Rationale:

• The documented methods to achieve tight control include several daily injections or insulin-pump therapy (continuous subcutaneous insulin infusion).

Evidence:

• The Diabetes Control and Complications Trial showed that tight glycemic control can be attained with aggressive management and that it decreased the progression of microvascular complications of diabetes (25).
• A study that examined the effects of intensive therapy and hyperglycemia on the development of hypertension, the Diabetes Control and Complications Trial, and the observational follow-up study, the Epidemiology of Diabetes Intervention and Complications study, found that hyperglycemia is a risk factor for incident hypertension in patients with type 1 diabetes and that intensive glycemic control reduces this risk (92).
• Insulin regimens should be individualized to provide intensive management (93).
• The use of insulin aspart and lispro in combination with long-acting analogs (glargine and detemir) was shown to decrease the risk of nocturnal hypoglycemia (94).

Comments:

• A preliminary report of follow-up in Diabetes Control and Complications Trial participants presented at a meeting of the American Diabetes Association in June 2005 also documents a decrease in macrovascular disease in patients with a history of tight glycemic control of 47%.