SA Journal of Diabetes & Vascular Disease: Vol 11, Issue 4, November 2014

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SAJDVD: VOLUME 11, ISSUE 4, NOVEMBER 2014

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South African hypertension practice guideline 2014 : review
Authors: YK Seedat, BL Rayner, Yosuf Veriava
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 4, November 2014
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Abstract: Outcomes : Extensive data from many randomised, controlled trials have shown the benefit of treating hypertension (HTN). The target blood pressure (BP) for antihypertensive management is systolic < 140 mmHg and diastolic < 90 mmHg, with minimal or no drug side effects. Lower targets are no longer recommended. The reduction of BP in the elderly should be achieved gradually over one month. Co-existent cardiovascular (CV) risk factors should also be controlled.
Benefits : Reduction in risk of stroke, cardiac failure, chronic kidney disease and coronary artery disease.
Recommendations : Correct BP measurement procedure is described. Evaluation of cardiovascular risk factors and recommendations for antihypertensive therapy are stipulated. Lifestyle modification and patient education are cornerstones of management. The major indications, precautions and contra-indications are listed for each antihypertensive drug recommended. Drug therapy for the patient with uncomplicated HTN is either mono- or combination therapy with a low-dose diuretic, calcium channel blocker (CCB) and an ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB). Combination therapy should be considered ab initio if the BP is ≥ 160/100 mmHg. In black patients, either a diuretic and/or a CCB is recommended initially because the response rate is better compared to an ACEI. In resistant hypertension, add an alpha-blocker, spironolactone, vasodilator or β-blocker.
Sodium-glucose co-transporter (SGLT) inhibitors: a novel class of oral anti-diabetic drugs : review
Authors: P Naidoo, K Ho, V Rambiritch, N Butkow
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 4, November 2014
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Abstract: The prevalence of type 2 diabetes mellitus has reached pandemic proportions. The armamentarium of anti-diabetic agents is vast, but there remain unmet medical needs. The latest addition is the sodium glucose co-transporter inhibitors. Members of the class include dapagliflozin, canagliflozin, empagliflozin, ipragliflozin and tofoglilozin. This class of agents reduce blood glucose concentrations by inhibiting renal re-absorption of glucose. This mechanism of action is independent of beta-cell function and insulin resistance. This article explores potential effects of this class of agents, extrapolated from the mechanism of action, and compares these potential effects to effects demonstrated in clinical studies.
Excess cardiovascular risk in patients with type 2 diabetes: do we need to look beyond LDL cholesterol? : review
Authors: A Rees
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 4, November 2014
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Abstract: Despite impressive advances in treatment, cardiovascular disease (CVD) remains a significant healthcare burden in the UK and worldwide. The clustering of CVD risk factors in patients with type 2 diabetes underlines the need for a multifactorial treatment approach, yet even when receiving optimal therapy according to best standards of care, there remains a substantial risk of CVD and microvascular disease. Risk-prediction tools traditionally provide an estimate of risk over 10 years, however this approach is dominated by chronological age and gender and has a number of recognised limitations. A move from 10-year to lifetime risk calculation has been proposed, and should encourage intervention at a much earlier stage. This move, alongside aggressive and broad control of modifiable risk factors, aims to ease the burden of atherosclerosis prior to the manifestations of CVD. This will be of particular benefit to those with type 2 diabetes, who have been exposed to hyperglycaemia and other risk factors for extended periods of time. The atherogenic dyslipidaemia common in this group also ensures they will benefit most from treatment strategies under investigation to further reduce macro- and microvascular risk.
The foot attack: where are the defense mechanisms? : current topic
Authors: S Vig, T Alchikhal, B Turner, on behalf of Diabetes UK
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 4, November 2014
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Abstract: There is a need to raise awareness of foot complications and to decrease amputations in people with diabetes. The cost of care for these patients is high once they develop foot complications. With the correct management, up to 80% of amputations are preventable, and decision makers are acknowledging that they can play an important role in the prevention and treatment of foot complications and thereby reduce the amputation rate. Commissioning high-quality foot-care and auditing standards of foot management pathways will be beneficial, as will prompt patient referral to a multidisciplinary foot-care team. Signposting of these services to patients and carers may be the most important factor in preventing a minor foot problem escalating to an amputation.
Anxiety associated with self-monitoring of capillary blood glucose : learning from practice
Authors: A Schlomowitz, MD Feher
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 4, November 2014
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Abstract: Aims: The aims were to evaluate (1) prevalence and con-tributing factors of anxiety to the finger-prick method used to self-monitor glucose; (2) whether individuals report avoidance of self-monitoring due to fear of the finger-prick method; and (3) levels of general anxiety.
Methods: Individuals attending a specialist diabetes out-patient centre, and who self-monitored their capillary blood glucose concentrations, were invited to complete a standardised questionnaire to assess anxiety associated with the finger-prick method of blood glucose measurement, and general day-to-day anxiety.
Results: From 315 (58% male) individuals with diabetes, finger-prick anxiety was observed in 30% and general anx-iety in 33%. Positive correlations were found for finger-prick anxiety with avoidance of testing and with general anxiety. Older individuals had less general anxiety and females reported greater anxiety to the finger-prick method and general anxiety. There were ethnic differences in anxiety to the finger-prick method and avoidance of testing, but not to general anxiety.
