The 2012 SEMDSA Guideline for the Management of Type 2 Diabetes (Revised)

Gaps in the type 2 diabetes care cascade: a national perspective using South Africa's National Health Laboratory Service (NHLS) database

BACKGROUND

Research out of South Africa estimates the total unmet need for care for those with type 2 diabetes mellitus (diabetes) at 80%. We evaluated the care cascade using South Africa's National Health Laboratory Service (NHLS) database and assessed if HIV infection impacts progression through its stages.

METHODS

The cohort includes patients from government facilities with their first glycated hemoglobin A1c (HbA1c) or plasma glucose (fasting (FPG); random (RPG)) measured between January 2012 to March 2015 in the NHLS. Lab-diagnosed diabetes was defined as HbA1c ≥ 6.5%, FPG ≥ 7.0mmol/l, or RPG ≥ 11.1mmol/l. Cascade stages post diagnosis were retention-in-care and glycaemic control (defined as an HbA1c < 7.0% or FPG < 8.0mmol/l or RPG < 10.0mmol/l) over 24-months. We estimated gaps at each stage nationally and by people living with HIV (PLWH) and without (PLWOH).

RESULTS

Of the 373,889 patients tested for diabetes, 43.2% had an HbA1c or blood glucose measure indicating a diabetes diagnosis. Amongst those with lab-diagnosed diabetes, 30.9% were retained-in-care (based on diabetes labs) and 8.7% reached glycaemic control by 24-months. Prevalence of lab-diagnosed diabetes in PLWH was 28.6% versus 47.3% in PLWOH. Among those with lab-diagnosed diabetes, 34.3% of PLWH were retained-in-care versus 30.3% PLWOH. Among people retained-in-care, 33.8% of PLWH reached glycaemic control over 24-months versus 28.6% of PLWOH.

CONCLUSIONS

In our analysis of South Africa's NHLS database, we observed that 70% of patients diagnosed with diabetes did not maintain in consistent diabetes care, with fewer than 10% reaching glycemic control within 24 months. We noted a disparity in diabetes prevalence between PLWH and PLWOH, potentially linked to different screening methods. These differences underscore the intricacies in care but also emphasize how HIV care practices could guide better management of chronic diseases like diabetes. Our results underscore the imperative for specialized strategies to bolster diabetes care in South Africa.

Evolution of Guideline Recommendations on Insulin Therapy in Type 2 Diabetes Mellitus Over the Last Two Decades: A Narrative Review

The prevalence of type 2 diabetes mellitus has been increasing worldwide. As the therapeutic options for type 2 diabetes mellitus have evolved over the last 2 decades, national and global guidelines related to type 2 diabetes mellitus pharmacotherapy issued by various organizations have tended to vary in their recommendations. This narrative review aimed to analyze the key recommendations by major global and national guidelines on the initiation of insulin therapy in patients with type 2 diabetes mellitus over the last 20 years. Strategies for insulin therapy for titration and intensification were also assessed. All guidelines recommend initiation of insulin (basal/ premixed/other formulations) when glycemic targets are not achieved despite lifestyle measures and oral antidiabetic drugs. In the recent decade, early initiation of insulin has been recommended when the glycated hemoglobin levels are >10% or blood glucose levels are ≥300 mg/dL (16.7 mmol/L). Initiation is recommended at a dose of 10 units or 0.1-0.2 U/kg. Titration is advised to achieve the optimal dosage, while intensification is recommended when glycemic targets are not achieved despite titrating to an acceptable level. Glucose monitoring at periodic intervals is recommended for adequate glycemic control. The guidelines further suggest that the choice of insulin should be individualized, considering the clinical status of patients with type 2 diabetes mellitus. The physicians as well as patients should be a part of the decisions made regarding the therapeutic choice of regimen, preparation, and delivery device.

Optimization of gliclazide loaded alginate-gelatin beads employing central composite design

Objective: The aim of this study was to optimize the formulation of alginate-gelatin (AL-GL) beads containing gliclazide (GLZ) employing design of experiments (DOE).Significance: DOE enabled identification of the interaction between the studied factors, deep understanding of GLZ release pattern and acceleration of the optimization process.Methods: A three-factor, three-level face centered design was employed. The effects of GLZ content (GLZ%, X₁), polymer ratio (AL:GL ratio, X₂), crosslinker concentration (glutaraldehyde, GA%, X₃), and their interaction on incorporation efficiency (IE) and release rate were studied. The optimized formulation was prepared using numerical optimization and evaluated by DSC, FT-IR, SEM and release rate studies.Results: Increasing GA% (X₃) decreased IE (Y₁) with the highest magnitude of effect among the studied factors. On the other hand, increasing alginate content in AL:GL ratio (X₂) increased IE (Y₁). The amount of GLZ released Q_0.5h, Q_2h(pH 1.2) and Q_4h(pH 7.4) decreased by increasing GLZ% (X₁) and AL:GL ratio (X₂). Both drug content and AL:GL ratio appeared to affect water penetration into the gel matrix and drug release. Generally, there was a direct relationship between GA% (X₃) and GLZ release in pH 1.2 (Q_0.5h and Q_2h). However, in pH 7.4 (Q_4h), increasing GA% decreased GLZ release. In addition, increasing GA% caused deviation from zero-order release model. The actual responses of the optimized formulation were in close agreement with the predicted ones.Conclusion: The selected factors and their levels studied in the optimization design were useful for tailoring the anticipated formulation characteristics and GLZ release pattern.

