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VOLUME 9 NUMBER 3 • SEPTEMBER 2012
CONFERENCE REPORT
SA JOURNAL OF DIABETES & VASCULAR DISEASE
Prof Willie Mollentze
Head of Department
of Internal Medicine,
Faculty of Health Sci-
ences, University of the
Free State.
He is interested in the
epidemiology and
clinical management
of diabetes as well as
geriatric medicine.
O
f the 340 million people with diabetes
globally, 80% are found in developing
countries. Diabetic complications are the
third leading cause of death; and two-
thirds of those with type 2 diabetes face
cardiovascular disease as the cause of
mortality. Prof Mollentze briefly described
the four main categories of diabetes; types
1
and 2, gestational diabetes and the eight
different sub-categories arising from chronic
pancreatitis.
Diabetes is a heterogeneous disorder with
variable pathogenesis. Using rigid guidelines
with limited therapeutic agents is not
successful, as more than half of the patients
fail to reach clinical targets. Ideally, care should
be organised around the diabetic individual,
incorporating a multi- and interdisciplinary
team focused on self-care management.
Initial evaluation of a type 2 diabetes patient,
whether established or newly diagnosed,
presents a unique opportunity to individualise
a comprehensive care plan.
The World Health Organisation accepts
a diabetes diagnosis from an HbA
1
c
level ≥
6.5%;
however Prof Mollentze does not
recommend this as a standard test, as point
of care is not a good indicator. There is also
the question of other anaemic considerations
affecting the result.
A superior diagnostic method is provided
by a 75-g oral glucose tolerance test (OGTT),
particularly in those high-risk individuals
with a family history of diabetes. A fasting
plasma glucose (FPG) ≥ 5.6% and < 7.0%
and a RPG? ≥ 5.6 and < 11.0% is considered
diagnostic of diabetes. Improved diagnostic
levels require the proper equipping of
primary care clinics and appropriate staff
training.
Lowering of HbA
1
c
levels to ≤ 7% reduces
the long-term development of microvascular
complications in the diabetic patient. Early
intensive glycaemic control also translates to
a reduction in macrovascular disease.
Regular exercise is strongly advised,
preventing the onset of type 2 diabetes
in high-risk individuals through improving
glucose control, reducing cardiovascular risk
and promoting weight loss. The American
Diabetes Association (ADA) recommends
150
minutes of moderate aerobic activity
in a week, spread out over three days, with
no more than two consecutive days elapsing
without exercise.
Nutritional therapy is also integral to the
lifestyle changes required of type 2 diabetes
patients. Counselling should ideally be given
by a registered dietician.
Referring to the ADA therapeutic guide-
lines, Prof Mollentze indicated that met-
formin (unless contra-indicated) should be
initiated concomitantly with lifestyle changes
and nutritional intervention in newly diag-
nosed type 2 diabetes patients. Should the
HbA
1
c
target level not be met within the first
six months, a second agent from a different
class (e.g. sulphonlyurea) should be added.
He stated that each class of non-insulin
agent added to initial therapy can decrease
HbA
1
c
levels by 0.9–1.1%.
The ADA and the Canadian Diabetes
Association recommend that newly diag-
nosed patients with an HbA
1
c
level > 9% or
with marked hyperglycaemia should be con-
sidered for insulin therapy from the outset,
with or without the use of other agents.
One should be vigilant in looking for signs
of hypoglycaemia that may result from the
use of insulin and insulin secretagogues.
In special circumstances, Prof Mollentze
advised alternative therapies that could
be considered, including acarbose and
the newer incretin-based agents, GLP-1
agonists and DPP-4 inhibitors. As an aside,
he mentioned a recent FDA warning on
the concerns of increased cardiovascular
mortality with the use of rosiglitazone,
and also raised the association of increased
risk of bladder cancer with the use of
pioglitazone.
Cardiovascular risk factors of type 2
diabetes patients may be managed with
low-dose aspirin. Prof Mollentze indicated
that low-dose aspirin may be beneficial
in diabetics for the primary prevention
of cardiovascular disease, as well as a
secondary-prevention strategy in those with
a history of cardiovascular disease. Aspirin is
not recommended for those diabetic adults
at low cardiovascular risk.
Guidelines for lipid management include
total cholesterol < 4.5 mmol/l, low-density
lipoprotein cholesterol < 2.7 mmol/l and high-
density lipoprotein cholesterol > 1.0 mmol/l in
men or > 1.2mmol/l inwomen. Prof Mollentze
emphasised that statin therapy should only
be added after lifestyle interventions have
been tried, unless there is pre-existing kidney
disease or the patient is older than 40 years
of age, has been diabetic for more than
10
years, and exhibits additional cardiovascular
risk.
At diagnosis, one-third of diabetic
patients present with hypertension. This
may rapidly progress to renal failure unless
treated aggressively. Treatment goals for
hypertensive diabetics are a blood pressure
of < 130/80 mmHg. Should blood pressure
targets not be met with initial lifestyle inter-
vention, pharmacological therapy should be
considered. This includes an ACE inhibitor
or an ARB (if the ACE is not tolerated), a
calcium-channel blocker or a thiazide-type
diuretic.
Diabetes is the leading cause of chronic
kidney disease (CKD). Approximately 40%
of diabetic patients will develop CKD,
highlighting the need for screening at
the time of diabetes diagnosis. Diabetic
nephropathy usually progresses from sub-
clinical disease and is characterised by
persistent proteinuria.
Referral for specialist renal care is
necessary when there is a progressive loss
of renal function, estimated glomerular
filtration rate (eGFR) < 30 ml/min, acute
renal failure > 60 mg/ml and failure to reach
blood pressure targets. Diabetic adults with
persistent albuminuria should be given an
ACE inhibitor to delay progression of CKD by
either preventing or delaying a progressive
decline in eGFR.
Prof Mollentze advises follow-up testing
of serum creatinine and potassium levels
within two weeks of a patient being initiated
on an ACE inhibitor or ARB. Referral to a
nephrologist should be considered when
there is a chronic, progressive loss of
renal function, despite the recommended
interventions.
Also common among diabetics is
retinopathy. Of diabetic patients, 40% have
diabetic retinopathy and 8% have sight-
threatening retinopathy. Screening should
be performed annually or in the case of
an abnormality. Few South African primary
healthcare workers are adequately trained to
screen diabetic retinopathy; many patients
need to be referred to a skilled professional
for screening. Tight glycaemic control, and
Management of type 2 diabetes in primary healthcare
