What the primary healthcare worker needs to know about the management of type...

[Full title: What the primary healthcare worker needs to know about the management of type 2 diabetes]

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SA Hypertension Society Supplement: What the primary healthcare worker needs to know about the management of type 2 diabetes S 20 S Afr Fam Pract 2012 Vol 54 No 2 Supplement 1 Globally, type 2 diabetes remains the most common type of diabetes, and its prevalence is rising, unabatedly driven by physical inactivity and the emerging epidemic of obesity 1 The risk of developing type 2 diabetes is especially increased in rural girls, of whom up to 25% are already overweight or obese in late adolescence 2 Ideally, diabetes care is organised around the person with diabetes, incorporating a multiand interdisciplinary diabetes healthcare team, focused on self-care management 3 This ideal remains largely elusive in the South African public healthcare sector, although significant progress has made in the private healthcare sector 4 Diabetes patient care flow sheets, care objectives and patient information leaflets are freely available 5 Initial evaluation of a patient with type 2 diabetes, whether newly diagnosed or established, presents a unique opportunity to individualise a comprehensive care plan 6 The lowering of haemoglobin A 1 c levels (HbA 1 c ) to 7%, or lower reduces the development of microvascular complications in the long term. If initiated early, intensive glycaemic control also translates to a reduction in macrovascular disease, the so-called legacy effect of tight control 7 Less stringent control is acceptable in patients with a history of severe hypoglycaemia and co-morbid disease, and reduced life expectancy. Regular exercise is strongly advised for all patients, in the absence of contraindications 6 Exercise prevents the onset of type 2 diabetes in high-risk individuals, and also improves glucose control, reduces cardiovascular risk, improves well-being, and promotes weight loss. The American Diabetes Association (ADA) recommendation with regard to exercise is very specific. It advocates at least 150 minutes/week of moderate-intensity aerobic physical activity, spread out over three days, with no more than two consecutive days lapsing without exercise 6 Medical nutrition therapy (MNT) forms an integral part of the lifestyle changes aimed at moderate and sustained weight loss, and improves diabetes control. Ideally, it should be combined with regular exercise 6 Nutrition counselling should preferably be delivered by a registered dietitian, and is equally effective when given to a small group, or on a one-to-one basis 6 In contrast to past policy, the ADA now recommends that metformin therapy should be initiated, along with lifestyle interventions and MNT, unless metformin is contraindicated in newly diagnosed patients with type 2 diabetes 6 A second agent from a different class, such as a sulphonylurea, should be added if HbA 1 c targets are not met within three to six months. It is of interest that each class of non-insulin agent that is added to the initial therapy decreases HbA 1 c by 0.9-1.1% on average 6 Both the ADA and the Canadian Diabetes Association now recommend that in newly diagnosed patients with type 2 diabetes, and with marked hyperglycaemia or elevated HbA 1 c (> 9%), insulin therapy should be considered from the outset, with or without additional agents 6,8 Alternative therapies that may be considered in special circumstances include acarbose and the newer classes of agents, such as the incretins and dipeptidyl peptidase-4 (DPP-4) inhibitors 6 The US Food and Drug Administration recently issued a warning on the continued use of rosiglitazone, due to concerns about an increase in cardiovascular mortality 9 The remaining thiazolidenedione, pioglitazone, has recently been associated with an increased risk of bladder cancer 10 Hypoglycaemia may result from the use of insulin and insulin secretagogues, such as sulphonylureas, and is the main limiting factor for glycaemia management in patients with type 2 diabetes 6 Severe hypoglycaemia in older adults increases the risk of dementia 11 Patients should be fully informed about the precipitating factors for hypoglycaemia, and how to recognise symptoms. Relatives What the primary healthcare worker needs to know about the management of type 2 diabetes Mollentze WF , MD, FCP(SA), MMed(Int), FACE, FRCP Department of Medicine, University of the Free State Correspondence to : Willie Mollentze, e-mail: mollentzewf@ufs.ac.za Keywords : primary healthcare worker, type 2 diabetes, management © Medpharm S Afr Fam Pract 2012;54(2)(Suppl 1):S 20-S 22

