Management of Type 2 Diabetes in Developing Countries: Balancing Optimal Glycaemic Control and Outcomes with Affordability and Accessibility to Treatment

A retrospective cohort study of a community-based primary care program's effects on pharmacotherapy quality in low-income Peruvians with type 2 diabetes and hypertension

Little is known about the effects of the Chronic Care Model (CCM) and community health workers (CHWs) on pharmacotherapy of type 2 diabetes and hypertension in resource-poor settings. This retrospective cohort implementation study evaluated the effects of a community-based program consisting of CCM, CHWs, guidelines-based treatment protocols, and inexpensive freely accessible medications on type 2 diabetes and hypertension pharmacotherapy quality. A door-to-door household survey identified 856 adults 35 years of age and older living in a low-income Peruvian community, of whom 83% participated in screening for diabetes and hypertension. Patients with confirmed type 2 diabetes and/or hypertension participated in the program's weekly to monthly visits for < = 27 months. The program was implemented as two care periods employed sequentially. During home care, CHWs made weekly home visits and a physician made treatment decisions remotely. During subsequent clinic care, a physician attended patients in a centralized clinic. The study compared the effects of program (pre- versus post-) (N = 262 observations), and home versus clinic care periods (N = 211 observations) on standards of treatment with hypoglycemic and antihypertensive agents, angiotensin converting enzyme inhibitors, and low-dose aspirin. During the program, 80% and 50% achieved hypoglycemic and antihypertensive standards, respectively, compared to 35% and 8% prior to the program, RRs 2.29 (1.72-3.04, p <0.001) and 6.64 (3.17-13.9, p<0.001). Achievement of treatment standards was not improved by clinic compared to home care (RRs 1.0 +/- 0.08). In both care periods, longer retention in care (>50% of allowable time) was associated with achievement of all treatment standards. 85% compared to 56% achieved the hypoglycemic treatment standard with longer and shorter retention, respectively, RR 1.52 (1.13-2.06, p<0.001); 56% compared to 27% achieved the antihypertensive standard, RR 2.11 (1.29-3.45, p<0.001). In a dose-dependent manner, the community-based program was associated with improved guidelines-based pharmacotherapy of type 2 diabetes and hypertension.

The correlation between mitochondrial derived peptide (MDP) and metabolic states: a systematic review and meta-analysis

BACKGROUND

MOTS-c is known as mitochondrial open reading frame (ORF) of the twelve S c, produced by a small ORF-encoded peptides (SEPs) in mitochondrial 12S rRNA region. There is growing evidence that MOTS-c has a strong relationship with the expression of inflammation- and metabolism-associated genes and metabolic homeostasis, and even offering some protection against insulin resistance (IR). However, studies have reported inconsistent correlations between different population characteristics and MOTS-c levels. This meta-analysis aims to elucidate MOTS-c levels in physiological and pathological states, and its correlation with metabolic features in various physiological states.

METHODS

We conducted a systematic review and meta-analysis to synthesize the evidence of changes in blood MOTS-c concentration, and any association between MOTS-c and population characteristic. The Web of Science, PubMed, EMBASE, CNKI, WANGFANG and VIP databases were searched from inception to April 2023. The statistical analysis was summarized using the standardized mean difference (SMD) and 95% confidence interval (95% CIs). Pearson correlation coefficient was used to analyze the correlation and generate forest plots through a random-effects model. Additional analyses as sensitivity and subgroup analyses were performed to identify the origins of heterogeneity. Publication bias was retrieved by means of a funnel-plot analysis and Egger's test. All related statistical analyses were performed using Revman 5.3 and Stata 15 statistical software.

RESULT

There are 6 case-control studies and 1 cross-sectional study (11 groups) including 602 participants in our current meta-analysis. Overall analysis results showed plasma MOTS-c concentration in diabetes and obesity patients was significantly reduced (SMD = - 0.37; 95% CI- 0.53 to - 0.20; P < 0.05). After subgroup analysis, the present analysis has yielded opposite results for MOTS-c changes in obesity (SMD = 0.51; 95% CI 0.21 to 0.81; P < 0.05) and type 2 diabetes mellitus (T2DM) (SMD = - 0.89; 95% CI - 1.12 to - 0.65; P < 0.05) individuals. Moreover, the correlation analysis was performed to identify that MOTS-c levels were significantly positively correlated with TC (r = 0.29, 95% CI 0.20 to 0.38) and LDL-c (r = 0.30, 95% CI 0.22 to 0.39). The subgroup analysis results showed that MOTS-c decreased significantly in patients with diabetes (SMD = - 0.89; 95% CI- 1.12 to - 0.65; P < 0.05). In contrast, the analysis result for obesity persons (BMI > 28 kg/ m2) was statistically significant after overweight people (BMI = 24-28 kg/ m2) were excluded (SMD = 0.51; 95% CI 0.21 to 0.81; P < 0.05), which is completely different from that of diabetes. Publication bias was insignificant (Egger's test: P = 0.722).

CONCLUSION

Circulating MOTS-c level was significantly reduced in diabetic individuals but was increased significantly in obesity patients. The application of monitoring the circulating levels variability of MOTS-c in routine screening for obesity and diabetes is prospects and should be taken into consideration as an important index for the early prediction and prevention of metabolic syndrome in the future. PROSPERO registration number CRD42021248167.

Glycaemic control is still central in the hierarchy of priorities in type 2 diabetes management

A panel of primary care and diabetes specialists conducted focused literature searches on the current role of glycaemic control in the management of type 2 diabetes and revisited the evolution of evidence supporting the importance of early and intensive blood glucose control as a central strategy to reduce the risk of adverse long-term outcomes. The optimal approach to type 2 diabetes management has evolved over time as the evidence base has expanded from data from trials that established the role of optimising glycaemic control to recent data from cardiovascular outcomes trials (CVOTs) demonstrating organ-protective effects of newer glucose-lowering drugs (GLDs). The results from these CVOTs were derived mainly from people with type 2 diabetes and prior cardiovascular and kidney disease or multiple risk factors. In more recent years, earlier diagnosis in high-risk individuals has contributed to the large proportion of people with type 2 diabetes who do not have complications. In these individuals, a legacy effect of early and optimal control of blood glucose and cardiometabolic risk factors has been proven to reduce cardiovascular and kidney disease events and all-cause mortality. As there is a lack of RCTs investigating the potential synergistic effects of intensive glucose control and organ-protective effects of newer GLDs, this article re-evaluates the evolution of the scientific evidence and highlights the importance of integrating glycaemic control as a pivotal early therapeutic goal in most people with type 2 diabetes, while targeting existing cardiovascular and kidney disease. We also emphasise the importance of implementing multifactorial management using a multidisciplinary approach to facilitate regular review, patient empowerment and the possibility of tailoring interventions to account for the heterogeneity of type 2 diabetes.

