Can we afford intensive management of diabetes?

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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.

Samir Malhotra
Assistant Professor
P. Pandi
Professor and Head
Department of Pharmacology
Post Graduate Institute of Medical Education and Research
Chandigarh City
India

We thank the authors for pointing out our error in the calculations. With regard to the generalisability of our conclusions, we agree that they are less relevant to the Indian situation, except to the extent that it is essential that the opportunity cost of an intervention that requires more intensive use of general practitioners' time is considered in the decision-making processes.