An algorithm for the treatment of type 2 diabetes in Latin America

Call-to-action: timely and appropriate treatment for people with type 2 diabetes in Latin America

Latin America faces a unique set of challenges in the treatment of type 2 diabetes mellitus (T2DM). This report identifies these challenges and provides a framework for implementation of the strategies, policies and education programs which are needed to optimize the management of this condition. In order to improve future diabetes care, it will be necessary to address existing problems such as limitation of resources, inadequate management of hyperglycemia, and inappropriate education of healthcare team members and people with diabetes. Achieving these goals will require collaborative efforts by many individuals, groups and organizations. These include policymakers, international organizations, healthcare providers, those responsible for setting medical school curricula, patients and society as a whole. It is anticipated that improved/continuing education of healthcare professionals, diabetes self-management education and development of a team approach for T2DM care will lead to optimization of patient-centered care. Implementation of multicentric demonstration studies and rational use of antidiabetic treatments will be necessary to demonstrate the long-term favorable impact of these strategies upon quality of care, prevention of chronic complications, mortality, healthcare costs and patient quality of life.

Efficacy of alogliptin in type 2 diabetes treatment: a meta-analysis of randomized double-blind controlled studies

BACKGROUND

Alogliptin is a new dipeptidyl peptidase (DPP-4) inhibitor, which is under investigation for treatment of type 2 diabetes either alone or in combination with other antidiabetic drugs. The aim of this meta-analysis was to assess the efficacy and tolerability of alogliptin in patients with type 2 diabetes.

METHODS

Computer based search was performed in MEDLINE, Cochrane library, and HINARI (Health InterNetwork Access to Research Initiative) databases. Meta-analysis was carried out by incorporating double-blind randomized controlled studies done on the efficacy of alogliptin in patients with type 2 diabetes. The efficacy and tolerability of alogliptin was determined by standardized mean differences (SMDs) and Mantel-Haenszel odds ratio. Heterogeneity was assessed by the chi-squared test (Cochran Q test) and I2 statistics.

RESULTS

The pooled SMDs demonstrated a significant reduction in HbA1c in patients treated with alogliptin 12.5 mg (SMD = -0.81; 95% CI, -1.11 to -0.51) or alogliptin 25 mg (SMD= -0.98; 95%CI= -1.30 to -0.66) as compared with controls. The SMD for reduction in fasting plasma glucose level (FPG) from baseline was also statistically significant among alogliptin treated patients. However, the effect of alogliptin on body weight change was inconclusive. The proportion of patients who discontinued alogliptin due to adverse events was not different from controls. Similarly, the meta-analyses of specific adverse events did not demonstrate statistically significant differences.

CONCLUSIONS

Alogliptin alone or in combination with other antidiabetic drug has shown a significant reduction in HbA1c and FPG level in patients with type 2 diabetes. However, its consistent efficacy for longer duration of therapy needs further investigation.

A comparative profile of methanol extracts of Allium cepa and Allium sativum in diabetic neuropathy in mice

Introduction:

Diabetic Neuropathy (DN) is a major microvascular complication of uncontrolled diabetes. This may result from increased oxidative stress that accompanies diabetes. Hence plants with antioxidant action play an important role in management of diabetes and its complications.

Materials and Methods:

This study was designed to evaluate preventive as well as curative effect of methanol extracts of outer scales and edible portions of two plants with established antioxidant action - Allium cepa and Allium sativum, in induced DN in albino mice. Mice were divided into control, diabetic and test extracts treated groups. Test extracts were administered daily at a dose of 200 mg/kg p.o. for 21 days, in the preventive group prior to onset of DN, and in the curative group after the onset of DN. Hyperalgesia and oxidative stress markers were assessed. STZ-diabetic mice showed a significant thermal hyperalgesia (as assessed by the tail-flick test), indicating development of DN.

Results:

Treatment with test extracts prevented loss in body weight, decreased plasma glucose level, and significantly ameliorated the hyperalgesia, TBARS, serum nitrite and GSH levels in diabetic mice.

Conclusion:

Methanol extract of outer scales of onion has shown most significant improvement; may be due to higher content of phenolic compounds in outer scales of A. cepa.

Are clinical practical guidelines (CPGs) useful for health services and health workforce planning? A critique of diabetes CPGs

AIMS

Chronic disease management is increasingly informed by clinical practice guidelines (CPGs). However, their implementation requires not only knowledge of guideline content by clinicians and practice processes that support implementation, but also a health workforce with the capacity to deliver care consistent with CPGs. This has a health services planning as well as a health workforce dimension. However, it is not known whether CPGs are described in a way that can inform health services and health workforce planning and potentially drive better quality care. This study aimed to ascertain whether CPGs are useful for health service and health workforce planning.