Current Position of Gliclazide and Sulfonylureas in the Contemporary Treatment Paradigm for Type 2 Diabetes: A Scoping Review

The increasing burden of type 2 diabetes (T2D), in relation to alarming rise in the prevalence; challenges in the diagnosis, prevention, and treatment; as well as the substantial impact of disease on longevity and quality of life, is a major concern in healthcare worldwide. Sulfonylureas (SUs) have been a cornerstone of T2D pharmacotherapy for over 60 years as oral antidiabetic drugs (OADs), while the newer generation SUs, such as gliclazide modified release (MR), are known to be associated with low risk of hypoglycemia in addition to the cardiovascular neutrality. This scoping review aimed to specifically address the current position of gliclazide MR among other SUs in the contemporary treatment paradigm for T2D and to provide a practical guidance document to assist clinicians in using gliclazide MR in real-life clinical practice. The main topics addressed in this paper include the role of early and sustained glycemic control and use of SUs in T2D management, the properties of gliclazide MR in relation to its effectiveness and safety, the use of gliclazide therapy in special populations, and the place of SUs as a class and gliclazide MR specifically in the current T2D treatment algorithm.

Role of Synbiotics (Prebiotics and Probiotics) as Dietary Supplements in Type 2 Diabetes Mellitus Induced Health Complications

Diabetes is a metabolic disorder whose prevalence has become a worrying condition in recent decades. Chronic diabetes can result in serious health conditions such as impaired kidney function, stroke, blindness, and myocardial infarction. Despite a variety of currently available treatments, cases of diabetes and its complications are on the rise. This review article provides a comprehensive account of the ameliorative effect of prebiotics and probiotics individually or in combination i.e. synbiotics on health complications induced by Type 2 Diabetes Mellitus (T2DM). Recent advances in the field underscore encouraging outcomes suggesting the consumption of synbiotics leads to favorable changes in the gut microbiota. These changes result in the production of bioactive metabolites such as short-chain fatty acids (crucial for lowering blood sugar levels), reducing inflammation, preventing insulin resistance, and encouraging the release of glucagon-like peptide-1 in the host. Notably, novel strategies supplementing synbiotics to support gut microbiota are gaining attraction as pivotal interventions in mitigating T2DM-induced health complications. Thus, by nurturing a symbiotic relationship between prebiotics and probiotics i.e. synbiotics, these interventions hold promise in reshaping the microbial landscape of the gut thereby offering a multifaceted approach to managing T2DM and its associated morbidities. Supporting the potential of synbiotics underscores a paradigm shift toward holistic and targeted interventions in diabetes management, offering prospects for improved outcomes and enhanced quality of life for affected individuals. Nevertheless, more research needs to be done to better understand the single and multispecies pre/pro and synbiotics in the prevention and management of T2DM-induced health complications.

Insulin therapy among diabetic patients in rural communities of Sub-Saharan Africa: a perspective review

In this perspective review, we describe a brief background on the status quo of diabetes mellitus-related therapies and glycemic control among patients in rural communities in sub-Saharan Africa. The article discusses insulin therapy as well as the difficulties in obtaining insulin and oral hypoglycemic medications for diabetic patients living in sub-Saharan Africa. We wrap up our discussion with suggestions on solutions and opportunities for future research to tackle this health challenge in these impoverished communities. We conducted a literature search from PubMed and Google Scholar up until August 2023. Key words were used to generate search terms used to retrieve the required information. All types of literature with pertinent information on the current topic were included in the study. Diabetes mellitus is on the rise in sub-Saharan Africa. Several studies have reported poor glycemic control, low screening rates for diabetes mellitus, cigarette smoking, high alcohol consumption, prescription of antidiabetic therapy, and associated costs as contributors to the uptake of antidiabetic treatment. Although there is paucity of data on the extent of insulin therapy uptake and its possible modifiable contributors among the diabetic patients in the region, the anticipated increase in the number of people with diabetes on the continent makes it critical for global leaders to address the research gaps in insulin therapy among rural communities of sub-Saharan Africa, thus reducing the burden of diabetes in these populations.

Mobilizing morality: how caregivers in Vietnam handle the challenges of daily diabetes care

BACKGROUND

As a chronic disease, type 2 diabetes (T2D) often involves long-term care obligations for patients' family members. Understanding the socially and culturally specific challenges that family caregivers face and how they cope with them is crucial in developing targeted and effective interventions to support both caregivers and patients with T2D. This research examined family caregiving for people with T2D living in rural northern Vietnam. Although there is a growing literature on family support in Vietnam, little is known about the personal experiences of family caregivers for people with T2D. This paper seeks to fill this gap revealing some of the challenges and coping strategies of family caregivers to people with T2D.

METHODS

This qualitative study is based on ethnographic research using primarily semi-structured interviews with 21 caregivers to a person with T2D in Vietnam. The research was conducted in 2022 by a Vietnamese-Danish research team. Each interview was voice-recorded, transcribed verbatim and thematically coded.

RESULTS

Four major challenges emerged from the analysis: physical health concerns, psychological exhaustion, economic burdens, and lack of support. Caregivers expressed motivation to overcome these challenges as they felt a deep sense of responsibility towards their family member with diabetes. The primary caregiver's sense of responsibility toward their family would often cause them not to share the burdens from caregiving with other family members to avoid burdening them as well. However, negative experiences from caregiving were decreased and positive feelings increased in the instances where caregiving was shared between multiple family members.

CONCLUSION

While family members expressed motivation to take care of the patient because of moral obligations, some caregivers, specifically primary caregivers, did not want to burden other family members with care tasks and were reluctant to ask for assistance. For families who did share the caregiving tasks among several family members, some of the negative sentiments associated with caregiving were diminished. Having multiple members of a family forming a caregiving community thus motivated people in handling care challenges.

A Survey on Factors Affecting Knowledge and Satisfaction with Care Among Persons with Diabetes Mellitus in an Urban Health Centre and its Outreach Clinics in South India

Objective

To determine the level of knowledge and factors affecting knowledge and satisfaction with diabetes care among persons with diabetes at urban health centre (UHC) and community health worker (CHW)-led outreach clinics (ORC) in South India.

Methodology

A cross-sectional study was carried out using a structured questionnaire. One hundred patients at the UHC and 200 patients at the ORC were included.

Results

Patients with DM of more than eight years, with co-morbidities and maintained on insulin had good knowledge at the UHC. At the ORC, participants who received education beyond the primary level and belonging to non - Hindu religion had higher knowledge. Patients at the ORC experienced better satisfaction in terms of waiting time for appointments, consultation, registration system and counselling. At the UHC, those who received primary education or those with lower educational attainment had better satisfaction. Overall, knowledge (p = 0.03) and satisfaction (p = 0.00001) of diabetes care was better at the ORC than at the UHC.

Conclusions

Our study found better knowledge and satisfaction with diabetes care at the ORC than at the UHC. Whether or not the difference can be attributed to CHW-based clinics in the community needs to be further elucidated.

