Can we afford intensive management of diabetes?
The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by their responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.
Letter to the editor
Editor, – The article 'Can we afford intensive management of diabetes?' (Aust Prescr 2002;25:102-3) presents an altogether different view of the management of diabetes. In developing countries the practicality of intensive control may be limited. The prevalence of type 2 diabetes mellitus is more than 11% in the urban population of India and is increasing.1In this context the interpretation of data from the United Kingdom Prospective Diabetes Study (UKPDS)2assumes great importance.
The authors correctly pointed out that six patients need to be treated intensively for blood pressure over 10 years to prevent one patient developing any complication.3However, the number needed to treat (NNT) to prevent one case of microvascular disease is not 196 patients treated for 10 years. From our calculations the NNT to prevent one microvascular complication is 42. The NNT is the reciprocal of absolute risk reduction, and the absolute risk reduction is the difference in the event rates between the control group (PC) and the treatment group (PT). In the UKPDS, the corresponding values for microvascular complications were 225 out of 2729 patients in the intensive treatment group (PT = 225/2729 = 0.082) and 121 out of 1138 in the conventional treatment group (PC = 121/1138 = 0.106). Absolute risk reduction (PC - PT) is therefore 0.024. This gives an NNT of 42 (1/0.024).
We agree that controlling blood pressure is more important for the prevention of complications, but the relative merits of intensive control of diabetes are greater than the article would make us believe. We also agree with the author that the UK results may not be generalisable to other countries, especially developing countries. The increased pressure on resources caused by an intensive approach would mean stretching the healthcare system to the limit and diverting resources away from other illnesses like infections and malnutrition that still remain number one killers in poor countries.
Professor and Head
Department of Pharmacology
Post Graduate Institute of Medical Education and Research
- Ramchandran A, Snehalatha C, Latha E, Vijay V, Viswanathan N. Rising prevalence of NIDDM in an urban population in India. Diabetologia 1997;40:232-7.
- Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study. Lancet 1998;352:837-53.
- Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. Br Med J 1998;317:703-13.