A snapshot of diabetes management in the real

world

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Brief Report

A snapshot of diabetes management in the realworld

K. Swaminathan*

Consultant Endocrinologist, Kovai Medical Center & Hospital, Coimbatore, India

a r t i c l e i n f o

Article history:

Received 1 August 2014

Accepted 6 November 2014

Available online xxx

Keywords:

Diabetes

Cardiovascular disease

Microvascular

* Tel.: þ91 8526421150; fax: þ91 422 26277E-mail address: drkrishnanswaminathan

Please cite this article in press as: Swam(2014), http://dx.doi.org/10.1016/j.apme.2

http://dx.doi.org/10.1016/j.apme.2014.11.0020976-0016/Copyright © 2014, Indraprastha M

a b s t r a c t

Background: Patients with diabetes are at high risk of vascular events. Aggressive treatment

of hyperglycemia, hyperlipidemia and hypertension are cornerstones of diabetes man-

agement in an effort to reduce risk of vascular disease. Our aim was to get a snapshot of

diabetes management in the community in terms of the above three risk factors, so that

deficient areas can be targeted to educate physicians and diabetologists.

Methods: All consecutive patients with known history of diabetes managed in the com-

munity who had enrolled for a diabetes master health check over a one year period from

Jan 2013 to December 2013 at Apollo Speciality Hospital, Madurai were included in this

study. Local Ethics Committee approval was obtained. Variables were collected and

analyzed using Microsoft Excel 2007.

Results: Data from one hundred and one patients were analyzed. Mean age of patients was

53.8 years with an average duration of diabetes of 3.5 years. Mean glycosylated hemoglobin

was 8.6%. About 90% of patients had a blood pressure within the target range. Nearly two-

thirds of patients were not on a statin. The rates of newly detected neuropathy, retinop-

athy and microalbuminuria were 40%, 30% and 35% respectively.

Conclusion: Physicians should adopt a more holistic approach to microvascular and car-

diovascular risk factors in patients with diabetes, adhering to evidence based guidelines

with personalized targets.

Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

There is data to suggest that diabetes patients without a pre-

vious myocardial infarction have as high a risk of such an

event as nondiabetic patients with a history of myocardial

infarction, thereby elevating diabetes as a Coronary Heart

Disease equivalent.1 It is therefore often quoted that “Diabetes

is not only ametabolic disorder but a vascular disease aswell”.

82.@kmchhospitals.com.

inathan K, A snapshot014.11.002

edical Corporation Ltd. A

The evidence for atherogenic risk factors in diabetes is

strongest for hypertension, lipids, smoking and hyperglyce-

mia.2 Aggressive risk factor reduction based on established

national and international guidelines is vital in reducing the

risk of both micro and macrovascular complications in dia-

betes. However, many health care professionals find it diffi-

cult to follow evidence based guidelines due to a variety of

reasons ranging from clinical inertia, uncertainty of real life

scenarios against guideline based management and the ever

of diabetes management in the real world, Apollo Medicine

ll rights reserved.

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e32

present argument of experience based medicine versus evi-

dence basedmedicine. Data from a large Indian study recently

has shown that glycemic control is extremely poor in India

with a high prevalence of micro and macrovascular compli-

cations.3 Our aim was to get a snapshot of a real world risk

factor management in patients with diabetes from the South

Indian city of Madurai.

2. Methods

All consecutive patients attending a diabetes master health

check at Apollo Speciality Hospitals, Madurai were included in

this study. All the participants were managed in the com-

munity for their diabetes and were “first timers” for the

comprehensive check at our institution. Local Ethical Com-

mittee approval was obtained. A waiver of consent was given

as this was a retrospective observational study. Data was

prospectively collected and analyzed on Microsoft Excel 2007.

The following variables were collected from our patients; age,

sex, waist circumference, body mass index, blood pressure,

fasting glucose, post-prandial glucose, glycosylated hemo-

globin (HbA1c), fasting lipid profile, urinary microalbumin,

retinopathy graded by an ophthalmologist and neuropathy

grades using a biothesiometer. All patients underwent a

detailed counseling session by a dedicated diabetes educator

highlighting the importance of diet, lifestyle and risk factor

management in diabetes.

3. Results

A total of one hundred and one patients were analyzed. Mean

age of patients was 53.8 years with a predominance of type 2

diabetes (98%). Most of the patients (95%) had no history of

cardiovascular disease. Themean duration of diabeteswas 3.5

years. Mean glycosylated hemoglobin was 8.6% with a fasting

glucose of 175 mg/dl and a 2 h post-prandial of 289.7 mg/dl.

Details of all other variables are tabulated in Table 1.