Phytochemical profiling, in vitro antioxidants, and antidiabetic efficacy of ethyl acetate fraction of Lespedeza cuneata on streptozotocin-induced diabetic rats

In the recent past, phytomolecules are exponentially applied in discovering the antidiabetic drug due to less adverse effects. This work screened the active solvent fraction of Lespedeza cuneata based on the phytochemical, enzyme inhibition, and antioxidant properties. The antioxidant efficacy of the different fractions of the L. cuneata was assessed by 1,1-diphenyl-2-picrylhydrazyl (DPPH), 2,2'-azino-bis(3-ethylbenzothiazoline-6-sulfonic acid) (ABTS), ferric reducing power, hydrogen peroxide, and hydroxyl radical scavenging assays. The digestive enzyme (α-amylase and α-glucosidase) inhibitory activity was also evaluated. The phytochemical composition of ethyl acetate fraction of L. cuneata (Lc-EAF) was studied by UHPLC-QTOF-MS/MS. The effect of Lc-EAF treatments on glucose uptake was studied in insulin resistance HepG2 cells (IR-HepG2). Further, the antidiabetic effect of Lc-EAF in streptozotocin (STZ)-induced diabetic mice were demonstrated. Ethyl acetate, hexane, and methanol fractions of the L. cuneata showed notable antioxidant, α-amylase, and α-glucosidase inhibitory properties. Among the fractions, Lc-EAF was found to be the most potent. The Lc-EAF exhibited an IC₅₀ of 205.32 ± 23.47 µg/mL and 105.32 ± 13.93 µg/mL for α-amylase and α-glucosidase inhibition, respectively. In addition, 75 µg/mL of Lc-EAF exposure enhanced glucose uptake (68.23%) in IR-HepG2 cells. In vivo study indicated that treatment of Lc-EAF (100 mg/kg b.wt) maintained the blood glucose level through reduced insulin level while improving the lipid profile, hepatic, and renal markers. These findings suggest that Lc-EAF could be considered a prominent source for antidiabetic, anti-hyperlipidemic, and anti-ROS potentials.

Adjusting the Use of Glucose-Lowering Agents in the Real-World Clinical Management of People with Type 2 Diabetes: A Narrative Review

Despite the availability of new treatment classes, glycaemic control in patients with diabetes remains suboptimal globally. The latter is associated with high risk of premature mortality related to diabetes and its microvascular and macrovascular complications. Practice guidelines typically focus on glycated haemoglobin < 7.0% as a therapeutic goal in type 2 diabetes (T2D). Reducing glycated haemoglobin has been proven to reduce the risk of these complications while early attainment of glycaemic goal can have a legacy effect in later life. Both glucocentric and cardiorenal-centric treatment strategies have complementary effects in reducing the trajectory of cardiorenal diseases. In real-word settings, implementation of practice guidelines developed in the USA and Europe may not be applicable to regions such as Asia, where differences in epidemiology, patient phenotypes, cultures, resource availability, and treatment affordability are important considerations. In the present review, we discuss the need to use a pragmatic, albeit evidence-based approach, to combine glucocentric and cardiorenal risk reduction strategies to improve the outcomes in patients with T2D, with particular relevance to Asia Pacific.

International evidence-based guidelines on hypertension and type 2 diabetes mellitus: A systematic review

This systematic review provides a high-quality, comprehensive summary of recommendations on hypertension (HT) and type 2 diabetes mellitus (T2DM), accentuating patient blood pressure, HbA1c levels, patterns of drug treatment, management, and screening of these diseases. The overall objective of the review is to support adapting existing clinical practice guidelines in Indonesia, Vietnam, and Myanmar. The database PubMed and the web search engines Google and Google Scholar were searched from October to December 2019 for evidence-based guidelines covering the overall disease management in Europe, the United States of America, and low and middle-income countries (Indonesia, Vietnam, and Myanmar-IVM later on). Nine studies were selected for the review, seven concerning HT and five T2DM. Guidelines in IVM and Europe identified HT as increased blood pressure (BP; ≥140/90 mmHg). IVM guidelines also recommended commencing drug treatment if lifestyle interventions were not successful. Four international HT guidelines recommended monitoring BP every few months, and the other three guidelines gave recommendations based on the patient's current BP levels. All five T2DM guidelines recommended target HbA1c levels below 7%-6.5%, but only IVM guidelines included re-examination every 3-6 months. Metformin was recommended as the first choice of medical treatment, if not contraindicated. Amid the guidelines' recommendations, there were no major variations in the Class of recommendation and Level of evidence (except IVM guidelines where COR and LOE were missing). Revision and completion of IVM guidelines by this grading system would enhance evidence-based and informed decisions in clinical care.

Real-world usage of sulphonylureas in Asian patients with type 2 diabetes using the Joint Asia Diabetes Evaluation (JADE) register

AIMS

To explore the patterns of use of oral glucose-lowering drugs (OGLDs) in Asian patients with type 2 diabetes (T2D), focusing on sulphonylureas (SUs), and to describe patient profiles according to treatment regimen.

METHODS

We conducted a cross-sectional analysis of data from adults with T2D from 11 Asian countries/regions with structured assessment enrolled in the prospective Joint Asia Diabetes Evaluation (JADE) register between November 2007 and December 2019. Patients receiving insulin and/or injectable glucagon-like peptide-1 receptor agonists were excluded.

RESULTS

Amongst 62 512 patients (mean ± standard deviation age: 57.3 ± 11.8 years; 53.6% men), 54 783 (87.6%) were treated with OGLDs at enrolment. Most received one (37.5%) or two (44.2%) OGLDs. In the entire cohort, 59.4% of treated patients received SU-based therapy with variations amongst countries/regions. Overall, 79.5% of SU regimens were based on SUs plus metformin, and 22.1% on SUs plus dipeptidyl peptidase-4 inhibitors. Among SU users, gliclazide was most commonly prescribed (46.7%), followed by glimepiride (40.0%) and glibenclamide (8.1%). More gliclazide users entered the cohort with glycated haemoglobin levels <53 mmol/mol (7%) than non-gliclazide SU users (odds ratio [OR] 1.09, 95% CI 1.02-1.17), with less frequent self-reported hypoglycaemia in the 3 months before registration (OR 0.81, 95% CI 0.72-0.92; adjusted for sociodemographic factors, cardiometabolic risk factors, complications, use of other OGLDs, country/region and year of registration).

CONCLUSION

In Asia, SUs are a popular OGLD class, often combined with metformin. Good glycaemic control and safety profiles associated with the use of SUs, including gliclazide, support their position as a key treatment option in patients with T2D.