Conclusions: One-third of a general diabetes out-patient cohort had general anxiety and anxiety to the finger-prick method for glucose testing. There are important implications for both patients and healthcare professionals in identifying barriers to achieving improved diabetes control.
Losing weight at any age can improve cardiovascular health : learning from practice
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 4, November 2014
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Weight loss at any age in adulthood is worthwhile because it could yield long-term heart and vascular benefits. The results are from a study ongoing from 1946, examining the impact of lifelong patterns of weight change on cardiovascular risk factors in a group of British men and women followed since birth.
The use of liraglutide, a GLP-1 agonist, in obese people with type 1 diabetes : learning from practice
Authors: SMR Gillani, BM Singh
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 4, November 2014
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Aim: Optimisation of glycaemic control in type 1 diabetes often results in unwanted weight gain. Glucagon-like peptide-1 (GLP-1) agonist use is associated with weight reduction in type 2 diabetes but its use in type 1 diabetes is little studied.
Methods: We developed a protocol for GLP-1 use in people with type 1 diabetes and obesity in which liraglutide was initiated and up-titrated while insulin doses were simul-taneously titrated according to glycaemic parameters.
Results: Of 15 patients offered treatment, eight proceeded. Baseline parameters were (n = 8, mean ± SD): (age 50 ± 6 years, BMI 40.4 ± 5.5 kg/m2, weight 123.0 ± 23.9 kg, HbA1c 8.5 ± 1.7%, total daily insulin dose 131 ± 112 units/day. By intention to treat analysis (n = 8, 12 months), at three, six and 12 months compared to baseline, weight loss was 6.8 ± 4.1 kg, 10.0 ± 5.6 kg and 8.9 ± 8.4 kg, respectively (p = 0.026). The reductions in insulin dosage were significant over six months (n = 8, p = 0.045) or when analysing only those who completed 12 months of liraglutide therapy (n = 6, p = 0.044).
Conclusions: GLP-1 agonist use in patients with type 1 diabetes may be advantageous where weight reduction becomes both a constraint and a therapeutic objective.
Obstructive sleep apnoea in diabetes: assessment and awareness : learning from practice
Authors: IW Seetho, SV O’Brien, KJ Hardy, JPH Wilding
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 4, November 2014
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Abstract: In 2008, the International Diabetes Federation (IDF) task force on epidemiology and prevention released a consensus statement recommending targeted screening for obstructive sleep apnoea (OSA) in people with obesity and type 2 diabetes with classic OSA symptoms, and screening for diabetes, hypertension and dyslipidaemia in those with OSA. We conducted a survey to gain a greater understanding of current practice in relation to the IDF recommendations for the assessment of patients in diabetes clinics in the UK. An online survey that was made accessible to diabetes healthcare professionals with the support of the websites of several diabetes organisations was performed. Most (approximately two-thirds) of diabetes healthcare professionals who responded to this survey were not aware of the IDF recommendations either for diabetes screening in OSA patients or for OSA assessment in type 2 diabetes and obesity. Participants indicated that their local diabetes guidelines did not incorporate assessment for OSA in those deemed to be at risk. Furthermore, most participants perceived OSA investigations to be primarily the domain of the respiratory team rather than the diabetes team. The observations from this survey provide a better understanding of the application and impact of the IDF guidance in diabetes clinics.
Can pre-operative carbohydrate loading be used in diabetic patients undergoing colorectal surgery? : learning from practice
Authors: A Farrukh, K Higgins, B Singh, R Gregory
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 4, November 2014
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Abstract: The introduction of enhanced recovery after surgery (ERAS) has been associated with shortening post-operative recovery. It achieves such outcomes by minimising the physical and physiological trauma of surgery. Benefits include superior pain control, reduced duration of ileus, improved pulmonary function and a reduction in thrombo-embolic and cardiac events. Within the ERAS approach, the role of oral carbohydrate supplements is based on dealing with insulin resistance which characterises periods of stress. Aggressive control of blood glucose levels has been shown to benefit both diabetic and non-diabetic patients admitted to intensive care units, however original studies in this area have not been consistently reproducible. The development of low-osmolality carbohydrate drinks during the mid-1990s opened up the possibility of extending these benefits to surgical patients by providing them with a carbohydrate load two to three hours prior to anaesthesia. The benefits of the ERAS approach to colorectal surgery has been confirmed in several reports. However, its role in diabetic patients has, as yet, received limited attention. This review examines this limited number of publications and considers the potential benefit of pre-operative carbohydrate loading in all diabetic patients.
Diabetes and obesity: South Africa's healthcare crisis : diabetes news
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 4, November 2014
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Abstract: November 14 marked World Diabetes Day and this year, the condition has been under the microscope even more than usual, thanks to leading sport scientist and author of The Real Meal Revolution, Prof Tim Noakes.
Novo Nordisk 'Changing Diabetes' annual cycle relay takes to the road : diabetes news
Authors: P Wagenaar
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 4, November 2014
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Abstract: The third annual Novo Nordisk 'Changing Diabetes' cycle relay took to the road again on 6 November. The gruelling two-day, non-stop marathon, which featured both cycling professionals and enthusiastic amateurs, is a unique advocacy event aimed at raising much-needed awareness of the growing diabetes pandemic. It is not a competition as such, however, and there are no winners - all participants are given equal recognition for their support of diabetes awareness.

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