SA JOURNAL OF DIABETES & VASCULAR DISEASE
DRUG TRENDS
VOLUME 8 NUMBER 1 • MARCH 2011
37
Drug Trends
Clinical perspectives on managing diabetes: an expert South African view
A
t a recent meeting of specialist diabetolo-
gists held in Sun City, out-spoken South
African clinicians challenged firstly, the sim-
plistic approach of treating all type 2 diabetes
patients as a single homogenous group, and
secondly, compartmentalising type 1 and type
2 diabetes into two separate groups. Human
nature seeks to simplify and reduce complex-
ity in order to manage the issues at hand; yet
in doing this, clinicians may undervalue break-
throughs in knowledge and practice.
Using clinical insight to treat the
diversity of the type 2 condition
‘Treating type 2 diabetes as a single disease
contributes to the development of dogma and
broad standard guidelines that may result in
poorer individual clinical care. This grouping of
multi-aetiology type 2 diabetes as a single con-
dition may also contribute to weaker results in
diabetes clinical trials.’ This view was presented
by Dr Aslam Amod from Durban, who noted
the muddled thinking presented to patients by
many healthcare professionals.
‘They present the concept that you are
overweight because you are insulin resistant.
This is physiologically incorrect. Insulin’s func-
tion is predominantly anabolic and it pro-
motes weight gain. In its functional absence,
the result is weight loss. In severe cases of
insulin resistance, such as children with an
inherited condition of extreme insulin resist-
ance (leprachaunism) and in polycystic ovarian
syndrome, diabetic patients do not have sub-
cutaneous fat and are not obese’, Dr Amod
argued.
‘If the primary event is insulin resistance,
the patient is not overweight. If however the
primary event is being overweight, then insu-
lin resistance follows as a secondary event to
protect the body from the consequences of
being overweight. These two distinct versions
of a type 2 diabetic patient could perhaps be
called the Jekyll and Hyde of type 2 diabetes.
The same patient; or a very different patient, in
my view’, Dr Amod said.
‘In the overweight situation where the
insulin-resistant patient has normal
β
-cell func-
tion, glucose levels remain normal. If, however,
there is a
β
-cell defect, insulin production fal-
ters, with resultant hyperglycaemia’, Dr Amod
pointed out.
‘The role of insulin resistance as a protec-
tion mechanism in the overweight situation
may be a reason why the insulin-sensitising gli-
tazones show poorer-than-expected outcome
results in clinical studies’, Dr Amod speculated.
‘In treating the non-obese type 2 diabetic
patient with insulin resistance, even metformin
has little or no science behind its use’, Dr
Amod added. ‘However, we use this agent for
practical reasons without solid outcomes data.’
‘In insulin-resistant, overweight patients,
treatment with metformin, acarbose and
exenatide makes physiological sense. Treat-
ing non-obese, insulin-resistant patients with
sulphonylureas followed by insulin, then
adding metformin also makes physiological
sense. If you follow the step-by-step guidelines
of SEMDSA and other expert bodies, you cer-
tainly will get to effective care, but you may
well have lost valuable time and perhaps the
β
-cells of your patient’, he added.
A neglected diagnosis in type 2 diabetes is
the descriptive ‘lemon on a matchstick’ phe-
nomenon of lipidodystrophic diabetes. ‘This
has not been identified as being genetically
determined as yet, but it is probably due to a
post-receptor defect in the peripheral tissue.
Therapy should be targeted at maximising
insulin sensitivity with pioglitazone, met-
formin and GLP-1 agonists. Adding insulin also
becomes necessary.’
Adding to the diversity of diabetic aetiology
are cases of pancreatic diabetes, latent auto-
immune diabetes, pan-hypopituitarism and
drug- or chemical-induced diabetes.
In conclusion, Dr Amod argued for the
development of an approach to the diagnosis
of type 2 diabetes as one of diagnostic exclu-
sion: ‘exclude the genetic aspects, disease
of the pancreas and other aetiologies, then
conclude that your patient is in fact a type 2
diabetic characterised by overweight, insulin
resistance and
β
-cell dysfunction.’
The metabolic syndrome: weighing
up its value
The metabolic syndrome exists but it has little
medical value as it does not contribute to
improved clinical management of patients.
‘Syndrome X has in fact become an X syn-
drome and recent reviews by WHO, EASD and
ADA expert committees have indicated that
further efforts to define the condition are inap-
propriate’, Dr Brian Kramer, CDE, Houghton,
told delegates at the Sanofi-Aventis-sponsored
academic meeting at Sun City.
‘Clustering symptoms together as a syn-
drome should contribute to the understanding
of the syndrome or identifying causes of the
condition. As an example, the cluster of cough,
weight loss and night sweats, initially described
in a single entity as consumption, later led to
the discovery of
Mycobacterium tuberculosis
’,
Dr Brian Kramer
Dr Aslam Amod