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SA Hypertension Society Supplement: What the primary healthcare worker needs to know about the management of type 2 diabetes S 21 S Afr Fam Pract 2012 Vol 54 No 2 Supplement 1 should be instructed on how to manage severe hypoglycaemia, including the use of glucagon 6 Cardiovascular risk factors in patients with type 2 diabetes should be aggressively managed. Lowdose aspirin may be beneficial in diabetics for the primary prevention of vascular disease and in subjects who have a 10-year risk of cardiovascular disease (CVD) events exceeding 10%, and who are not at increased risk of bleeding 12 Aspirin should not be recommended for primary prevention of CVD to adults with diabetes who are at low CVD risk (< 5%) 12 The ADA also recommends low-dose aspirin as a secondary prevention strategy in diabetics with a history of CVD 6 Low-density lipoprotein (LDL) cholesterol levels should be lowered to < 2.6 mmol/l initially in most patients with diabetes, together with optimal glycaemic control, MNT, and lifestyle intervention 6 Statin therapy should be considered in patients who do not respond to nonpharmacological measures, in patients older than 40 years with additional risk factors, and in those with clinical CVD, regardless of the LDL cholesterol level. In such patients, the LDL cholesterol goal should be < 1.8 mmol/l 6 Severe hypertriglyceridaemia [triglyceride levels > 10 mmol/l] may cause acute pancreatitis, and should be managed immediately with MNT, fibrates, niacin, or fish oil 6 Diabetes is the leading cause of end-stage renal disease in Europe and the USA 13 Approximately 40% of patients with diabetes will develop chronic kidney disease (CKD) 13 Classic diabetic nephropathy progresses from subclinical disease to the earliest clinically detectable stage, and is characterised by persistent proteinuria 14 Before each screening and urine dipstick testing, transient causes of albuminuria [such as recent strenuous exercise, menstruation, fever, urinary tract infections, pregnancy, uncontrolled heart failure or acute severe elevation in blood pressure (BP) or blood glucose], low estimated glomerular filtration rate (such as dehydration and hypovolaemia) and acute renal failure on clinical grounds should be excluded 14 All patients with type 2 diabetes should be screened for microalbuminuria at the time of diagnosis, since type 2 diabetes may be present for some time before diagnosis 15 Adults with diabetes and persistent albuminuria [albumin/creatinine ratio (ACR) > 2 mg/ mmol in males, > 2.8 mg/mmol in females] should be given an angiotensin-converting enzyme (ACE) inhibitor to delay progression of CKD, 16 even in the absence of hypertension 14 Typically ACE inhibitors such as enalapril 10-20 mg daily, perindopril 2 mg daily, ramipril 2.5-10 mg daily and lisinopril 5-20 mg daily were used in clinical trials to prevent, or delay, a progressive decline in glomerular filtration rate 17 Patients should be monitored with follow-up testing of their serum creatinine and potassium levels, within one to two weeks of initiation of an ACE inhibitor or angiotensin-receptor blocker (ARB) or titration of the dose in the event of significant worsening of the renal function, or the development of hyperkalaemia 14 Serum creatinine may increase by up to 30% above baseline, after initiation of an ACE inhibitor or an ARB 18 In such an event, the ACE inhibitor or ARB should be discontinued. Referral to a nephrologist or a physician who is experienced in the management