Approximately 65% of patients were not on a statin. Blood

pressure goals of �130/80 mm Hg was documented in 90% of

patients, with predominant use of angiotensin converting

enzyme inhibitors or angiotensin receptor blockers. Some

degree of neuropathy was present in 40% of the patients, with

severe neuropathy documented in 15%. Nearly 30% had reti-

nopathy with 3% needing urgent assessment for proliferative

Table 1 e Characteristics of study population {Mean (SD)}.

Total number of patients (n) 101

Mean age (years) 53.8 years (10.2)

Male:Female (n) 61:40

Type 2 diabetes:type 1 diabetes (n) 98:3

Mean duration of diabetes (years) 3.5 years (2.01)

Mean body mass index (kg/m2) 27 (4.43)

Mean glycosylated hemoglobin (%) 8.6% (2.07)

Mean systolic blood pressure (mm Hg) 128 mm Hg (16.6)

Mean diastolic blood pressure (mm Hg) 75.3 mm Hg (8.5)

Mean LDL-C (mg/dl) 104.2 mg/dl (33.9)

Mean HDL-C (mg/dl) 39.3 mg/dl (10.2)

Mean triglycerides (mg/dl) 156 mg/dl (93.7)

Please cite this article in press as: Swaminathan K, A snapshot(2014), http://dx.doi.org/10.1016/j.apme.2014.11.002

diabetic retinopathy. In patients with less than three years

duration of diabetes, the mean glycosylated hemoglobin was

8.7% and nearly 67% of these patients were not on statins.

4. Discussion

Our study highlights the presence of clinical inertia especially

early in the course of type 2 diabetes, precisely when health

care professionals should be aggressive in treating cardio-

vascular risk factors.

The mean glycosylated hemoglobin (HbA1c) in our study

was 8.6%. Hyperglycemia is an important risk factor in

microvascular disease.4 In a recent large meta-analysis of

34,912 participants with type 2 diabetes, there was a sig-

nificant reduction in the risk of microvascular complications

in the intensive compared to standard glycemic control

group.5 The rates of newly detected microvascular compli-

cations in our study were significantly high ranging from 30

to 40 % for retinopathy, microalbuminuria and neuropathy.

High prevalence of microvascular complications early in the

course of type 2 diabetes has been reported by few other

Indian studies as well.3,6 The link between hyperglycemia

and macrovascular disease is less straightforward. However,

the concept of “legacy effect”, where a sustained period of

glycemic control early in the course of diabetes has a long

term benefit in reducing cardiovascular mortality7 may be

very relevant in the way we approach glycemic targets in the

first few years of type 2 diabetes. Most of our patients were

free of macrovascular disease and were early in the course

of type 2 diabetes. This should be an added incentive for

physicians to treat glycemic targets aggressively with early

combination therapy of medications with low side effect

profiles.

Nearly two-thirds of our patients were not prescribed a

statin, even though the beneficial effects of statins in diabetes

have been established by landmark clinical trials.8e10 This is

of particular concern in India where the burden of coronary

artery disease is high.11 Interestingly, as of January 2010, there

were 259 distinct statin products available to the Indian con-

sumers and nevertheless only a fraction of those eligible for

statin therapy appeared to receive this therapy.12 Unlike some

of their diabetes counterparts like gliptins, statins are not

costly and are available at less than two rupees in combina-

tion with aspirin or anywhere between three and ten rupees

depending on the strength of statin. The reasons for low usage

of statin in India are probably multi-factorial. Data from the

INTERHEART study showed that LDL-C (low density lipopro-

tein) from South Asians are lower, with a significant propor-

tion of participants with acute myocardial infarction and

controls having a baseline LDL-C < 100 mg/dl.13 Physicians

often erroneously feel that the low density lipoprotein levels

(LDL-C) are normal and fail to prescribe a statin on those

grounds. However, Indians have a more atherogenic dyslipi-

demic profile compared to Western counterparts.14 Unless

there is a reason not to, all patients with diabetes >40 years of

age (probably lower) in India should be receiving a statin,

based on current evidence. It is important to educate physi-

cians and patients to increase appropriate statin use in dia-

betes to prevent the rising burden of cardiovascular disease.

of diabetes management in the real world, Apollo Medicine

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e3 3

The one silver lining in our study was excellent control of

hypertension. Blood pressure targets of �130/80 mm Hg were

documented in nearly 90% of patients. Prevalence of hyper-

tension in India is high with some recent estimates showing

values as high as 33% in urban India and 25% in rural India.15

Anecdotally, we see physicians and general practitioners

more liberal in prescribing fixed dose antihypertensives and at

least patients in our study seem to be compliant in taking

medications for hypertension.