The impact of long-term exposure to PM10, SO2, O3, NO2, and CO on incident dysglycemia: a population-based cohort study

To examine the associations between long-term exposure to five major air pollutants including SO₂, PM₁₀, O₃, NO₂, and CO_, and incident dysglycemia, impaired fasting glucose (IFG), and diabetes, separately. A total of 4254 (1720 men) normoglycemic individuals aged 20-69 years at baseline were followed from 2001 to 2018 every 3 years. To measure the long-term hazards of air pollutants for incident dysglycemia, the Weibull proportional hazards models for every 10-unit increment adjusted for diabetes risk factors were fitted. The air pollutants were put in the models in the form of averages of 1-, 2-, and 3-year periods. During a median follow-up of 12.2 years, we observed 1780 dysglycemia events. In contrast to NO₂, the increase in SO₂, O₃, and PM₁₀ levels were significantly associated with a higher risk of dysglycemia and IFG in all time spans excluding PM₁₀ at 2 years. The largest hazard ratios for incident dysglycemia and IFG were attributable to PM₁₀ in 3 years (2.20 (95% CI 1.67, 2.89) and 2.08 (1.55, 2.80), respectively). Moreover, exposure to all the pollutants except NO₂ in 1 year (0.89 (0.80, 0.98)) had no significant associations with incident diabetes. There was a signal that younger (< 45 years) and never-smoker individuals were more predispose to dysglycemic effects of air pollution (all P for interactions > 0.03). Our findings suggested that long-term exposure to air pollution increased incident dysglycemia risk, the effect which was mainly attributable to IFG status.

Effects of Heat-Moisture Treatment on the Digestibility and Physicochemical Properties of Waxy and Normal Potato Starches

Heat-moisture treatment (HMT) is a safe, environmentally friendly starch modification method that reduces the digestibility of starch and changes its physicochemical properties while maintaining its granular state. Normal potato starch (NPS) and waxy potato starch (WPS) were subjected to HMT at different temperatures. Due to erosion by high-temperature water vapor, both starches developed indentations and cracks after HMT. Changes were not evident in the amylose content since the interaction between the starch molecules affected the complexation of amylose and iodine. HMT increased pasting temperature of NPS from 64.37 °C to 91.25 °C and WPS from 68.06 °C to 74.44 °C. The peak viscosity of NPS decreased from 504 BU to 105 BU and WPS decreased from 384 BU to 334 BU. The crystallinity of NPS decreased from 33.0% to 24.6% and WPS decreased from 35.4% to 29.5%. While the enthalpy values of the NPS declined from 15.74 (J/g) to 6.75 (J/g) and WPS declined from 14.68 (J/g) to 8.31 (J/g) at 120 °C. The solubility and swelling power of NPS decreased while that of WPS increased at 95 °C. Due to the lack of amylose in WPS, at the same HMT processing temperature, the reduction in peak viscosity of treated WPS compared to that of native starch was smaller than that of NPS. The resistant starch (RS) content of NPS after HMT at 120 °C was 73.0%. The slowly digestible starch (SDS) content of WPS after HMT at 110 °C was 37.6%.

A retrospective database study of the demographic features and glycemic control of patients with type 2 diabetes in Kinshasa, Democratic Republic of the Congo

BACKGROUND

The Kin-Antwerp project aimed at improving the quality of care provided to patients with diabetes in Kinshasa, the Democratic Republic of the Congo in Central Africa, including the digitalisation of routine clinical data to improve patients' follow-up. We aim to analyse the data of a study population of Kin-Antwerp to characterise their demographic features, assess their achievement of glycemic target over time, and identify groups requiring prioritised attention.

METHODS

We performed a secondary database analysis of routinely collected information from primary care patients with type 2 diabetes followed from 1991 to 2019. Data included demographics (age, sex), anthropometrics (weight, height), clinical parameters (blood pressure, plasma glucose), and anti-diabetic treatments. Achievement of glycemic target, defined as fasting plasma glucose < 126 mg/dL, over time was assessed using a multilevel mixed-effects logistic regression model.

RESULTS

Our study population of patients with type 2 diabetes (N = 8976) comprised a higher proportion of women (67%) and patients between 40 and 65 years old (70.4%). At the first follow-up, most patients were on treatment with insulin (56.5%) and had glycemic levels under the target (79.9%). Women presented more often with obesity (27.4%) and high systolic blood pressure (41.8%) than men (8.6% and 37.0%, respectively). Patients had a median follow-up of 1.8 (interquartile range: 0.5-3.4) years. Overall, the odds of achieving glycemic target increased by 18.4% (odds ratio: 1.184, 95% CI: 1.130 to 1.239; p < 0.001) per year of follow-up. Stratified analyses suggested that the odds of achieving glycemic control over time increased among older patients (> 40 years), but not among younger patients (< 40 years).

CONCLUSION

In our study population, an overall poor glycemic control was observed albeit with a modest improvement in the achievement of glycemic target throughout patients' follow-up. Younger patients may benefit from prioritised attention to achieve glycemic targets. Based on the information provided by the database, continue monitoring and improvement of the project Kin-Antwerp is recommended. Introducing further efforts to improve type 2 diabetes management should include robust glycemia-monitoring tools and haemoglobin A1c, as well as further outlining self-management strategies.

Completeness of pharmaceutical industry insulin adverse event reports from Africa and the Middle East

BACKGROUND

Growing numbers of patients with diabetes mellitus in Africa and the Middle East on antidiabetic therapies necessitate an understanding of adverse event reporting in these regions. We assessed pharmaceutical industry insulin individual case safety report (ICSR) completeness and completeness-associated variables.

RESEARCH DESIGN AND METHODS

The observational cross-sectional study, set in an insulin-manufacturing company's safety database, assessed vigiGrade® completeness scores of African and Middle Eastern post-marketing ICSRs during January to December 2018, and the effects of case variables on completeness. Low vigiGrade® scores indicated poorly documented ICSRs.

RESULTS

We analyzed 4854 ICSRs; 59.8% from the Middle East. The mean vigiGrade® score was 0.58. Middle Eastern ICSRs had higher mean scores than African ICSRs (0.65 vs. 0.46, p<0.001). Scores peaked at 0.32, 0.70, and 1.00, for Middle Eastern ICSRs compared to 0.35 and 0.50 for African ICSRs. Middle Eastern serious (0.77 vs. 0.47; p<0.001) and solicited (0.70 vs. 0.48; p<0.001) ICSRs had higher mean scores than African ICSRs. Mean scores were highest for Middle Eastern physicians (0.89) and other healthcare professionals (0.82) whereas, in Africa, scores were highest for consumer- (0.47) and pharmacist-reported ICSRs (0.47) (p<0.001).

CONCLUSIONS

Middle Eastern pharmaceutical industry insulin ICSRs were documented with greater detail than African ICSRs. Event seriousness, report source, and reporter type significantly impacted ICSR completeness.

Current practices and future preferences of type 2 diabetes care in Ethiopia: A qualitative study on the perspectives of patients, health professionals, and policymakers

BACKGROUND AND AIMS

This study aimed to examine perspectives of patients, health professionals, and policymakers on current practices and their future preferences for type 2 diabetes care in a tertiary hospital in Ethiopia.

METHODS

An exploratory qualitative study was undertaken through interviews and focus groups with patients, health professionals, and policymakers. The participants were purposively sampled. Thematic analysis was undertaken.