of renal disease should be considered when there is chronic progressive loss of renal function in spite of the suggested measures. This also applies when any of the following criteria are present: estimated glomerular filtration rate is < 30 ml/minute, ACR is persistently above 60 mg/mmol; BP targets cannot be reached, patients cannot tolerate ACE inhibitors or ARBs due to hyperkalaemia, and a > 30% increase in serum creatinine within three months of starting these agents 14 Up to 40% of patients with diabetes have diabetic retinopathy, while 8% have sight-threatening retinopathy 19 All patients with type 2 diabetes should be screened for diabetic retinopathy at diagnosis 20 Since few primary healthcare workers in South Africa are adequately trained to screen for diabetic retinopathy, most patients at primary healthcare level will have to be referred to a skilled professional for screening. Diabetic retinopathy may be prevented, or delayed, by tight glycaemic control, and by treating elevated BP and lipids to target 20 Hypertension is present in about one third of patients with type 2 diabetes at diagnosis 21 Hypertension in diabetes is aggressive and progresses rapidly to renal failure, unless it is treated aggressively 21 The treatment goals for hypertension in persons with diabetes and hypertension should be a systolic BP (SBP) < 130 mmHg and diastolic BP (DBP) < 80 mmHg 6,21 Lifestyle intervention, including MNT, should be the first step towards the lowering of BP in patients with a BP ≥ 130/80 mmHg, normal urinary albumin excretion, and without chronic kidney disease 22 Should BP targets not be reached with these measures, pharmacological therapy should be introduced. Monotherapy, with any one of the following medications, should be considered: an ACE inhibitor (or an ARB, if the ACE is not tolerated), a dihydropyridine (DHP) calcium-channel blocker or a thiazide-type diuretic 22 If monotherapy fails, these agents could be used in combination. For patients with BP ≥ 130/80 mmHg and microalbuminuria,

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SA Hypertension Society Supplement: What the primary healthcare worker needs to know about the management of type 2 diabetes S 22 S Afr Fam Pract 2012 Vol 54 No 2 Supplement 1 an ACE inhibitor (or an ARB if the ACE inhibitor is not tolerated) is the first choice 22 If the BP target is not reached, a DHP calcium-channel blocker or a thiazide diuretic should be added 22 Two or more agents at maximal dose are usually required to achieve BP targets 22 If ACE inhibitors, ARBs or diuretics are used, kidney function and serum potassium levels should be monitored 6 In a large cohort of patients with type 2 diabetes, 59% had some form of neuropathy, while polyneuropathy was present in 45% of these 23 Foot ulceration and amputation are costly complications of diabetic neuropathy 24 Annual screening for neuropathy can be performed reliably and rapidly by either the 5.07/10 g Semmes-Weinstein monofilament method, or vibration sense testing with a 128 Hz tuning fork utilising the on-off method 25 Intensive glycaemic control in the United Kingdom Prospective Diabetes Study (UKPDS) reduced the development of microvascular complications, including neuropathy 26 The plethora of pharmacological agents recommended for the treatment of painful polyneuropathy 24 gives an indication of the difficulty of treating this often crippling condition successfully. Counselling patients at high risk of foot ulceration can prevent this from happening, while performing regular examinations of the feet, by both the patient and a healthcare professional, is a proven strategy in ultimately preventing amputation 27 Conclusion Type 2 diabetes is a chronic, and often debilitating, condition, calling for a multidisciplinary approach and ongoing medical care. Patient education and self-care is central to the prevention of acute complications, and that of chronic macroand microvascular complications References 1. Diabetes. World Health Organization [homepage on the Internet]. c 2012. Available from: http://www.who.int/mediacentre/factsheets/ fs 312/en/ 2. Kimani-Murage EW, Kahn K, Pettifor JM, et al. The prevalence of stunting, overweight and obesity, and metabolic disease risk in rural South African children. BMC Public Health. 