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

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

Egypt

Iran

Iraq

Saudi

Arabia

Algeria

Mor

occo

Syria

Sudan

UAE

Tunisi

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Kuwait

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Libya

Bahra

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2003

2025

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

12

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)

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

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Additional Concerns

• Depression and other mental disorders

• Dental disease

• Increased risk of infection

• Can affect fertility

• Severe hyper- or hypo- glycemic events

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

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 yearNIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2010.

Relative Risk of Progression of Relative Risk of Progression of Diabetic ComplicationsDiabetic Complications

DCCT Research Group, N Engl J Med 1993, 329:977-986.

RELA

TIV

E

RIS

K

Mean A1C

Who Is At Risk?• Age 45 or older

• Overweight

• Inactive

• Ethnic or minority population

• Family history of diabetes

• Excess abdominal fat

• High blood pressure

• Pre-diabetes

• High blood fats

• Darkening of the skin

• Polycystic ovary syndrome

• History of Gestational Diabetes or large baby

Could You be at Risk for Diabetes?

Where do you start?• ADA Risk Test (paper or online)

www.diabetes.org

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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 patient-centered approach, Position Statement by the ADA and the EASD. Diabetes Care. 2012;35:1364-79.

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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

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.

The Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) Collaborative Group. NEJM. 2008;358(24):2560-72. Duckworth W, Abraira C, Moritz T, et al. NEJM. 2009;360(2):129-39.

Intensive Glycemic Control and Intensive Glycemic Control and Cardiovascular Outcomes: ACCORDCardiovascular Outcomes: ACCORD

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

©2008 New England Journal of Medicine. Used with permission.

Primary Outcome: Nonfatal MI, nonfatal stroke, CVD death

HR=0.90 (0.78-1.04)

Intensive Glycemic Control and Intensive Glycemic Control and Cardiovascular Outcomes: ADVANCECardiovascular Outcomes: ADVANCE

©2008 New England Journal of Medicine. Used with permission.

Primary Outcome: Microvascular plus macrovascular (nonfatal MI, nonfatal stroke, CVD death)

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

HR=0.90 (0.82-0.98)

Intensive Glycemic Control and Intensive Glycemic Control and Cardiovascular Outcomes: VADTCardiovascular Outcomes: VADT

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

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.

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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,

non-fatal MI, composite microvascular complications, or retinopathy

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

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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.

Ultimate Goals Of Diabetes Treatment

Sustained Normal BloodGlucose Control

Lowest Incidence of Hypoglycemia

No Long Term DiabetesComplications

No Acute DiabetesComplications

=

=

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 ManagementPrimary Objectives of Effective Management

A1C%

SBPmm Hg

LDLmg/dL

45 50 55 60 65 70 75 80 85 90

9

Diagnosis

8

7

130

100

145

140

Patient Age

Reduction of both

micro- and macro-

vascular event rates

…by 75%!

lGæde 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.

Glycemic Recommendations forGlycemic Recommendations forNonpregnant Adults with Diabetes (1)Nonpregnant Adults with Diabetes (1)

A1C <7.0%*

Preprandial capillary plasma glucose

70–130 mg/dL* (3.9–7.2 mmol/L)

Peak postprandial capillary plasma glucose†

<180 mg/dL* (<10.0 mmol/L)

*Individualize goals based on these values.†Postprandial glucose measurements should be made 1–2 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 Recommendations: Glycemic, Blood Pressure, Lipid Control in AdultsPressure, Lipid Control in Adults

A1C <7.0%*

Blood pressure <140/80 mmHg†

Lipids: LDL cholesterol

<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:Recommendations:Coronary Heart Disease Treatment (1)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– β-blockers should be continued for at least

2 years after the event (B)

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

*If not contraindicated.

Recommendations:Recommendations:Coronary Heart Disease Treatment (2)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: RetinopathyRecommendations: 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: NephropathyRecommendations: 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