|Year : 2019 | Volume
| Issue : 3 | Page : 134-139
Middle East and North Africa region guidelines for the management of type 2 diabetes
A Samad Shera1, Abdul Basit2, Asher Fawwad3
1 Diabetic Association of Pakistan and WHO Collaborating Centre, Baqai Medical University, Karachi, Pakistan
2 Department of Medicine, Baqai Medical University, Karachi, Pakistan
3 Research, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, Pakistan; Department of Biochemistry, Baqai Medical University, Karachi, Pakistan
|Date of Web Publication||27-Aug-2019|
Prof. Abdul Basit
Department of Medicine, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi.
Source of Support: None, Conflict of Interest: None
The International Diabetes Federation is divided into seven regions, Africa (AFR), Europe (EUR), Middle East and North Africa (MENA), North America and Caribbean (NAC), South and Central America (SACA), South East Asia (SEA) and Western Pacific (WP), with the aim of enhancing the work of national diabetes associations and strengthening the collaboration between them. In the MENA region, adult population (aged 20–79 years) was estimated 387 million in 2015 from which 35.4 million were suffering from diabetes and is expected to increase up to 72.1 million in 2040. Of the 35.4 million people affected by diabetes, nearly 40.6% were estimated to be undiagnosed. Therefore, at considerable risk of diabetes complications and poor health outcomes. The importance of glycemic control in preventing and delaying the progression of diabetes complications is well well-known. Diabetes poses extreme financial load to diabetic subjects. Local guidelines help to upgrade management strategies. It provides ideas for health care providers to improve quality of life of patient. Guidelines were prepared reviewing the literature, reviewing the available guidelines, consultative meetings between the experts and country representatives from the region.
Keywords: Complications of diabetes, non-pharmacological management, pharmacological management, referral criteria
|How to cite this article:|
Shera A S, Basit A, Fawwad A. Middle East and North Africa region guidelines for the management of type 2 diabetes. J Diabetol 2019;10:134-9
| Introduction|| |
The International Diabetes Federation (IDF) is a federation of over 230 national diabetes associations in 170 countries and territories. The IDF is divided into seven regions, with the aim of enhancing the work of national diabetes associations and strengthening the collaboration between them. IDF’s national diabetes associations are divided into the following regions: Africa, Europe, Middle East and North Africa (MENA), North America and Caribbean, South and Central America, South East Asia and Western Pacific.
In IDF, there are 24 diabetic organisations are register of 19 countries., In the MENA region, adult population (aged 20–79 years) was estimated 387 million in 2015 from which 35.4 million were suffering from diabetes and is expected to increase up to 72.1 million in 2040. Of the 35.4 million people affected by diabetes, nearly 40.6% were estimated to be undiagnosed and therefore at a considerable risk of diabetes complications and poor health outcomes. The importance of glycaemic control in preventing and delaying the progression of diabetes complications is well well-known. Diabetes poses extreme financial load to diabetic patients. Local guideline helps to upgrade management strategies. It provides ideas for health-care providers to improve the quality of life of the patient. For developing the regional guideline, regional authorities to discuss with the responsible person (care leavers) this co-work to produce a meaningful guideline that reflects the need of care leavers. The effectiveness of guideline is proper which defines quality differently among doctors, payers and managers.
| Referral Criteria for Different Levels of Care|| |
For referral criteria, primary, secondary and tertiary care plays an important role in the management of diabetes. The primary physician is the first level of contact for individuals, families and communities, in the health-care system. Primary health-care facility for diabetic patients is mostly provided by certified diabetes doctors and educators. The secondary care is based on multidisciplinary team supervised by a physician having post-graduate qualification or specialised training in diabetes care. The team includes qualified and trained diabetes educators and diabetic foot care assistants. Tertiary care level is a university-based teaching hospital consisting of an outpatient and inpatient integrated care also with research and education programmes. Routine integrated care involves the patient, physician with special interest in diabetes, clinical nurse specialist or educators trained in diabetes, dieticians, diabetic foot care assistants and/or podiatrists. In all levels of care, proper record maintenance for all treated diabetic patients is advisable [Table 1],[Table 2],[Table 3],[Table 4]., , ,
| Non-Pharmacological Management of Diabetes|| |
Lifestyle modifications (LSM) are an important and foremost pillar of management of diabetes. Unbalanced eating habits and unsatisfactory physical activity are main contributors to the development of diabetes., Intake of balanced and safe food, number of meals and proper calculation of energy/caloric requirement plays a vital role in maintaining normoglycaemia. Physical activity like 30min walk 5 days a week can result in adequate benefits in metabolic control, energy expenditure, better work capabilities, feeling of wellbeing and improvement in cardiovascular risk., Education of people with diabetes about the management of hypoglycaemia and hyperglycaemia as well as self-monitoring of blood glucose, knowing about the signs and symptoms of foot problems and awareness of sick day rules prevents the patients from acute emergencies.