2010;10:158. 3. Ludwig S, Clement M, Dunbar P, Johnson JA. Organization of diabetes care. Clinical practice guidelines for the prevention and management of diabetes. Can J Diab. 2008;32:S 20-S 24 4. Distiller LA, Brown MA, Joffe BI, Kramer BD. Striving for the impossible dream: a community-based multi-practice collaborative model of diabetes management. Diabet Med. 2010;27(2):197-202 5. Sample diabetes patient care flow sheet for adults. Clinical practice guidelines for the prevention and management of diabetes. Can J Diab. 2008;S 195-197 6. Position statement: standards of medical care in diabetes - 2012. Diabetes Care. 2012;35 Suppl 1:S 11-S 63 7. Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359(15):1577-1589 8. Harper W, Hanna A, Woo V, et al. Pharmacologic management of type 2 diabetes. Clinical practice guidelines for the prevention and management of diabetes. Canadian Journal of Diabetes. 2008;32:S 53-S 61 9. Woodstock J, Sharfstein J, Hamburg M. Regulatory action on rosiglitazone by the US Food and Drug Administration. N Eng J Med. 2010;363(16):1489-1491 10. Piccinni C, Motala D, Marchesini G, Poluzzi E. Assessing the association of pioglitazone use and bladder cancer through drug adverse event reporting. Diab Care. 2011;34(6):1369-1371 11. Whitmer RA, Karter AJ, Yaffe K, et al. Hypoglycaemic episodes and risk of dementia in older patients with type 2 diabetes. JAMA. 2009:301(15):1565-1572 12. Pignone A, Alberts MJ, Colwell JA, et al. Aspirin for primary prevention of cardiovascular events in people with diabetes: a position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation. Diab Care. 2010;33(6):1395-1402 13. Palmer AJ, Valentine WJ, Chen R, et al. A health economic analysis of screening and optimal treatment of nephropathy in patients with type 2 diabetes and hypertension in the USA. Nephrol Dial Transplant. 2008;23(4):1216-1223 14. McFarlane P, Culleton B. Chronic kidney disease in diabetes: 2008 clinical practice guidelines. Canadian Medical Journal. 2008:S 126-S 133 15. Ballard DJ, Humphrey LL, Melon LJ, et al. Epidemiology of persistent proteinuria in type II diabetes mellitus. Diabetes. 1998;37(4):405-412 16. Lewis EJ, Hunsicker LG, Bain RP, et al. The effect of angiotensin converting enzyme inhibition on diabetic nephropathy. N Engl J Med. 1993;329(20):1456-1462 17. Chaturvedi N. Should all patients with type 1 diabetes mellitus and microalbuminuria receive angiotensin-converting enzyme inhibitors? Ann Int Med. 2001;134(5):370-379 18. Bakris GL, Weir MR. Angiotensin-converting enzyme inhibitor-associated elevations in serum creatinine: is this a cause for concern? Arch Intern Med. 2000;160(5):685-693. 19. Kempen JH, O’Colmain BJ, Leske MC, et al. The prevalence of diabetic retinopathy among adults in the United States. Arch Ophthalmol. 2004;122(4):552-563 20. Boyd SR, Altomere F. Retinopathy. Canadian Diabetes Association: 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diab. 2008;S 134-S 139 21. Seedat YK, Rayner BL. South Africn hypertension guideline 2011. S Afr Med J. 2012;102(1):57-88 22. Culleton B, Drouin D, LaRochelle P, et al. Treatment of hypertension. Canadian Diabetes Association 2008: clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diab. 2008;32:S 115-S 118. 23. Dyck PJ, Kratz KM, Karnes JL, et al. The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the Rochester Diabetic Neuropathy Study. Neurology.1993;43(4):817-824 24. Bril V, Perkins B. Neuropathy. Canadian Diabetes Association 2008: clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diab. 2008;32:S 140-S 142. 25. Perkins BA, Olaleye D, Zinmen B, Bril V. Simple screening tests for neuropathy in the diabetes clinic. Diabetes Care. 2001;24(2):250-256 26. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352(9131):837-853 27. Bowering K, Ekoé J-M, Kalla TP. Foot care. Canadian Diabetes Association 2008: clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diab. 2008;32:S 143-S 146.