Diabetes in Egypt

Tariq Zayan

Definition
Diabetes mellitus is a heterogeneous primary disorder of

carbohydrate metabolism with multiple etiologic factors that

generally involve absolute or relative insulin deficiency or both and is characterized by metabolic disorders of carbohydrates, lipids and proteins.

Egypt will face explosive growth of diabetes

9,000
Source: Diabetes Atlas, 2nd edition, IDF

8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0

Due to a rapidly increasing & ageing population, Egypt will have the largest number of people with diabetes in the region by 2025
2003 2025

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Diabetes: What is Diabetes

Not just a sugar problem Interaction of food, insulin, other hormones (glucagon) Physical activity/Obesity Pancreatic function Genetics Other commonly associated conditions: hypertension, lipid problems The complications, not just the diagnosis of diabetes, cause the problems Diabetes is common, serious BUT treatable

Microvascular Complications:

Nephropathy
Retinopathy Neuropathy Foot ulcers/lesions Numbness, pain

Sexual dysfunction
Gastroparesis
http://www.mayomedicallaboratories.com/images/articles/communique/2009/09fig1.jpg

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Macrovascular Complications
Cardiovascular Diseases (CVD) Coronary Artery Disease (CAD)

Myocardial Infarction (MI)

Stroke or transient ischemic
attack (TIA)

Peripheral Artery Disease (PAD)

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http://womenshealth.gov/heart-health-stroke/images/heart-attack-signs.gif

Additional Concerns
Depression and other mental
disorders

Dental disease

Increased risk of infection

Can affect fertility Severe hyper- or hypoglycemic events

http://diabeticradio.com/wp-content/uploads/2010/06/hypoglycemia.jpg

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Diabetes means:
2 x the risk of high blood pressure 2 to 4 x the risk of heart disease 2 to 4 x the risk of stroke #1 cause of adult blindness #1 cause of kidney failure Causes more than 60% of non-traumatic lower-limb amputations each year
NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2010.

Relative Risk of Progression of Diabetic Complications

RELATIVE RISK

Mean A1C
DCCT Research Group, N Engl J Med 1993, 329:977986.

Who Is At Risk?
Age 45 or older Overweight High blood pressure Pre-diabetes

Inactive
Ethnic or minority population

High blood fats

Darkening of the skin Polycystic ovary syndrome History of Gestational Diabetes or large baby

Family history of diabetes

Excess abdominal fat

Could You be at Risk for Diabetes?

Where do you start?
ADA Risk Test (paper or online) www.diabetes.org

Goals for therapy

Choosing an A1C goal for a patient should be individualized just like the therapy selected

Guidelines recommend lowering A1C to below or around 7% to reduce microvascular complications (range 6.5% - 8%) May also reduce macrovascular complications in some patients if implemented soon after diagnosis For other patients, older, greater duration of disease, benefit of lower A1C may not outweigh risk of hypoglycemia Variance in cardiovascular outcomes between large trials

Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a patient21 centered approach, Position Statement by the ADA and the EASD. Diabetes Care. 2012;35:1364-79.

Brief on Trials for Tight Glycemic Control

UKPDS

Intensive Control associated with improved microvascular outcomes

ACCORD

Intensive therapy/targets increased mortality without significantly reducing cardiovascular events

ADVANCE

Intensive control resulted in relative reduction of combined major cardiovascular events

and microvascular events

VADT

No significant effect on rates of major cardiovascular events, death, or microvascular complications

The Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) Collaborative Group. NEJM. 2008;358(24):2560-72. 22 Duckworth W, Abraira C, Moritz T, et al. NEJM. 2009;360(2):129-39. Stratton IM, Adler AI, Neil HAW, et al. BMJ. 2000;321:405-12. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study Group. NEJM. 2008;358(24):2545-59.

Intensive Glycemic Control and Cardiovascular Outcomes: ACCORD

Primary Outcome: Nonfatal MI, nonfatal stroke, CVD death
HR=0.90 (0.78-1.04)

2008 New England Journal of Medicine. Used with permission.

Gerstein HC, et al, for the Action to Control Cardiovascular Risk in Diabetes Study Group. N Engl J Med 2008;358:2545-2559.

Intensive Glycemic Control and Cardiovascular Outcomes: ADVANCE

Primary Outcome: Microvascular plus macrovascular (nonfatal MI, nonfatal stroke, CVD death)
HR=0.90 (0.82-0.98)

2008 New England Journal of Medicine. Used with permission.

Patel A, et al,. for the ADVANCE Collaborative Group. N Engl J Med 2008;358:2560-2572.

