diabetes in egypt
DESCRIPTION
Diabetes in EgyptTRANSCRIPT
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
a
Jord
an
Kuwait
Leba
non
Libya
Bahra
in
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
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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
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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.
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