Basic HTML Version
SA JOURNAL OF DIABETES & VASCULAR DISEASE
EDITORIAL
VOLUME 9 NUMBER 1 • MARCH 2012
3
Correspondence to: Dr Landi Lombard
Netcare Kuilsrivier Hospital, Cape Town
Tel: +27 0(21) 900-6350
e-mail: lclombard@mweb.co.za
S Afr J Diabetes Vasc Res
2012;
9
: 3
New therapies change diabetes practice
LANDI LOMBARD
T
he rising prevalence of diabetes, as a result of
urbanisation (and associated lifestyle changes)
and demographic and epidemiological tran-
sitions, is a recurring consideration in primary
healthcare. Diabetes is now among the most common
non-communicable diseases in South Africa, with
studies showing marked geographical and ethnic
variations in prevalence. We know that diabetes,
particularly type 2, is associated with cardiovascular
disease (CVD). Mortality from CVD is two- to fourfold
higher in the diabetic patient, regardless of variations
in South African epidemiology.
Dysglycaemia and cardiovascular risk
The relationship between dysglycaemia and CVD is linear and
sometimes starts below the diagnostic level of diabetes. In a study
of mixed-ancestry South Africans in Bellville, Cape Town (page
13), researchers used a 30-year CVD risk-assessment model,
with sobering results. Significant predictors of CVD were found
to be sibling history of diabetes, and triglyceride, low-density
lipoprotein cholesterol and glycated haemoglobin levels. More
surprising however, was the finding of a high lifetime CVD risk
in normoglycaemic and younger subjects. This has important
public health implications, as CVD is often underestimated in the
young. More local studies are urgently needed in our complex
ethnic population and funding must be made available for this
purpose.
Anticoagulation and antithrombotic therapy
Among CVD concerns is risk and management of cardioembolic
stroke as well as venous and arterial thromboembolism. The use
of warfarin as the cornerstone of antithrombotic therapy has both
benefits and drawbacks. Warfarin has a narrow therapeutic range,
leading to difficulties in achieving adequate time in therapeutic
range (TTR). This is compounded by the numerous drug and
dietary interactions of warfarin.
In this issue, Dr Wessels reviews anticoagulation therapy in
diabetic patients prone to a high risk of developing arterial disease,
including considerations of antiplatelet and anticoagulation
combination therapy (page 6). Furthermore, a review of new
antithrombotic drugs in stroke management (hailed a revolution
in stroke management) by Dr Bryer, addresses the advent of
the direct thrombin inhibitors and factor Xa inhibitors (page
4). These agents exhibit stable pharmacokinetics, obviating the
need for coagulation monitoring or dose titration.
Another advantage is that, at this juncture, they
do not have clinically significant interactions
with food or drugs and have been shown to be
either non-inferior or superior to warfarin in reducing
the risk of stroke and systemic embolisation.
However, long-term data and analysis of cost-
effectiveness to assess their true risk benefit are
required.
Familiarise yourself with agents such as
dabigatran, apixaban and rivaroxaban, as it is likely
that such agents will be an important replacement
for warfarin as treatment of choice for the prevention
of cardioembolic stroke. Unfortunately the price
of these agents will limit widespread usage. Also in this issue,
the patient information leaflet has valuable tips on patient self-
monitoring and the interaction of warfarin with other medications
(page 29).
New therapeutic entities for the management
of type 2 diabetes
Two topical articles on new therapeutic entities that have just
been launched and will soon be available in South Africa present
a comprehensive review of the DPP-4 inhibitors. The review gives
the reader more information to be able to select the best DDP-4
inhibitor for the specific clinical setting (page 9). The second
article, by Dr Khutsoane on liraglutide, a newly launched GLP-1
analogue, supports the many potential benefits of this class of
drugs (page 47). It is unfortunate that these drugs are premium
priced and therefore not available to most of the patients who
desperately need them.
Sanofi specialist diabetes meeting report
Of general interest is a report on the Sanofi specialist diabetes
meeting in Cape Town (page 31), covering a range of topics.
Included are summaries of presentations on the incretins and
metformin. Other discussions included peripheral neuropathy
(painful diabetic neuropathy), bariatric surgery, environmental
interaction with our genomes (epigenetics) and the fascinating
question of whether exercise improves or impedes glycaemic
control in type 1 diabetes. We hope to have a more comprehensive
article by the same author on this challenging entity in diabetes
care in this journal in the future.
In addition, there is also a short report on another arrow in
metformin’s quiver; it lowers the risk of pancreatic cancer in
women. This interesting report adds to recent data suggesting
that this drug also lowers the risk of many other cancers, which
are known to be of increased prevalence in diabetics.
In two basic science research articles done in the clinical setting
on diabetic patients, cytokines such as TNF-alpha and IL-6 and
sRAGE were studied. They may hold promise for future prediction
of vascular complications in diabetics.
Landi Lombard