Psychosocial stress in South African patients with type 2 diabetes

Objective: Diabetes mellitus is considered an emotionally and behaviourally demanding condition which adds to the stress of a patient’s daily living. There is a paucity of literature in South Africa regarding stress and diabetes. This study therefore aims to identify the areas and contributory factors of psychosocial stress in South African patients with diabetes.Method: A cross-sectional study was conducted at two public facilities and five private medical practices on the north coast of KwaZulu-Natal, South Africa. The Questionnaire on Stress in Diabetes – Revised was administered to 401 participants.Results: Eighteen percent of the sample reported having extreme psychosocial stress. Depression, physical complaints and self-medication/diet were the main areas which contributed to high psychosocial stress. Factors that also contributed to high levels of psychosocial stress were low educational level, unemployment, female gender, attending the public sector and high HbA1c levels.Conclusion: Psychosocial stress affects metabolic control in patients with diabetes, thereby increasing the risks of long-term complications.

Improving diabetic foot screening at a primary care clinic: A quality improvement project

Background

Foot screening is an important part of diabetic care as it prevents significant morbidity, loss of function and mortality from diabetic foot complications. However, foot screening is often neglected.

Aim

This project was aimed at educating health care workers (HCWs) in a primary health care clinic to increase diabetic foot screening practices.

Setting

A primary health care clinic in the Western Cape province of South Africa

Methods

A quality improvement project was conducted. HCWs’ needs were assessed using a questionnaire. This was followed by focus group discussions with the HCWs, which were recorded, transcribed and assessed using a general inductive approach. An intervention was designed based on common themes. Staff members were trained on foot screening and patient information pamphlets and screening tools were made available to all clinic staff. Thirty-two consecutive diabetic patient folders were audited to compare screening in 2013 with that in 2014 after initiation of the quality improvement cycle.

Results

HCWs’ confidence in conducting foot screening using the diabetic foot assessment questionnaire improved markedly after training. Diabetic foot screening practices increased from 9% in 2013 to 69% in 2014 after the first quality improvement cycle. A strengths, opportunities, aspirations and results (SOAR) analysis showed promise for continuing quality improvement cycles.

Conclusion

The findings showed a significant improvement in the number of diabetic patients screened. Using strategic planning with appreciative intent based on SOAR, proved to be motivational and can be used in the planning of the next cycle.

Serum Oxidized LDL Levels in Type 2 Diabetic Patients with Retinopathy in Mthatha Region of the Eastern Cape Province of South Africa

Oxidized low-density lipoprotein (ox-LDL) is a powerful natural prooxidant derived from native LDL by cell-mediated oxidation. Such oxidation occurs more easily in glycated LDL as observed in diabetes mellitus. We evaluated and compared selected biomarkers of oxidative stress and total antioxidant (TAO) levels in type 2 diabetes mellitus (T2DM) patients with and without retinopathy in the Mthatha region of the Eastern Cape Province, South Africa. The participants totaled to 140 and this number comprised 98 diabetic patients on treatment, stratified by diabetes (54) and diabetes with retinopathy (44). Forty-two nondiabetic healthy controls made up the 140. Fasting plasma glucose (FPG), glycosylated hemoglobin (HbA1c), lipid profile, serum ox-LDL, thiobarbituric acid reactive substances (TBARS), and TAO levels were measured. A statistically significant increase in FPG, HbA1c, TBARS, and ox-LDL and a significant decrease in TAO levels were seen in T2DM patients with retinopathy as compared to controls. A significant negative correlation was observed between TAO and ox-LDL levels in the diabetic group. In multiple linear regression analyses, duration of diabetes, triglyceride, TAO, and LDL cholesterol were found to be significantly associated with ox-LDL. In multiple logistic regression analyses, ox-LDL [OR 1.02 (1.01–1.03), P = 0.005] was the only risk factor and was significantly associated with the presence of retinopathy.