Strategies for maintaining good glycaemic control without recurrent hypogl

Patients with insulin-dependent diabetes face a major challenge in attempting to maintain normal blood glucose concentrations by effectively balancing their insulin dose, food intake and physical activity. An inadequate amount of insulin relative to food and activity, will lead to elevated blood glucose concentrations and increase the chances of developing the long-term complications of diabetes, whilst an excess of insulin will increase the chances of blood glucose falling to undesirably low levels. The Diabetes Control and Complications Trial (DCCT; The Diabetes Control and Complications Trial Research Group, 1993) showed quite clearly that improving glucose control by intensive insulin therapy reduced the development of diabetic complications such as retinopathy, but that this was at the expense of an increased incidence of severe hypoglycaemia (an occurrence which required the assistance of another person). In other studies, it has become clear that one of the major barriers to patients improving their blood glucose control is the fear of becoming hypoglycaemic (Ramming et al. 1991), and this situation needs to be remedied if a major impact is to be made on the long-term complications of diabetes. The purpose of the present review is to consider the mechanisms by which improved glucose control increases the incidence of hypoglycaemia in patients with insulin-dependent diabetes, and what strategies have been used successfully to prevent this from occurring.