Long-term compliance of intensified insulin therapy

Results of the DCCT trial (N. Engl. J. Med. 329, 977-986) demonstrate that therapy in insulin-dependent diabetes mellitus (IDDM) should aim at near-normoglycemia. For reaching this standard, intensified insulin therapy--either intensified conventional therapy (ICT) or continuous subcutaneous insulin infusion (CSII)--is mandatory. These regimes demand much long-term motivation and discipline from the diabetics. With > 95%, long-term compliance of ICT is good, according to the few published data available and our own experience. For CSII, on the other hand, cumulated studies reveal discontinuation rates ranging from 0% to 36%, averaging 20.4% and being significantly correlated with metabolic control before start of CSII in terms of glycosylated hemoglobin levels (r = 0.66; P < 0.05). The major reasons for discontinuation of CSII were skin problems (22.1%), inconvenience of the pump (21.4%) and lack of metabolic improvement (9.6%). A conclusion drawn from these meta-analytical data is that a stepwise approach to CSII is recommended for increasing compliance. A period of ICT long enough to gain experience with blood glucose self-control and self-adjustment of meal-related insulin should precede CSII. Furthermore, a general increase of CSII among IDDM patients is necessary to come closer to the standard of near-normoglycemia for these diabetics. Therefore, diabetes treatment and education resources must be improved, especially concerning psychosocial problem solving and cooperation between diabetologists and general practitioners.