RESULTS

Fifty-nine participants were involved in the study. Participants' perspectives on current practices and future preferences comprised three themes: organisation of type 2 diabetes care delivery and infrastructure; continuity of care; and structured diabetes education. The current organisation comprised physicians, such as endocrinologists and endocrinology fellows, and nurses. Some nurses received training on diabetes foot and diabetic eye, which enabled patients to receive diabetes foot and diabetic eye care, respectively. The hospital lacked essential resources, such as medications, laboratory and diagnostic services, and diabetes educators, which hindered patient-centred care. Patients complained that the physical set-up at the hospital was not conducive to their privacy during consultations. Participants reported infrequent patient follow-up and monitoring, which contributed to uncontrolled diabetes. Future preferences involved access to essential resources and comprehensive diabetes care, such as structured diabetes education for improved patient outcomes. Participants sought out the development of tailored and context-specific diabetes management approaches that could meet specific patient needs and preferences.

CONCLUSIONS

The findings have implications for designing patient-centred diabetes care tailored to the hospital's context and key stakeholders' preferences. This tailoring requires strong leadership to ensure availability of essential resources.

The joint effects of physical activity and air pollution on type 2 diabetes in older adults

BACKGROUND

Older adults with type 2 diabetes are at higher risk of developing common geriatric syndromes and have a lower quality of life. To prevent type 2 diabetes in older adults, it's unclear whether the health benefits of physical activity (PA) will be influenced by the harms caused by increased exposure to air pollution during PA, especially in developing countries with severe air pollution problem. We aimed to investigate the joint effects of PA and long-term exposure to air pollution on the type 2 diabetes in older adults from China.

METHODS

This cross-sectional study was based on the China Multi-Ethnic cohort (CMEC) study. The metabolic equivalent of PA was calculated according to the PA scale during the CMEC baseline survey. High resolution air pollution datasets (PM₁₀, PM_2.5 and PM₁) were collected from open products. The joint effects were assessed by the marginal structural mean model with generalized propensity score.

RESULTS

A total of 36,562 participants aged 50 to 79 years were included in the study. The prevalence of type 2 diabetes was 10.88%. The mean (SD) level of PA was 24.93 (18.60) MET-h/d, and the mean (SD) level of PM₁₀, PM_2.5, and PM₁ were 70.00 (23.32) µg/m³, 40.45 (15.66) µg/m³ and 27.62 (6.51) µg/m³, respectively. With PM₁₀ < 92 µg/m³, PM_2.5 < 61 µg/m³, and PM₁ < 36 µg/m³, the benefit effects of PA on type 2 diabetes was significantly greater than the harms due to PMs when PA levels were roughly below 80 MET-h/d. With PM₁₀ ≥ 92 µg/m³, PM_2.5 ≥ 61 µg/m³, and PM₁ ≥ 36 µg/m³, the odds ratio (OR) first decreased and then rose rapidly with confidence intervals progressively greater than 1 and break-even points close to or even below 40 MET-h/d.

CONCLUSIONS

Our findings implied that for the prevention of type 2 diabetes in older adults, the PA health benefits outweighed the harms of air pollution except in extreme air pollution situations, and suggested that when the air quality of residence is severe, the PA levels should ideally not exceed 40 MET-h/d.

Continuous glucose monitoring demonstrates low risk of clinically significant hypoglycemia associated with sulphonylurea treatment in an African type 2 diabetes population: results from the OPTIMAL observational multicenter study

INTRODUCTION

People living with diabetes in low-resource settings may be at increased hypoglycemia risk due to food insecurity and limited access to glucose monitoring. We aimed to assess hypoglycemia risk associated with sulphonylurea (SU) and insulin therapy in people living with type 2 diabetes in a low-resource sub-Saharan African setting.

RESEARCH DESIGN AND METHODS

This study was conducted in the outpatients' diabetes clinics of two hospitals (one rural and one urban) in Uganda. We used blinded continuous glucose monitoring (CGM) and self-report to compare hypoglycemia rates and duration in 179 type 2 diabetes patients treated with sulphonylureas (n=100) and insulin (n=51) in comparison with those treated with metformin only (n=28). CGM-assessed hypoglycemia was defined as minutes per week below 3mmol/L (54mg/dL) and number of hypoglycemic events below 3.0 mmol/L (54 mg/dL) for at least 15 minutes.

RESULTS

CGM recorded hypoglycemia was infrequent in SU-treated participants and did not differ from metformin: median minutes/week of glucose <3 mmol/L were 39.2, 17.0 and 127.5 for metformin, sulphonylurea and insulin, respectively (metformin vs sulphonylurea, p=0.6). Hypoglycemia risk was strongly related to glycated haemoglobin (HbA1c) and fasting glucose, with most episodes occurring in those with tight glycemic control. After adjusting for HbA1c, time <3 mmol/L was 2.1 (95% CI 0.9 to 4.7) and 5.5 (95% CI 2.4 to 12.6) times greater with sulphonylurea and insulin, respectively, than metformin alone.

CONCLUSIONS

In a low-resource sub-Saharan African setting, hypoglycemia is infrequent among people with type 2 diabetes receiving sulphonylurea treatment, and the modest excess occurs predominantly in those with tight glycemic control.

Development of a Complex Intervention for Effective Management of Type 2 Diabetes in a Developing Country

There has been little focus on designing tailored diabetes management strategies in developing countries. The aim of this study is to develop a theory-driven, tailored and context-specific complex intervention for the effective management of type 2 diabetes at a tertiary care setting of a developing country. We conducted interviews and focus groups with patients, health professionals, and policymakers and undertook thematic analysis to identify gaps in diabetes management. The results of our previously completed systematic review informed data collection. We used the United Kingdom Medical Research Council framework to guide the development of the intervention. Results comprised 48 interviews, two focus groups with 11 participants and three co-design panels with 24 participants. We identified a lack of structured type 2 diabetes education, counselling, and collaborative care of type 2 diabetes. Through triangulation of the evidence obtained from data collection, we developed an intervention called VICKY (patient-centred collaborative care and structured diabetes education and counselling) for effective management of type 2 diabetes. VICKY comprised five components: (1) patient-centred collaborative care; (2) referral system for patients across transitions of care between different health professionals of the diabetes care team; (3) tools for the provision of collaborative care and documentation of care; (4) diabetes education and counselling by trained diabetes educators; and (5) contextualised diabetes education curriculum, educational materials, and documentation tools for diabetes education and counselling. Implementation of the intervention may help to promote evidence-based, patient-centred, and contextualised diabetes care for improved patient outcomes in a developing country.

