[Insulin therapy for non-insulin-dependent diabetes: minimal or intensive]

The indications for continuous insulin therapy during non-insulin-dependent diabetes (NIDD) are numerous. In addition to patients with a contraindication to oral treatment, the greatest cause is "failures resulting from the use of hypoglycaemic agents". According to data in large series published to date, these secondary failures occur at an annual rate ranging from 2 to 10% and are more frequent in subjects whose weight is normal or moderately high. In current medical practice in France, the indications for insulin therapy are considered late, in the presence of severe hyperglycaemia indicative of beta-cell failure. From then on, the problem raised is that of the glycaemic goal to be reached, which has an influence on the therapeutic strategy to be adopted. In addition to the risk of microangiopathy, NIDD patients run a very high risk of macroangiopathy, particularly when insulin therapy is initiated late. In patients whose life expectancy is fairly long (7 to 10 years or more), a body of convergent clinical and epidemiological evidence favours strict glycaemic control, i.e. intensive insulin therapy. The results of the DCCT are apparently applicable to NIDD with respect to microangiopathy, and hyperglycaemia is an independent risk factor for cardiovascular disease in NIDD patients. Strict glycaemic control is often associated with improvement in certain risk factors (lipids, hemorheology). Despite the fact that no large controlled prospective study similar to the DCCT is currently available for NIDD, efficient insulin therapy ensuring good glycaemic balance should be performed in these patients. However, the difficulties inherent to the implementation of intensive insulin therapy during NIDD should not be neglected: hypoglycaemic risk, weight gain, problems in elderly subjects, difficulties in instructing patients, and follow-up. Finally, the return to adequate glycaemic control should be coordinated with an overall care plan for risk factors relative to macroangiopathy.