Pitfalls in the management of diabetes

Type 2 diabetes mellitus (T2DM) is really emerging to be a major public health problem in our country. The experts are alarmed at the increasing prevalence worldwide, particularly in Southeast Asia, and it looks like the Philippines is one of the hot spots that have to be closely monitored. In fact, diabetes is a major culprit why we also have an increasing rate of end-stage renal disease requiring lifelong dialysis or kidney transplantation.

Several days ago, I had the privilege to facilitate a forum on the clinical pitfalls in the management of diabetes mellitus, organized by LRI-Therapharma. Dr. Augusto Litonjua, considered by many as the “Father of Philippine Endocrinology,” and the founding president of the Philippine Society of Endocrinology, Diabetes and Metabolism (PSEDM); Philippine Center for Diabetes Education Foundation (PCDEF), and several other endocrinology associations in the country and in Asia, headed the panel.

Since T2DM is a multisystemic problem damaging every organ of the body particularly the heart and kidneys, equally renowned specialists in these organs were also present, namely, Dr. Nelson Abelardo, chief of the cardiovascular section and assistant medical director of Manila Doctor’s Hospital; and Dr. Agnes Estrella, head of the dialysis units of the ACE Medical Center, Our Lady of Mercy General Hospital and Galvez Medical Center in Bulacan.

The big problem

The whole panel stressed that the big problem in the management of T2DM is that patients usually have no symptoms for a good number of years, and many remain undiagnosed; or if diagnosed, they do not take their prescribed medicines because anyway, they don’t have any symptom. Little do they realize that slowly, their heart, kidneys, brain, eyes, nerves and arteries are slowly being affected leading to irreversible damage and complications like heart attack and heart failure, stroke, kidney failure, blindness and leg gangrene requiring amputation—just to name a few.

Early treatment and control of T2DM is beneficial and leads to a good “legacy effect,” says Dr. Litonjua. He explains that a legacy effect means that early diagnosis and treatment can lead to long-term benefits in preventing the dreaded complications of T2DM caused by injury to the small blood vessels (microvascular) and big blood vessels (macrovascular). Examples of microvacular complications are kidney disease (nephropathy) and eventual failure, nerve injury or neuropathy, and eye problems leading to blindness (retinopathy). Examples of macrovascular complications are narrowing of the heart and brain arteries leading to heart attack and stroke.

Screening guidelines

To diagnose T2DM early, the PSEDM, Diabetes Philippines, Institute for Studies on Diabetes Foundation (ISDF) and PCDEF came up with screening guidelines for early detection, and they recommend this be done if one or more of the following are present:

• Sustained blood pressure (BP) equal or more than 140/90 mm Hg;
• Obesity; and
• Age more than 40 years.

Elevated BP and obesity are common accompanying problems of T2DM. They usually cluster together; hence, when found together, they’re called “Metabolic Syndrome.” Why 40 years of age as a cut-off age? That’s the age older than which the incidence of T2DM shoots up remarkably, based on the findings of a local survey—the National Nutrition and Health Survey.

The panel also cited a recent update of treatment guidelines published by the American Association of Clinical Endocrinologists (AACE), which also has a local chapter (AACE-Philippines). The following underlying principles are emphasized as the basis for management of T2DM:

1. Blood sugar target, reflected by the blood test called HbA1c, should be individualized based on age, life expectancy, comorbidities, diabetes duration, hypoglycemic risk, etc.
2. Self-monitoring of blood sugar levels at home by the patient can serve as an important guide for adjusting medications.
3. Patient-related and medication-related factors should be considered in prescribing the most suitable antidiabetic therapy for a patient.
4. To prevent hypoglycemia and reduce the risk for weight gain are accompanying priorities for any antidiabetic therapy.

Since the main goal in the management of T2DM is to prevent complications, the following approaches are also considered important:

• Yearly dilated eye examinations (fundoscopy) to determine any damage of the nerves (retinopathy);
• Annual microalbumin determination in the urine to determine the earliest sign of kidney involvement;
• Foot examinations at each visit, checking the pulses and determining any sign of poor circulation in the legs and feet;
• HbA1c every three to six months to determine if target blood sugar levels are attained (which should be individualized depending on age, life expectancy, other concomitant problems);
• Blood pressure preferably less than 130/80 mm Hg, and even lower if there is kidney involvement already (diabetic nephropathy); and

• Statin therapy to reduce low-density lipoprotein cholesterol, even if the cholesterol levels are average or even normal.