Trends in Antidiabetic Drug Discovery: FDA Approved Drugs, New Drugs in Clinical Trials and Global Sales

Type 2 diabetes mellitus (T2DM) continues to be a substantial medical problem due to its increasing global prevalence and because chronic hyperglycemic states are closely linked with obesity, liver disease and several cardiovascular diseases. Since the early discovery of insulin, numerous antihyperglycemic drug therapies to treat diabetes have been approved, and also discontinued, by the United States Food and Drug Administration (FDA). To provide an up-to-date account of the current trends of antidiabetic pharmaceuticals, this review offers a comprehensive analysis of the main classes of antihyperglycemic compounds and their mechanisms: insulin types, biguanides, sulfonylureas, meglitinides (glinides), alpha-glucosidase inhibitors (AGIs), thiazolidinediones (TZD), incretin-dependent therapies, sodium-glucose cotransporter type 2 (SGLT2) inhibitors and combinations thereof. The number of therapeutic alternatives to treat T2DM are increasing and now there are nearly 60 drugs approved by the FDA. Beyond this there are nearly 100 additional antidiabetic agents being evaluated in clinical trials. In addition to the standard treatments of insulin therapy and metformin, there are new drug combinations, e.g., containing metformin, SGLT2 inhibitors and dipeptidyl peptidase-4 (DPP4) inhibitors, that have gained substantial use during the last decade. Furthermore, there are several interesting alternatives, such as lobeglitazone, efpeglenatide and tirzepatide, in ongoing clinical trials. Modern drugs, such as glucagon-like peptide-1 (GLP-1) receptor agonists, DPP4 inhibitors and SGLT2 inhibitors have gained popularity on the pharmaceutical market, while less expensive over the counter alternatives are increasing in developing economies. The large heterogeneity of T2DM is also creating a push towards more personalized and accessible treatments. We describe several interesting alternatives in ongoing clinical trials, which may help to achieve this in the near future.

Economic Analysis of glucagon like peptide-1 receptor agonists from the Saudi Arabia Payer Perspective

Objectives

To perform a cost of control analysis of glucagon like peptide-1 receptor agonists (GLP1RA) in Saudi Arabia (SA) and determine the economic impact of adopting GLP1RAs.

Methods

A budget impact model that captures the cost of control model was constructed to simulate hypothetical patient on six treatment options: a current mix of 60% liraglutide and 40% dulaglutide, semaglutide, liraglutide, dulaglutide, exenatide, and lixisenatide. We estimated the relative amounts of SAR spend to achieve HbA1c targets (≤6.5% or < 7.0%). For each treatment option, annual treatment cost, proportion of patients achieving HbA1c targets, and cost to treat major adverse cardiovascular events (MACE) were aggregated to estimate the cost of control per patient per year (CCPPPY) over 5-year horizon (2021–2025). Probabilistic sensitivity analysis (PSA) was performed as a confirmatory analysis.

Results

The CCPPPY to achieve HbA1c ≤ 6.5%/<7.0% using current mix, semaglutide, liraglutide, dulaglutide, exenatide, and lixisenatide were SAR 17,097/SAR 14,113, SAR 12,889/SAR 11,123, SAR 15,594/SAR 12,892, SAR 19,184/SAR 15,940, SAR 580,211/SAR 380,936, and SAR 246,570/SAR 143,759, respectively. The relative amounts of SAR spend to achieve HbA1c ≤ 6.5%/<7.0% relative to 1 SAR on semaglutide in case of adopting current mix, liraglutide, dulaglutide, exenatide, and lixisenatide were SAR 1.42/SAR 1.18, SAR 1.30/SAR 1.07, SAR 1.60/SAR 1.33, SAR 48.33/SAR 31.73, and SAR 20.54/SAR 11.97, respectively. These results were confirmed in the PSA.

Conclusions

Semaglutide 1 mg once weekly was the most economically favorable GLP1RA; associated with the least CCPPPY, and amount of SAR spent to achieve HbA1c of ≤6.50%/<7.00% versus all other GLP1RAs.

Association between diabetes and edentulism and their joint effects on health status in 40 low and middle-income countries

INTRODUCTION

Previous studies on the diabetes-edentulism relationship have yielded conflicting results. Therefore, the goal of this study was to investigate the association between diabetes and edentulism, and their joint effects on health status in adults from 40 low and middle-income countries (LMICs).

RESEARCH DESIGN AND METHODS

Data from the World Health Survey were used for this cross-sectional study (2002-2004). Forty countries (18 low-income and 22 middle-income countries) were included. Edentulism and diabetes were assessed using yes-no questions based on self-report. Health status was assessed in seven different domains (self-care, pain/discomfort, cognition, interpersonal activities, sleep/energy, affect, and perceived stress). The association between diabetes (exposure) and edentulism (outcome) was analyzed using multivariable logistic regression models, while their joint effects on health status were assessed using multivariable linear regression models.

RESULTS

There were 175 814 adults aged ≥18 years included in this study (mean (SD) age 38.4 (16.0) years; 49.3% men). Overall, the prevalence of edentulism was 6.0% and diabetes was 2.9%. There was a positive and significant association between diabetes and edentulism in the overall sample (OR=1.40, 95% CI 1.18 to 1.66), in low-income countries (OR=1.78, 95% CI 1.21 to 2.62) and in middle-income countries (OR=1.24, 95% CI 1.04 to 1.47). In addition, people with comorbid diabetes and edentulism had worse health status in the domains of cognition, sleep/energy, and perceived stress, compared with those with diabetes only.

CONCLUSIONS

Diabetes was positively associated with edentulism in this sample of more than 175 000 individuals living in LMICs. Providing oral care to individuals with diabetes may potentially lead to a reduction in their risk of edentulism.

Hundred-year experience with insulin and lipohypertrophy: An unresolved issue

In the article recently published in Diab Res Clin Pract (1), we described one of the most exciting paths in the history of medicine from the perspective of diabetologists and people with type 1 diabetes. Such a history lasted 100 years, from the discovery of insulin to the most technologically advanced technologies aimed at making treatment as close to physiology and user-friendly as possible. Indeed, we are luckier than others because, by living in Italy and the USA, respectively, we have access to miniaturized and computerized insulin delivery systems, but this is not the case worldwide. Due to that, while receiving many favorable comments from colleagues and friends, we were encouraged to further expand on the issue and go deeper into insulin injection technique.

Sulfonylureas in the Current Practice of Type 2 Diabetes Management: Are They All the Same? Consensus from the Gulf Cooperation Council (GCC) Countries Advisory Board on Sulfonylureas

Since their inception in the commercial market in the mid-twentieth century, sulfonylureas (SUs) have remained a therapeutic option in the management of type 2 diabetes (T2D). Despite their established glucose-lowering effects, there is no consensus among global experts and modern guidelines regarding the priority of SUs in relation to other therapeutic options, given the lack of evidence that SUs are associated with a low risk of macrovascular events and excess mortality. However, findings from recent trials and real-time observations have resolved this contentious issue somewhat, albeit to varying degrees. The present consensus discusses the role of SUs in contemporary diabetes management in the Gulf Cooperation Council (GCC) countries. Regional experts from these countries gathered virtually to formulate a consensus following presentations of topics relevant to SU therapy with an emphasis on gliclazide, including long-term efficacy, cost, end-organ benefits, and side effects, based on up-to-date evidence. The present narrative review reflects the conclusions of this assembly and provides a platform upon which future guidelines for the use of SUs in the GCC can be tailored.

