DRUG TRENDS
SA JOURNAL OF DIABETES & VASCULAR DISEASE
88
VOLUME 7 NUMBER 2 • JUNE 2010
continued from page 86
Issues to consider include the following.
Biphasic insulins like NovoMix cause less fluc-
tuation than a basal plus oral antidiabetic regi-
men. Weight gain is greatest with basal/bolus
and lowest with basal plus oral antidiabetic
agent. Insulin detemir’s unique properties,
however, have positive implications for weight,
resulting in ‘reduced defensive snacking’.
Prof Omar challenged the school of thought
that basal/bolus is always the best choice. ‘If
control is not achieved with oral agents and
bedtime insulin, move to twice-daily bipha-
sic insulin first. It has its place, and is a much
easier regimen for patients to comply with.
Many patients are not happy with the more
numerous injections required by a basal/bolus
regimen, which could have negative implica-
tions for compliance. Only if the biphasic regi-
men is failing should we move to basal/bolus.’
He concluded as follows: ‘We should start
with an oral agent plus a bedtime basal insulin.
If this fails, move to biphasic insulin plus met-
formin. And only failing that, should a basal/
bolus regimen be introduced.’
The child and adolescent with new-onset
diabetes – no small matter
Dr Yasmeen Ganie, head of Paediatric Endo-
crinology, Inkosi Albert Luthuli Hospital
When treating diabetes in children and
•
adolescents, it is important to focus on the
family/carers.
Education is the cornerstone of manage-
•
ment and must be tailored to the individual
child and their cultural context.
The first few years are critical to assess
•
and address resistance and bad behaviours
before they become established.
It is important to ensure the correct dose
•
necessary to achieve euglycaemia without
adverse events and impact on growth and
development, which need to be closely
monitored.
Always remember that these patients are
•
children first, and diabetics second; they
should be accepted and not made to feel
different.
Living with diabetes – how difficult can
that be?
Sister Laurie van der Merwe, Garden Centre
Clinic, Durban, noted that the patient is the
most important member of the diabetes-care
team. ‘Our responsibility is to ensure the dia-
betic patient is able to make an educated
evaluation and assessment of the information
for themselves.’ This is particularly relevant to
the field of alternative medicine, such as herbal
products. ‘I suggest to patients that they bring
in the product and then we discuss the claims
relative to available scientific information. I
provide information; the patient participates
and implements.’
Loosing weight – motivation is the key
Prof Fraser Pirie, University of KwaZulu-Natal
Prof Pirie noted the difficulty that patients
experience with regard to achieving weight
loss. ‘Effectively, there is no doubt that the
pathogenesis of obesity reflects the excess of
intake over energy expenditure – there is no
mystery about it!’ he noted. The highly moti-
vated individual can achieve weight loss and
the defining factor of success is ‘Is the patient
ready to lose weight?’
In the National Weight Control Registry of
successful weight losers (losses of
>
56 kg or
40% of body weight) whether by surgical or
non-surgical methods, the role of high levels of
physical activity in maintaining weight loss over
two years was pivotal.
‘Non-surgical patients had to work harder
to maintain weight loss than surgical patients;
yet it is re-assuring that similar benefits to bari-
atric surgery can be obtained by non-surgical
means’, Prof Pirie concluded.
Delivery of optimal diabetes care
Dr Larry Distiller, Centre for Diabetes and
Endocrinology, Johannesburg
Delivering optimal diabetes care requires time,
effort and commitment from the attending
doctor and his multidisciplinary support team.
‘We know that long-term outcomes are deter-
mined by the optimisation of care now’, Dr
Distiller pointed out.
‘In the care of a patient with a chronic con-
dition such as diabetes, there must be defined
goals of therapy, regular physical and psycho-
social assessment and a deep therapeutic rela-
tionship where the physician is trusted and can
negotiate with his patient to achieve the mutu-
ally set goals.’ The goal of regular routine care
from a dedicated unit is to keep the patient
well and deal with the following aspects com-
petently.
Normalisation of blood glucose:
The patient
should be seen a minimum of every six months
if the patient is achieving targets, or every three
months if not, in order achieve as near normali-
sation of blood glucose as possible. This means
blood glucose testing meters or readings must
be brought to every appointment. The patient
uses his/her meter of choice and the clinician
must have the expertise to interpret the results
of the record, discuss results with the patient
and intensify therapy as and when required.
Normal growth and development:
In the case
of children/adolescents, there must be up-to-
date height and weight measurements done
at every visit.
Prevention of acute complications:
Patients
must understand the dangers of hypogly-
caemia and have the necessary support (e.g.
glucagon kit) available. Patients need to know
their glycaemic targets and their limits. All type
1 diabetic patients must also have ketone strips
at home and know when to test.
Screening for chronic complications:
These
complications include the microvascular com-
plications of retinopathy, neuropathy and
nephropathy. Blood pressure, heart, feet and
urine examinations are essential. Blood pres-
sure needs to be taken at every visit. If raised,
recheck five minutes later and have confidence
in your assessment.
With regard to the heart, have a high index
of suspicion, as silent ischaemia is common.
‘Should every type 2 patient, be referred to a
cardiologist? In my view “no”, but the clinician
needs to be alert to vague symptoms of a car-
diac nature!’ Dr Distiller warned.
Examine the feet:
At every visit, examine the
feet – test for reflexes and neuropathy and cir-
culation. Refer the patient to a podiatrist for
ongoing foot care.
Laboratory and urine screens:
Do annual lipid
and urine screens for microalbuminuria and
proteinuria. The lipid screen must include trig-
lycerides, and HDL and LDL cholesterol – and
treat aggressively to target.
Practical diabetes management
The last session of the meeting dealt with prac-
tical diabetes management and the way for-
ward. Prof Ken Huddle, Wits University dealt
with the importance of hypoglycaemic avoid-
ance to protect neurological function and
reduce the development of hypoglycaemic
unawareness.
Dr I Paruk, endocrinologist at Albert Luthuli
Hospital in Durban pointed out that the art of
diabetes management is dynamic not static.
‘Guidelines and key processes of care are
influenced by clinical trials and advances’, he
pointed out. In the face of ever-increasing
numbers of diabetic patients, the clinician
can be supported by nurses who, if they are
trained with detailed management protocols,
can provide ‘a doctor service’ of excellent qual-
ity, according to a recent Cochrane Review of
nurse-led clinics’, he added.
Prof Ken Polonsky from the Washington
School of Medicine, USA, dealt with the new
incretin mimetics, which are fully discussed in
two separate articles in this issue of the Jour-
nal. His conclusion is, however, worthy of note,
saying that while these agents add significant
value to the armamentarium of clinicians, they
do not yet meet all the unmet needs of diabe-
tes patients.
J Aalbers, Special Assignments Editor and
Peter Wagenaar, Gauteng correspondent