| Pharmacological Management of Diabetes|| |
LSM and pharmacological management are most important initial steps in the management of Type 2 diabetes [Figure 1].
|Figure 1: Middle East and North Africa guideline for the management of type 2 diabetes. DPP IV: Dipeptidyl peptidase IV, GLP 1: Glucagon-like peptide 1, NPH: Neutral protamine Hagedorn, TZD: Thiazolidinedione, SGL2: Sodium–glucose cotransporter 2 inhibitors|
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| Sensitisers|| |
Along with LSM metformin is considered as a first-line drug, irrespective of their baseline body mass index (BMI).,,,,,, If metformin is unbearable or contraindicated, DPP4 Inhibitors, sulphonylureas (SUs) or insulin can be used alternatively. Mostly metformin is well tolerated, but common adverse effects are nausea, anorexia, diarrhoea and metallic taste which can be reduced if it is taken with meals. If metformin is contraindicated or unable to achieve normoglycaemia, then a combination therapy is preferred or second-line drugs are prescribed.
SUs decreases plasma glucose levels by enhancing insulin secretion, with an average A1c reduction of 1.5%. The major side effect is hypoglycaemia.
These insulin sensitisers are peroxisome proliferators-activated receptor gamma agonist.
The major side effects include oedema, weight gain, the risk of congestive heart failure and increased risk of fractures. This significantly limits their clinical use.
| Secretagogues|| |
Dipeptidyl peptidase IV inhibitors
Dipeptidyl peptidase IV inhibitors (DPP-4 inhibitors) lower HbA1c by approximately 0.6%–1.0% and are weight neutral. DPP-4 inhibitors have proven efficacy when combined with metformin, sulphonylurea or both metformin and sulphonylurea. They carry low risk of hypoglycaemia.
Glucagon-like peptide 1 agonists
The incretin hormone glucagon-like peptide 1 is known for the “incretin effect.” They facilitate insulin release in the state of hyperglycaemia. They also suppress pancreatic glucagon output, retard gastric emptying and diminish appetite. This usually results in weight reduction.
It is relatively short-acting stimulators of insulin secretion (<6h). The main risk is hypoglycaemia and weight gain.
| Nutrient Load Reducers|| |
Alpha glucosidase inhibitor
The digestion of carbohydrates including starch and table sugar is prevented by alpha-glucosidase inhibitor thus controls post-prandial hyperglycaemia. It can reduce HbA1c by 0.2% Its major side effects are bloating and flatulence.
Sodium–glucose cotransporter 2 inhibitors
These agents reduce HbA1c by 0.5%–1.0%. Their mechanism of action involves inhibiting the sodium-glucose co-transporter inhibitors 2 (SGLT2) in the proximal nephron, thereby reducing glucose reabsorption and increasing urinary glucose excretion by up to 80g/day. Because this action is independent of insulin, SGLT2 inhibitors may be used at any stage of Type 2 diabetes, even after insulin secretion has waned significantly. Additional potential advantages include modest weight loss (~2kg, stabilizing over 6–12 months) and consistent lowering of systolic and diastolic blood pressure in the order of ~2–4/~1–2 mmHg. The common side effect of SGLT2 inhibitor is genital infection, and its incidence raised four-fold in clinical trials.
It can be categorised according to either duration of action ranging from rapid-acting insulin to short-acting, intermediate acting, long-acting and very long-acting insulin or their source as human or analogue insulin. Different types of insulin and their duration of action are discussed in [Table 5].
| Diabetes in Elderly|| |
Prevalence of diabetes in older adults has almost doubled in the past 15 years. It is a diverse group which includes active individuals with few complications and co-morbidities on the other hand frail individuals with many co-morbidities and disabling complications. Management of diabetes should be done cautiously with pharmacotherapy and insulin under the supervision of caregivers.
| Acute Emergencies in Type 2 Diabetes|| |
Hypoglycaemia and hyperosmolar hyperglycaemic state (HHS) are two common acute emergencies occurring among Type 2 diabetic patients. From which, hypoglycaemia is a common and serious medical condition which usually occurs during the treatment of diabetes. Depending on its clinical presentation it is divided into mild-moderate and severe. Patients at risk of hypoglycaemia should have proper education on recognition, prevention and management of hypoglycaemia. Therefore, patients having a history of hypoglycaemia should carry a snack or meal with adequate carbohydrate and proteins. HHS is associated with significant morbidity and higher mortality than diabetic ketoacidosis and must be diagnosed immediately and managed competently.,, The clinical picture shows severe dehydration, without ketosis or significant acidosis. Plasma glucose level usually exceeds 600mg/dl. If HHS continues, severe dehydration will lead to seizures, coma and eventually death. The aim of treatment is to treat the underlying cause and to gradually normalise the osmolality with the replacement of fluid and electrolyte losses along with the correction of blood glucose. Underlying cause should be identified to prevent further episodes.