Diabetic Retinopathy in the Aging Population: A Perspective of Pathogenesis and Treatment

The elderly population in the United States is projected to almost double by the year 2050. In addition, the numbers of diabetics are rising, along with its most common complication, diabetic retinopathy (DR). To effectively treat DR within the elderly population, it is essential first to consider the retinal changes that occur due to aging, such as decreased blood flow, retinal thinning, and microglial changes, and understand that these changes can render the retina more vulnerable to oxidative and ischemic damage. Given these considerations, as well as the pathogenesis of DR, specific pathways could play a heightened role in DR progression in elderly patients, such as the polyol pathway and the vascular endothelial growth factor (VEGF) axis. Current ocular treatments include intravitreal corticosteroids, intravitreal anti-VEGF agents, laser photocoagulation and surgical interventions, in addition to better control of underlying diabetes with an expanding range of systemic treatments. While using therapeutics, it is also essential to consider how pharmacokinetics and pharmacodynamics change with aging; oral drug absorption can decrease, and ocular drug metabolism might affect the dosing and delivery methods. Also, elderly patients may more likely be nonadherent to their medication regimen or appointments than younger patients, and undertreatment with anti-VEGF drugs often leads to suboptimal outcomes. With a rising number of elderly DR patients, understanding how aging affects disease progression, pharmacological metabolism, and adherence are crucial to ensuring that this population receives adequate care.

Diabetes Technology Meeting 2020

Diabetes Technology Society hosted its annual Diabetes Technology Meeting on November 12 to November 14, 2020. This meeting brought together speakers to cover various perspectives about the field of diabetes technology. The meeting topics included artificial intelligence, digital health, telemedicine, glucose monitoring, regulatory trends, metrics for expressing glycemia, pharmaceuticals, automated insulin delivery systems, novel insulins, metrics for diabetes monitoring, and discriminatory aspects of diabetes technology. A live demonstration was presented.

Interaction between Omeprazole and Gliclazide in Relation to CYP2C19 Phenotype

The antidiabetic drug gliclazide is partly metabolized by CYP2C19, the main enzyme involved in omeprazole metabolism. The aim of the study was to explore the interaction between omeprazole and gliclazide in relation to CYP2C19 phenotype using physiologically based pharmacokinetic (PBPK) modeling approach. Developed PBPK models were verified using in vivo pharmacokinetic profiles obtained from a clinical trial on omeprazole-gliclazide interaction in healthy volunteers, CYP2C19 normal/rapid/ultrarapid metabolizers (NM/RM/UM). In addition, the association of omeprazole cotreatment with gliclazide-induced hypoglycemia was explored in 267 patients with type 2 diabetes (T2D) from the GoDARTS cohort, Scotland. The PBPK simulations predicted 1.4–1.6-fold higher gliclazide area under the curve (AUC) after 5-day treatment with 20 mg omeprazole in all CYP2C19 phenotype groups except in poor metabolizers. The predicted gliclazide AUC increased 2.1 and 2.5-fold in intermediate metabolizers, and 2.6- and 3.8-fold in NM/RM/UM group, after simulated 20-day dosing with 40 mg omeprazole once and twice daily, respectively. The predicted results were corroborated by findings in patients with T2D which demonstrated 3.3-fold higher odds of severe gliclazide-induced hypoglycemia in NM/RM/UM patients concomitantly treated with omeprazole. Our results indicate that omeprazole may increase exposure to gliclazide and thus increase the risk of gliclazide-associated hypoglycemia in the majority of patients.

Pharmacological treatment of type 2 diabetes in Saudi Arabia: A consensus statement from the Saudi Society of Endocrinology and Metabolism (SSEM)

BACKGROUND AND AIMS

The list of available treatment options for managing blood glucose in patients with type 2 diabetes (T2D) has grown over recent years making the task of choosing between traditional and newer glucose-lowering agents a difficult one for healthcare providers.

METHODS

We summarize treatment algorithms developed by popular professional societies and propose a patient-centered and culture-driven recommendations for selecting diabetes medications for people with T2D in Saudi Arabia.

RESULTS

Though most professional societies recognize patient's adherence to medications as an important factor in achieving glycemic targets, published algorithms schemes do not formally enlist adherence to medication as a deciding factor in the choice of glucose-lowering agents. Medication appeal to patients, an important determinant of medication adherence, is influenced by several factors including lifestyle, common beliefs, customs and traditions, health literacy, perception of health and disease, socioeconomic and cultural backgrounds, and religious commitments and obligations. In Saudi Arabia, poor adherence to therapy is a major obstacle to effective management of local people with T2D.

CONCLUSIONS

The Saudi population has a unique socioeconomic and cultural background that widely respect adherence to religion and culture; and the applicability of international guidelines for the management of T2D to the Saudi population has been called into question. In this consensus statement, we propose patient-centered and culture-driven recommendations that integrate medication-adherence and medication-cost into overall selection of diabetes medications for people with T2D in Saudi Arabia.

Changes in fasting patterns during Ramadan, and associated clinical outcomes in adults with type 2 diabetes: A narrative review of epidemiological studies over the last 20 years

Although religious guidance exempts some Muslims with type 2 diabetes from fasting during Ramadan, many choose to fast. The associated risks for fasting adults with diabetes includes hypoglycemia, hyperglycemia, ketoacidosis, dehydration, and thrombosis. Thus, it is important that healthcare professionals support individuals who choose to fast to minimize risks. We reviewed three epidemiologic studies to understand how fasting patterns during Ramadan and associated clinical outcomes in adults with type 2 diabetes have evolved over two decades (2000-2020). Over a period of time people with diabetes choosing to fast during Ramadan are displaying increasingly complex profiles in terms of their diabetes, with increased disease duration, greater body mass index, and elevated pre-Ramadan mean glycated hemoglobin levels. Despite this, in the most recent study, >85% of adults with type 2 diabetes still chose to fast. Increased risk of hypoglycemia remains a major concern despite some improvements over time, which could be attributable to enhanced education programs, and changes in treatment type and/or dose prior to and/or during Ramadan. Our review highlights the evolution in fasting patterns over two decades and serves as an update for healthcare professionals to provide appropriate guidance to ensure that Ramadan fasting is safe and rewarding.

Rhinocerebral mucormycosis to the rise? The impact of the worldwide diabetes epidemic

The authors present seven cases of rhinocerebral mucormycosis associated to diabetes mellitus, which is a disease with epidemic proportions affecting individuals worldwide, particularly in developing countries, and which poses significant morbidity and mortality. Mucormycosis is an opportunistic fungal infection with high mortality and requires an invasive therapeutic approach to save the patient’s life with significant morbidity and sequelae, thus prevention is crucial.