We have inherent limitations in this study. There was no

attempt to minimize bias based on demographics or socio-

economic status, as consecutive patients were selected in a

single hospital study. Therefore results should be interpreted

with caution.

In conclusion, our study highlights the need for physicians

to pursue evidence based glycemic and blood pressure targets

especially early in the course of diabetes. Physicians need to be

educated on the need to increase statin use in the appropriate

clinical context to reduce the burden ofmacrovascular disease.

A strong revalidation program, mandatory continuing profes-

sional development schemes and diabetes nurse specialist

teams as in western countries can be adopted in India to up-

date and ease the burden on physicians treating diabetes. A

more holistic approach to assessment and management of

microvascular and macrovascular risk factors is the urgent

need of the hour.

Conflicts of interest

The author has none to declare.

Acknowledgments

Dr KS was formerly Consultant Endocrinologist at Apollo

Speciality Hospital, Madurai and wishes to acknowledge

Apollo Speciality Hospital Ethical Committee and staff for

their help with this study.

r e f e r e n c e s

1. Haffner SM, Lehto S, R€onnemaa T, Py€or€al€a K. Laakso mortalityfrom coronary heart disease in subjects with type 2 diabetesand in nondiabetic subjects with and without priormyocardial infarction. N Engl J Med. 1998 Jul 23;339:229e234.

Please cite this article in press as: Swaminathan K, A snapshot(2014), http://dx.doi.org/10.1016/j.apme.2014.11.002

2. Turner RC, Millns H, Neil HA, et al. Risk factors for coronaryartery disease in non-insulin dependent diabetes mellitus:United Kingdom Prospective Diabetes Study (UKPDS: 23) BMJ.1998 Mar 14; 316:823-828.

3. Mohan V, Shah S, Saboo B. Current glycemic status anddiabetes related complications among type 2 diabetespatients in India: data from the A1chieve study. J AssocPhysicians India. 2013 Jan;61(suppl l):12e15.

4. Klein R, Klein BE, Moss SE, Cruickshanks KJ. Relationship ofhyperglycemia to the long-term incidence and progression ofdiabetic retinopathy. Arch Intern Med. 1994 Oct10;154:2169e2178.

5. Hemmingsen B, Lund SS, Gluud C, et al. Targeting intensiveglycemic control versus targeting conventional glycemiccontrol for type 2 diabetes mellitus. Cochrane Database SystRev. 2013 Nov 11;11:CD008143. http://dx.doi.org/10.1002/14651858.CD008143.pub3.

6. Gupta A, Gupta AK, Singh TP. Occurrence of complications innewly diagnosed type 2 diabetes patients: a hospital basedstudy. J Indian Med Assoc. 2013 Apr;111:245e247.

7. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year follow-up of intensive glucose control in type 2 diabetes.N Engl J Med. 2008 Oct 9;359:1577e1589.

8. Heart Protection Study Collaborative Group. MRC/BHF HeartProtection Study of cholesterol lowering with simvastatin in20,536 high-risk individuals: a randomised placebo-controlledtrial. Lancet. 2002 Jul 6;360:7e22.

9. Colhoun HM, Betteridge DJ, Durrington PN, et al, CARDSInvestigators. Primary prevention of cardiovascular diseasewith atorvastatin in type 2 diabetes in the CollaborativeAtorvastatin Diabetes Study (CARDS): multicentrerandomised placebo-controlled trial. Lancet. 2004 Aug 21-27;364:685e696.

10. Nakamura H, Arakawa K, Itakura H, et al, MEGA Study Group.Primary prevention of cardiovascular disease withpravastatin in Japan (MEGA Study): a prospective randomisedcontrolled trial. Lancet. 2006 Sep 30;368:1155e1163.

11. Gupta R. Burden of coronary heart disease in India. IndianHeart J. 2005 Nov-Dec;57:632e638.

12. Choudhry NK, Dugani S, Shrank WH, et al. Despite increaseduse and sales of statins in India, per capita prescriptionratesremain far below high-income countries. Health Aff (Millwood).2014 Feb;33:273e282.

13. Karthikeyan G, Teo KK, Islam S, et al. Lipid profile, plasmaapolipoproteins, and risk of a first myocardial infarctionamong Asians: an analysis from the INTERHEART Study. J AmColl Cardiol. 2009 Jan 20;53:244e253.

14. Manjunath CN, Rawal JR, Irani PM, Madhu K. Atherogenicdyslipidemia. Indian J Endocrinol Metab. 2013 Nov;17:969e976.

15. Anchala R, Kannuri NK, Pant H, et al. Hypertension in India: asystematic review and meta-analysis of prevalence,awareness, and control of hypertension. J Hypertens. 2014Jun;32:1170e1177.

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