8 February 2011

It’s a daily struggle for diabetes patients to achieve comprehensive glucose control, a vital measure to prevent future complications.

A LOT has been said and written about type 2 diabetes (T2D), otherwise known as non-insulin-dependent diabetes mellitus or adult-onset diabetes.

It is worrying that many Malaysians are showing symptoms of this disease; once diagnosed, life takes a new turn for patients in many ways.

Those diagnosed with T2D are responsible for the majority of their own self care. These include looking after one’s diet and exercise, handling medication, ensuring compliance, and monitoring one’s own blood glucose.

Add to this is the well known fact that those with T2D tend to have other associated diseases such as high blood pressure, high cholesterol, and obesity. These diseases have their own sets of medications.

When the disease progresses, many patients would suffer various complications such as heart disease, stroke, kidney failure, and blindness, to name a few. The presence of these complications adds a different dimension to the overall management of diabetes.

Managing T2D necessitates a change in lifestyle and can be quite an overwhelming experience for those who are newly diagnosed with the disease, where there is no cure.

While the patient can control or manage T2D, it must be done with regular visits to the doctor. However, as we are all human beings, the reality is that not everyone will be disciplined enough to regularly monitor blood glucose levels, keep appointments with doctors, and make lifestyle changes.

Quite often, it is the poor patient who has to juggle the many different types of medications and resist the temptations of food and drinks.

This is made worse if the patient is reluctant to introduce some kind of exercise into his or her lifestyle. It is a constant struggle, 24/7.

Three key measures

When doctors talk about T2D, we are referring to the glucose triad. It is a set of measures that are critical in managing and controlling T2D.

The first, known as fasting plasma glucose (FPG), refers to the blood sugar level before a meal. The second, known as post-prandial glucose (PPG), refers to the blood sugar level after a meal.

The third, known as haemoglobin A1C (HbA1c), evaluates the overall control of diabetes (over a period of three months) and the risk of complications.

It is accepted fact that tight glycaemic control significantly reduces the risk of microvascular diseases. The optimal control of both FPG and PPG is essential for achieving HbA1c targets.

T2D is characterised by a gradual decline in insulin production in response to nutrient loads, which means that it is primarily a disorder of PPG regulation.

Indeed, there is enough evidence to suggest that post-prandial hyperglycaemia is fairly common, even in people who are considered to have “good metabolic control”.

Therefore, it follows logically that controlling PPG levels, as well as FPG levels, are keys to managing T2D and achieving HbA1c targets.

Regulating FPG levels is necessary, but that alone is insufficient to achieve HbA1c goals in most instances.

PPG is also an essential component in the management of T2D.

Personalised medication

Managing T2D can be a huge challenge, even for the most disciplined and compliant of patients. Patients struggle when they see their HbA1c levels increasing, and they may not know the exact cause.

Add to this fact that many patients often need additional medications to keep their glucose levels in control, there is always the fear of side effects of more medications, mainly that of low blood glucose (hypoglycaemia).

Some patients can manage their blood sugar with diet and exercise alone, but these are exceptions. Most will need diabetes medication and insulin.

The decision about which medication, or combination of medications, depends on many factors and patients should consult their physicians thoroughly on individualised therapy.

Apart from insulin and GLIP-1 analogues, which are given by injections, there are six classes of oral medications that can be prescribed for T2D.

All these medications, which are taken by mouth, help control blood sugar levels using different mechanisms in the body.

Alpha-glucosidase inhibitors, known as AG inhibitors, delay digestion and absorption of carbohydrates in the gut. Biguanides, of which metformin is the only drug in this class, reduces glucose production by the liver during a fasting state.

The class known as sulphonylureas stimulate production of insulin, while the thiazolidinediane (TZD) class of drugs reduce insulin resistance by making muscle and fat cells more sensitive to insulin.

The class known as DPP-4 inhibitors are designed to enhance the body’s ability to increase insulin production, while at the same time reduce the liver’s production of glucose, and can be an effective add-on therapy to metformin or taken on its own.

There may be a strong case to combine drugs from different classes to help control blood sugar levels.

Therein lies the constant patient struggle – not only must the patient remember the combination of drugs, but in many cases, there are other medications to take in order to treat other conditions that are commonly associated with T2D.

More and better attention

“The goal of diabetes therapy should be to achieve glycaemic control as near to normal as safely possible in all three measures of glycaemic control, namely HbA1c, fasting pre-meal, and post-meal plasma glucose,” according to the International Diabetes Federation treatment guidelines.

Based on the 3rd National Health and Morbidity Survey (NHMS III) carried out in 2006 by the Health Ministry, the prevalence of T2D in Malaysia was 11.5% in those above 18 years, and 14.9% in those above 30 years.

The overall prevalence of diabetes among adults above 30 years increased by a staggering 80% over a decade (8.3% in NHMS II in 1996 to 14.9% in NHMS III in 2006), representing an 8% rise per year.

T2D in Malaysia needs more and better attention, lest we become a nation of T2D sufferers. Already, we are seeing an alarming number of children with T2D, meaning that they will grow up to be T2D adults.

The rate of diabetes prevalence in Malaysia has risen much faster than expected, almost doubling in magnitude between 1996 and 2006.

Public health and medical experts continue to work with health groups and other stakeholders to produce better quality educational programmes to increase awareness of T2D.

These programmes focus on giving patients and their doctors that extra help they need to manage this growing chronic disease.

Prof Dr Nor Azmi Kamaruddin is president of the Malaysian Endocrine and Metabolic Society. This article is supported by AstraZeneca’s ‘Extra Help’ campaign for diabetes awareness and education. It is for educational purposes only and should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a qualified health professional.

This article was published in www.thestar.com.my on 20 June 2010.