Intended for healthcare professionals

Clinical Review

Prevention and early detection of vascular complications of diabetes

BMJ 2006; 333 doi: (Published 31 August 2006) Cite this as: BMJ 2006;333:475

Diabetic complications: we must continue to improve or costs will escalate dramatically

As editor of a diabetic retinopathy website with patients regulary
sending letters, I would agree with Marshall and Flyvberg’s comments. (1).
Care is rapidly improving across the UK. However,

(a) about 25% of patients with retinopathy still present with severe
retinopathy at time of diagnosis of diabetes…they have not been screened
for diabetes, despite having it for 5-10 years

(b) 25% present with severe retinopathy have not been screened for
retinopathy (with known diabetes), often because patients themselves have
declined screening despite have been recommended it by medical

(c) there is evidence that basal bolus insulin regimes reduce
retinopathy progression versus bd regimes, even in type 2 patients, yet bd
insulin regimes remain popular ((2): a 0.2%HbA1c retinopathy improvement
with basal bolus regimes, equivalent to a 6% difference in retinopathy
progression: older studies show up to a 300% difference.)

(d) If diabetic control improves from a poor level, with retinopathy
present, and a significantly lower HbA1c is reached, the retinopathy may
progress rapidly. Good control will help in the long term, but not the
short term, and this issue has played a role in many people with severe

Thus, in addition to Marshall and Flyvberg’s suggestions, screening
for diabetes itself must improve if retinopathy is to be prevented (World
Health Organisation, ~1994); and people must make the lifestyle changes to
avoid type 2 diabetes (and even members of the medical profession still
take very little exercise…only 1/100 cycle to work in Birmingham)(3).

There are new and very effective drugs about to be launched to treat
diabetic retinopathy. Results of treatment will improve tremendously, but
their cost might literally bankrupt the NHS unless we have fewer patients
to treat (~£3-6000/course) (4).

SM Marshall and A Flyvbjerg
Prevention and early detection of vascular complications of diabetes
BMJ.2006; 333: 475-480

Liebl A et al. "Biphasic Insulin Aspart 30, Insulin Detemir and Insulin
Aspart Allow Patients with Type 2 Diabetes To Reach A1C Target: The PREFER
Study" Presented June 11, 2006 American Diabetes Association Scientific

One in three Americans has diabetes or its precursor Microvascular
Complications Today, Vol 3, (4), p6, 2006

Pegaptanib can reduce proliferative diabetic retinopathy progression
C G Koury, Diabetic Microvascular Complications Today, Vol 3, (4), p38-9,

Competing interests:
editor of website

Competing interests: No competing interests

02 September 2006
D J Kinshuck
Associate Specialist, Ophthalmology,
Good Hope Hospital, B75 7RR