| Microvascular Complications of Diabetes|| |
This section is associated with the management of microvascular complications of Type 2 diabetes which are classified as nephropathy, retinopathy and neuropathy. Diabetic nephropathy is the dominant cause of end-stage renal failure. All people with Type 2 diabetes should be screened annually for the presence of microalbuminuria, Consider referral to tertiary care if kidney disease is rapidly progressive. Referral is also considered if anaemia, electrolyte imbalance, resistant hypertension, any bone disease or secondary hyperparathyroidism is present. All patients of diabetes should have detailed history of previous eye disease or any pre-existing eye problem. A detailed eye examination is required by an ophthalmologist. If there are no signs of retinopathy than annual eye examination is required. If retinopathy is present, then the frequency of follow-up is suggested by an ophthalmologist., Fundoscopy is recommended in every patient at least once a year or more frequently is indicated. At first visit, examination of peripheral neuropathy is also recommended. Most common presenting complaints are pain, burning and tingling sensations. Almost 50% of patients are usually asymptomatic. Good metabolic control is a pillar of prevention or slow progression of microvascular complications.
| Macrovascular Complications of Diabetes|| |
One of the common co-morbidities of diabetes is hypertension which affects majority of diabetic patients and it is a common risk factor for both cardiovascular disease (CVD) and microvascular complications. Blood pressure should be measured at every routine visit. Patients newly diagnosed with systolic blood pressure of ≥140 mmHg or diastolic blood pressure of ≥90mm Hg should have blood pressure confirmed on a subsequent day. Patients with blood pressure >120/80 mmHg should be advised LSM which includes restriction of salt intake and increased consumption of fruits and vegetables. Pharmacotherapy with angiotensin-converting enzyme inhibitors and LSM is initiated if blood pressure persists >140/90 mmgHg.
Peripheral artery disease
Peripheral artery disease (PAD) is defined as any atherosclerotic arterial occlusive disease below the level of the inguinal ligament resulting in a reduction in blood flow to the lower extremity. Identification of PAD is important because its presence results in worst outcome of diabetic foot ulcer which leads to amputation. The patient should be examined annually with appropriate history taking and measurement of ankle brachial index. All patients with diabetes and an ischaemic foot ulcer should receive aggressive cardiovascular risk management, including smoking cessation, treatment of hypertension, control of glycaemia and prescription of a statin as well as low-dose aspirin or clopidogrel.
It may be manifested by elevation of the total cholesterol, low-density lipoprotein cholesterol and the triglyceride concentrations and/or a decrease in the high-density lipoprotein cholesterol concentration in the blood., Obtain lipid profile at presentation and annually. LSM especially targeting weight reduction in overweight or obese people. All the diabetic patients aged >40 without any other risk factor should be given low dose statin. If other CVD risk factors are present, consider moderate or high dose statins.
Low dose aspirin therapy is an option in people with diabetes with increased CVD risk. This includes a family history of CVD, hypertension, smoking, dyslipidaemia or albuminuria and age >50 years. It may not be recommended in people younger than these ages without additional CVD risk factors. People intolerant to aspirin or if there is any contraindication, clopidogrel is an alternate option.,
People with diabetes are at increased risk of foot ulcers and amputations. Around 85% of amputations are anticipated by ulcers which are preventable. Annual examination of the foot, assessment of neuropathy and history of claudication or rest pain in lower limb should be taken. For diabetic foot ulcer glycaemic control, appropriate antibiotic coverage, daily dressings, education about the warning signs and regular follow-up is recommended.
Obesity and diabetes are usually not universal. There is significant evidence that lifestyle/behavioural interventions for weight reduction, weight reducing medicines or bariatric surgery can improve glycaemic control and reduce the risk of diabetes.
Life style changes
People who are obese and do not have diabetes, can reduce risk of developing diabetes by over 50% by losing of 5% of body weight along with regular exercise and dietary modification, increase consumption of high fibre diet and limiting starchy and oily food.
Pharmacological management of obesity
Phentermine (since 1959) and Orlistat (since 1999) are currently available drugs to decrease obesity. Few newer drugs Liraglutide and Lorcaserin are also affected of weight reduction in an obese population.,
Bariatric surgical procedures are used to lose weight by restricting the amount of food the stomach can hold, results in malabsorption of nutrients, or by a combination of both gastric restriction and malabsorption. Indications for bariatric surgery include morbid obesity (BMI >40) or severe obesity (BMI >35) with co-morbidities. Other weight loss surgeries are also performed by using minimally invasive techniques (laparoscopic surgery). Gastric bypass, sleeve gastrectomy, adjustable gastric band and biliopancreatic diversion with duodenal switch are the common bariatric surgery procedures used.
| Diabetic Foot|| |
The guidelines for the people with diabetic foot ulcers are not included in this guideline. Please see the link for diabetic foot guideline at; http://iwgdf.org/guidelines-translations.
| Ramadan and Diabetes|| |
The guidelines for Ramadan and diabetes are also not included in this guideline. Please see the link for Ramadan and diabetes guideline at; https://www.daralliance. org/daralliance.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]