; p= 0,003). The intraindividual coefficient of variation of HBA1c was 11.6±7.4% (p= 0.0000) being 12.8±7.6 (p= 0.0000) in type 1 and 10.4±7.2% in type 2 (p= 0.0000) without difference between both groups. In conclusion: the majority of the patients in our study maintained a good control despite the intraindividual variability of HBA1c and the difficulty to keeping it in the normal range.

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The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus

S Genuth, C. Siebert, D. M. Nathan … (1993)

Long-term microvascular and neurologic complications cause major morbidity and mortality in patients with insulin-dependent diabetes mellitus (IDDM). We examined whether intensive treatment with the goal of maintaining blood glucose concentrations close to the normal range could decrease the frequency and severity of these complications. A total of 1441 patients with IDDM--726 with no retinopathy at base line (the primary-prevention cohort) and 715 with mild retinopathy (the secondary-intervention cohort) were randomly assigned to intensive therapy administered either with an external insulin pump or by three or more daily insulin injections and guided by frequent blood glucose monitoring or to conventional therapy with one or two daily insulin injections. The patients were followed for a mean of 6.5 years, and the appearance and progression of retinopathy and other complications were assessed regularly. In the primary-prevention cohort, intensive therapy reduced the adjusted mean risk for the development of retinopathy by 76 percent (95 percent confidence interval, 62 to 85 percent), as compared with conventional therapy. In the secondary-intervention cohort, intensive therapy slowed the progression of retinopathy by 54 percent (95 percent confidence interval, 39 to 66 percent) and reduced the development of proliferative or severe nonproliferative retinopathy by 47 percent (95 percent confidence interval, 14 to 67 percent). In the two cohorts combined, intensive therapy reduced the occurrence of microalbuminuria (urinary albumin excretion of > or = 40 mg per 24 hours) by 39 percent (95 percent confidence interval, 21 to 52 percent), that of albuminuria (urinary albumin excretion of > or = 300 mg per 24 hours) by 54 percent (95 percent confidence interval 19 to 74 percent), and that of clinical neuropathy by 60 percent (95 percent confidence interval, 38 to 74 percent). The chief adverse event associated with intensive therapy was a two-to-threefold increase in severe hypoglycemia. Intensive therapy effectively delays the onset and slows the progression of diabetic retinopathy, nephropathy, and neuropathy in patients with IDDM.