Cost-Effectiveness of Saxagliptin Compared With Glibenclamide as a Second-Line Therapy Added to Metformin for Type 2 Diabetes Mellitus in Ethiopia

Background. Metformin is a widely accepted first-line pharmacotherapy for patients with type 2 diabetes mellitus (T2DM). Treatment of T2DM with glibenclamide, saxagliptin, or one of the other second-line treatment agents is recommended when the first-line treatment (metformin) cannot control the disease. However, there is little evidence on the additional cost and cost-effectiveness of adding second-line drugs. Therefore, this study aimed to estimate the cost-effectiveness of saxagliptin and glibenclamide as second-line therapies added to metformin compared with metformin only in T2DM in Ethiopia. Methods. This cost-effectiveness study was conducted in Ethiopia using a mix of primary data on cost and best available data from the literature on the effectiveness. We measured the interventions' cost from the providers' perspective in 2019 US dollars. We developed a Markov model for T2DM disease progression with five health states using TreeAge Pro 2020 software. Disability-adjusted life year (DALY) was the health outcome used in this study, and we calculated the incremental cost-effectiveness ratio (ICER) per DALY averted. Furthermore, one-way and probabilistic sensitivity analysis were performed. Results. The annual unit cost per patient was US$70 for metformin, US$75 for metformin + glibenclamide, and US$309 for metformin + saxagliptin. The ICER for saxagliptin + metformin was US$2259 per DALY averted. The ICER results were sensitive to various changes in cost, effectiveness, and transition probabilities. The ICER was driven primarily by the higher cost of saxagliptin relative to glibenclamide. Conclusion. Our study revealed that saxagliptin is not a cost-effective second-line therapy in patients with T2DM inadequately controlled by metformin monotherapy based on a gross domestic product per capita per DALY averted willingness-to-pay threshold in Ethiopia (US$953).

Cost-Effectiveness of Gliclazide-Based Intensive Glucose Control vs. Standard Glucose Control in Type 2 Diabetes Mellitus. An Economic Analysis of the ADVANCE Trial in Vietnam

Introduction: ADVANCE was a large, multinational clinical study conducted over 5 years in type 2 diabetes mellitus (T2DM). In all, 11,140 patients were randomly assigned to receive gliclazide-based intensive glucose control (IGC) or standard glucose control (SGC). IGC was shown to significantly reduce the incidence of major macrovascular and microvascular events (composite endpoint) or major microvascular events compared with SGC, primarily by enhancing renal protection. We assessed the cost-effectiveness of IGC vs. SGC, based on the ADVANCE results, from a Vietnamese healthcare payer perspective. Materials and Methods: A partitioned survival times model across five health states (no complications, myocardial infarction, stroke, end-stage renal disease [ESRD], and diabetes-related eye-disease) was designed. Time-to-event curves were informed by the cumulative incidence of events and corresponding hazard ratios from the ADVANCE study. Health outcomes were expressed in terms of ESRD avoided and quality-adjusted life years (QALYs). Costs (in US $) comprised treatment costs and health state costs. Utility weights and costs were documented from literature reporting Vietnamese estimates. For sensitivity analyses, all parameters were individually varied within their 95% confidence interval bounds (when available) or within a ±30% range. Results: Over a 5-year horizon, IGC avoided 6.5 additional ESRD events per 1,000 patients treated compared with SGC (IGC, 3.5 events vs. SGC, 10.0 events) and provided 0.016 additional QALYs (IGC, 3.570 QALYs vs. SGC, 3.555 QALYs). Total costs were similar for the two strategies (IGC, $3,786 vs. SGC, $3,757). Although the total drug costs were markedly higher for IGC compared with SGC ($1,703 vs. $873), this was largely offset by the savings from better renal protection with IGC (IGC, $577 vs. SGC, $1,508). The incremental cost-effectiveness ratio (ICER) of IGC vs. SGC was $1,878/QALY gained, far below the threshold recommended by the World Health Organization (i.e., 1-3 × gross domestic product per inhabitant ≈$7,500 in Vietnam). The ICER of IGC vs. SGC per ESRD event avoided was $4,559/event. The findings were robust to sensitivity analysis. Conclusion: In Vietnam, gliclazide-based IGC was shown to be cost-effective compared with SGC from a healthcare payer perspective, as defined in the ADVANCE study.

Barriers and facilitators to successful management of type 2 diabetes mellitus in Latin America and the Caribbean: A systematic review

BACKGROUND

Given that most evidence-based recommendations for managing type 2 diabetes mellitus (T2DM) are generated in high-income settings, significant challenges for their implementation exist in Latin America and the Caribbean region (LAC), where the rates of T2DM and related mortality are increasing. The aim of this study is to identify the facilitators and barriers to successful management of T2DM in LAC, from the perspectives of patients, their families or caregivers, healthcare professionals, and/or other stakeholders.

METHODS

We conducted a systematic review in MEDLINE, Web of Science, SciELO, and LILACS. We included studies of disease management, prevention of complications and risk factor management. We qualitatively synthesized the verbatim text referring to barriers and/or facilitators of diabetes management according to the Theoretical Domain Framework and described their relative frequencies.

FINDINGS

We included 60 studies from 1,595 records identified. 54 studies (90%) identified factors related to the environmental context and resources, highlighting the importance of questions related to health care access or lack of resources in the health system, and the environmental context and living conditions of the patients. Issues related to "social influences" (40 studies) and "social/professional role and identity" (37 studies) were also frequently addressed, indicating the negative impact of lack of support from family and friends and clinicians' paternalistic attitude. 25 studies identified patients beliefs as important barriers, identifying issues such as a lack of patients' trust in the effectiveness of the medication and/or the doctor's advice, or preferences for alternative therapies.

CONCLUSIONS

Successful diabetes management in LAC is highly dependent on factors that are beyond the control of the individual patients. Successful disease control will require emphasis on public policies to reinforce health care access and resources, the promotion of a patient-centred care approach, and health promoting infrastructures at environmental level.

Impact and Trends in Global Ophthalmology

Purpose of Review

Our goal is to provide a review of the impact, global estimates, and projection of vision impairment as well as ongoing systems for eye care delivery.

Recent Findings

Many of the blinding diseases in developing countries are preventable or curable, but the lack of ophthalmologists, the lack of education, and the lack of access to any eye care are some of the major obstacles encountered.

Summary

As our world becomes more interconnected through globalization, the interactions between different cultures and populations increase. Global ophthalmology is a field dedicated to building sustainable eye care delivery systems to deliver high-quality care in minimal resource settings, with the aim of reducing blindness around the world.

Diabetes: From Research to Clinical Practice

The number of people living with diabetes, the number of deaths attributable to it, and the cost of treating the disease and its complications are increasing exponentially. Centuries of research led to the discovery of insulin and other drugs based on pathophysiology from "the triumvirate to ominous octet". The agonists of the glucagon-like peptide-1 (GLP-1) receptor, and the inhibitors of the sodium-glucose transport protein 2 (SGLT2) are the new drugs that improve cardiovascular outcomes and provide renal protection, and they are being used increasingly for evidence-based treatment of type 2 diabetes. Bariatric surgery, when indicated, results in excellent weight- and metabolic-control, and in many instances even remission of diabetes. Technological advances like Flash glucose monitoring, continuous subcutaneous insulin infusion (CSII), and continuous glucose monitoring (CGM) have improved glycemic control, reduced episodes of severe hypoglycemia, and improved quality of life. For the treatment of diabetic macular edema intravitreal injection of several anti-VEGF agents are being used. Numerous people living in the middle- and low-income countries cannot afford the costs of care of diabetes. Institutions like the World Health Organization, the World Bank and the International Monetary Fund should roll out plans to convince the politicians to invest more in improving the diabetes care facilities.