METHODS

This question was explored taking diabetes mellitus as a case study. A systematic search of Medline, EMBASE, CINAHL and Scopus was carried out to identify all CPGs relating to the management of diabetes mellitus in the primary healthcare setting. The search was limited to guidelines published in the English language between 2003 and 2009. The quality of guidelines was assessed against a subset of criteria set by the Appraisal of Guidelines for Research and Evaluation (AGREE) collaboration.

RESULTS

Seventy-five diabetes-related CPGs were identified, of which 27 met the inclusion criteria. In terms of quality, many guidelines adopted evidence-based recommendations for diabetes care (59%) and most were endorsed by national authorities (70%). With regards to coverage of 17 identified subpopulations, guidelines were generally selective in the populations they covered. Whilst many provided adequate coverage of common complications and comorbidities, approaches to management for those with reduced capacity for effective diabetes self-care were largely absent, except for indigenous populations.

CONCLUSIONS

Clinical practice guidelines are potentially useful for health services and health workforce planning, but would be more valuable for this purpose if they contained more detail about care protocols and specific skills and competencies, especially for subpopulations who would be expected to have reduced capacity for effective self-care. If service planning ignores these subgroups that tend to require more resource-intensive management, underprovision of services is likely.

An average/deprivation/inequality (ADI) analysis of chronic disease outcomes and risk factors in Argentina

Background

Recognition of the global economic and epidemiological burden of chronic non-communicable diseases has increased in recent years. However, much of the research on this issue remains focused on individual-level risk factors and neglects the underlying social patterning of risk factors and disease outcomes.

Methods

Secondary analysis of Argentina's 2005 Encuesta Nacional de Factores de Riesgo (National Risk Factor Survey, N = 41,392) using a novel analytical strategy first proposed by the United Nations Development Programme (UNDP), which we here refer to as the Average/Deprivation/Inequality (ADI) framework. The analysis focuses on two risk factors (unhealthy diet and obesity) and one related disease outcome (diabetes), a notable health concern in Latin America. Logistic regression is used to examine the interplay between socioeconomic and demographic factors. The ADI analysis then uses the results from the logistic regression to identify the most deprived, the best-off, and the difference between the two ideal types.

Results

Overall, 19.9% of the sample reported being in poor/fair health, 35.3% reported not eating any fruits or vegetables in five days of the week preceding the interview, 14.7% had a BMI of 30 or greater, and 8.5% indicated that a health professional had told them that they have diabetes or high blood pressure. However, significant variation is hidden by these summary measures. Educational attainment displayed the strongest explanatory power throughout the models, followed by household income, with both factors highlighting the social patterning of risk factors and disease outcomes. As educational attainment and household income increase, the probability of poor health, unhealthy diet, obesity, and diabetes decrease. The analyses also point toward important provincial effects and reinforce the notion that both compositional factors (i.e., characteristics of individuals) and contextual factors (i.e., characteristics of places) are important in understanding the social patterning of chronic diseases.

Conclusion

The application of the ADI framework enables identification of the regions or groups worst-off for each outcome measure under study. This can be used to highlight the variation embedded within national averages; as such, it encourages a social perspective on population health indicators that is particularly attuned to issues of inequity. The ADI framework is an important tool in the evaluation of policies aiming to prevent or control chronic non-communicable diseases.

Causes of blindness among hospital outpatients in Ecuador

BACKGROUND

There is a lack of published information on the causes of blindness in Ecuador and the Latin American region in general. This study is designed to enumerate the proportions of ocular conditions contributing to blindness in an outpatient population of an ophthalmology hospital in the coastal region of Ecuador.

METHODS

All cases presenting to an ophthalmology outpatient clinic over a 3-week period during September 2004 were reviewed (n = 802). Visual acuity was measured using a Snellen acuity chart and those who met the criteria for blindness were included in the study (n = 118). Blindness was defined under the World Health Organization protocol as visual acuity of <3/60. Both unilateral and bilateral blindness were included in the study. The diagnosis of ocular pathology contributing to blindness was recorded.

RESULTS

Among those considered to have unilateral blindness (n = 88), cataract was the most common cause (43%). This was followed by corneal pathologies (17%) and glaucoma (15%). Among those considered to have bilateral blindness (n = 30), refraction was the most common cause (37%), followed by cataract (23%) and glaucoma (17%).

CONCLUSION

The major causes of blindness found in this study reflected those in estimated data for the region. More studies are needed to improve the quality and quantity of epidemiological data on blindness in Ecuador and Latin America. Many obstacles to successful implementation of prevention of blindness programmes in South America still need to be overcome.