Intensive Glycemic Control and Cardiovascular Outcomes: VADT

Primary Outcome: Nonfatal MI, nonfatal stroke, CVD death, hospitalization for heart failure, revascularization
HR=0.88 (0.74-1.05)

2009 New England Journal of Medicine. Used with permission.

Duckworth W, et al., for the VADT Investigators. N Engl J Med 2009;360:129-139.

Meta-analysis on tight glycemic control

Lancet 2009: based on 5 randomised trials

Intensive therapy reduces coronary events without an increased risk of death

Notes variance between populations and rate of A1C reduction

BMJ 2011: based on 14 randomised trials (used trial sequence analysis)

Intensive control has not been proven to reduce all cause mortality

Increase in relative risk of hypoglycemia by 30 %

Evidence insufficient to draw conclusions on cardiovascular mortality, nonfatal MI, composite microvascular complications, or retinopathy

Ray KK, Kondapally Seshasai S, Wijesuriya S, et al. Lancet. 2009;373:1765-72. 26 Hemmingsen B, Lund SS, Gluud C, et al. BMJ. 2011;343:d6898 Doi: 10.1136/bmj.d6898.

Meta-analysis on tight glycemic control

BMJ 2011: based on 13 studies

Limited benefits to all cause mortality and cardiovascular-related death Values on both sides of the debate can not be ruled out by this analysis Risk and benefit for microvascular and macrovascular complications -

inconclusive
Risk of harm with hypoglycemia noted

Need for more trials

Boussageon R, Bejan-Angoulvant T, Saadatian-Elahi M, et al. BMJ. 2011;343:d4169 doi:10.1136/bmj.d4169.

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Ultimate Goals Of Diabetes Treatment

Sustained Normal Blood Glucose Control

= =

No Long Term Diabetes Complications No Acute Diabetes Complications

Lowest Incidence of Hypoglycemia

Best Quality of Life with a Chronic Disease

Control the ABCS

A1c: Glucose control Blood Pressure control Cholesterol (lipid) control Smoking cessation

Primary Objectives of Effective Management

A1C % 9 8 7 SBP mm Hg
145 130 Reduction of both micro- and macrovascular event rates by 75%!

Diagnosis

lGde P, Vedel P, Larsen N, Jensen GVH, Parving H-H, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003;348:383-393.

LDL mg/dL

140 100 45 50 55 60 65

70

75

80

85

90

Patient Age

Glycemic Recommendations for Nonpregnant Adults with Diabetes (1)

A1C Preprandial capillary plasma glucose <7.0%* 70130 mg/dL* (3.97.2 mmol/L)

Peak postprandial <180 mg/dL* capillary plasma glucose (<10.0 mmol/L)

*Individualize goals based on these values. Postprandial glucose measurements should be made 12 h after the beginning of the meal, generally peak levels in patients with diabetes. ADA. V. Diabetes Care. Diabetes Care 2013;36(suppl 1):S21; Table 9.

Recommendations: Glycemic, Blood Pressure, Lipid Control in Adults

A1C Blood pressure Lipids: LDL cholesterol <7.0%* <140/80 mmHg <100 mg/dL (<2.6 mmol/L) Statin therapy for those with history of MI or age >40+ or other risk factors

*More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on: duration of diabetes, age/life expectancy, comorbid conditions, known CVD or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations. Based on patient characteristics and response to therapy, higher or lower systolic blood pressure targets may be appropriate. In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/dL (1.8 mmol/L), using a high dose of statin, is an option. ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S33; Table 10.

Recommendations: Coronary Heart Disease Treatment (1)

To reduce risk of cardiovascular events in patients with known CVD, consider
ACE inhibitor (C) Aspirin* (A) Statin therapy* (A)

In patients with a prior MI

-blockers should be continued for at least 2 years after the event (B)

*If not contraindicated. ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S34.

Recommendations: Coronary Heart Disease Treatment (2)

Avoid thiazolidinedione treatment in patients with symptomatic heart failure (C) Metformin use in patients with stable CHF
Indicated if renal function is normal (C) Should be avoided in unstable or hospitalized patients with CHF (C)

ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S34.

Recommendations: Retinopathy
To reduce the risk or slow the progression of retinopathy
Optimize glycemic control (A) Optimize blood pressure control (A)

ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S36.

Recommendations: Nephropathy
To reduce the risk or slow the progression of nephropathy
Optimize glucose control (A) Optimize blood pressure control (A)

ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S34-S35.

Thanks