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VOLUME 15 NUMBER 1 • JULY 2018
37
SA JOURNAL OF DIABETES & VASCULAR DISEASE
DIABETES GUIDELINES
2017 SEMDSA diabetes management guidelines
David Webb
The updated 2017 South African guidelines for the
management of type 2 diabetes mellitus were launched on
5 May at the 52nd congress of the Society of Endocrinology,
Metabolism and Diabetes of South Africa (SEMDSA) in
Johannesburg. This is the fourth edition of the guidelines,
which were last updated in 2012. The 2017 edition has
been completely revised and updated using the most recent
clinical science, with contributions from more than 45
local experts in various aspects of diabetes management.
It is a comprehensive document, consisting of 29 chapters
covering epidemiology; definitions; diagnosis; screening and
organisation; lifestyle interventions; glucose management;
co-morbidities and complications (weight management,
cardiovascular risk, hypertension, diabetic kidney disease,
diabetic eye disease and diabetic foot); along with type
2 diabetes management in special patient populations
(pregnant women, children and adolescents, the elderly,
those with HIV, those observing Ramadan, drivers and men
with sexual dysfunction).
The guideline has been written with the clinician in mind
and is practical and easy to use. Recommendations are
summarised in table form at the beginning of each chapter
and information relating to support for the recommendations
is included in appendices at the end of the document.
The following is a brief summary of general recom-
mendations and highlights information that is new or where
recommendations from past editions of the guideline have
been updated.
KEY MESSAGES
• It is estimated that as many as one in four South African adults older than
45 years may have type 2 diabetes
• More than half of those with type 2 diabetes remain undiagnosed
• The diabetes epidemic is largely driven by modifiable risk factors, in particular
overweight and obesity
• Type 2 diabetes mellitus is a diagnosis of exclusion following careful
investigation for an aetiology
• In symptomatic patients, diagnosis is confirmed by random plasma glucose
≥ 11 mmol/l, fasting plasma glucose ≥ 7 mmol/l, or HbA
1c
≥ 6.5%
• All patients should receive ongoing diabetes education and support to
enable self-management and lifestyle change
• The target HbA
1c
for most treated patients is ≤ 7%
• If it is not contra-indicated and if it is tolerated, the initial pharmaco-
therapeutic choice is metformin, titrated to an appropriate dose for the
individual
• In patients with diabetes that is inadequately controlled with monotherapy,
the choice of add-on therapy should be individualised, with particular
attention paid to glycaemic target, risks of hypoglycaemia and weight gain,
co-morbidities and patient preferences and capabilities
• Statins are recommended for all patients with cardiovascular risk factors
• Low-dose aspirin is not recommended for primary cardiovascular protection
(in those who have not yet had a cardiovascular event).
Epidemiology of type 2 diabetes
Based on the 2015 statistics from the International Diabetes
Federation (IDF), there are approximately 2.3 million adults aged
between 20 and 79 years with type 2 diabetes in South Africa,
of whom approximately 60% remain undiagnosed. According to
the 2012 South African National Health and Nutrition Examination
Survey (SANHANES), the estimated prevalence of type 2 diabetes in
South Africans older than 15 years was 9.5%, with a further 9%
having impaired glucose regulation (HbA
1c
6.0–6.4%). However, in
individuals older than 45 years, the prevalence of type 2 diabetes
may be as high as 25%. Type 2 diabetes is most common among
the Asian (30%) and coloured (13%) populations, with equal
prevalence in blacks and whites (8%). It occurs in all sectors of
society, with a similar prevalence in rural informal dwellers and
urban formal dwellers.
Worldwide, the number of people who die annually from
type 2 diabetes exceeds the combined mortality from HIV/AIDS,
tuberculosis and malaria, and that is expected to rise. For example,
by 2040, it is anticipated that the number of people in Africa with
type 2 diabetes will have increased by 140%.
The diabetes epidemic is driven by interrelated risk factors,
including positive family history, psychosocial factors, overweight
and obesity, and insufficient physical exercise. Nevertheless, the
rising prevalence of type 2 diabetes is predominantly associated
with modifiable risk factors. The most important of these, and one
that demands urgent attention, is the increasing prevalence of
obesity. According to SANHANES, half of all South African males
and three-quarters of females between the ages of 45 and 54 years
are overweight or obese [body mass index (BMI) ≥ 25 kg/m
2
].
Definition and classification of diabetes
Diabetes mellitus is defined as ‘a metabolic disorder with hetero-
geneous aetiologies, which is characterised by chronic hypergly-
caemia and disturbances of carbohydrate, fat and proteinmetabolism
resulting from defects in insulin secretion, insulin action or both’.
Table 1.
Aetiological classification of diabetes mellitus
Type I diabetes
Type II diabetes
Specific aetiologies
• Genetic defects of
β
-cell function
• Genetic defects in insulin action
• Diseases of the exocrine pancreas (e.g. pancreatitis, trauma, neoplasia,
haemochromatosis)
• Endocrinopathies (e.g. acromegaly, Cushing’s syndrome, hyperthyroidism)
• Drug or chemical induced (e.g. glucocorticoids, nicotinic acid, thiazides,
atypical antipsychotics, antiretroviral therapy)
• Infections
• Uncommon forms of immune-mediated diabetes
• Other genetic syndromes sometimes associated with diabetes (e.g.
Down’s syndrome)
From SEMDSA 2017 Guidelines
Previously published by
DeNovo Medica
2017