Pfizer held its third Hidden Faces of Diabetes event, this time at the Sandton Hilton hotel, in Johannesburg chaired by Prof Larry Distiller. Medical Chronicle Editor, Claire Rush McMillan, covered the event.
A range of thought-provoking topics were presented and lively Q&A sessions ensued.
The scientific programme addressed many common challenges related to managing patients living with diabetes, with a special focus on painful peripheral neuropathy. The day was completed with an ethics discussion by Stephanie Esterhuyse, who looked at the regulatory framework, unprofessional conduct, contempt of council and the complaint process.
The diabetes epidemic – Dr Zaheer Bayat
Dr Bayat, Specialist Endocrinologist, indicted the clear link between diabetes mellitus (DM) and cardiovascular disease. Interestingly, diabetes has existed for over 2000 years but is becoming more common. In 2013 there were approximately 2.6 million people living with diabetes in SA. It affects working class predominantly, in terms of age, which has massive economic ramifications.
Approximately 64% of people living with diabetes are female, in urban areas. We are also seeing more adolescent diabetes. In 2013, for every one person living with HIV worldwide, there were roughly six living with malaria and 11 living with diabetes.
- A lot of people living with diabetes are currently undiagnosed. For every person living with diabetes there is one prediabetic or one impaired glucose tolerance.
- 1.2m undiagnosed patients living with diabetics.
- The biggest growth of diabetes is in Africa, with predicted increases of 109%. This is steadily increasing in all age groups.
- 75% of patients living with diabetes die from cardiovascular disease.
- Diabetes is the leading cause of blindness in working-class adults and the leading cause of end stage renal disease.
- Diabetes is the leading cause of nontraumatic amputations.
- Overweight and obesity is a global phenomenon. There is now a term called ‘super-morbid obesity’, as we have surpassed the stage of morbid obesity.
- Diabetes is reaching pandemic status.
- A severe disease with many complications. These complications are expensive to treat.
- Does lifestyle intervention work? Yes, across all age groups, but it is difficult to implement.
Type 2 diabetes an independent CV risk factor – Dr Farouk Mamdoo
Dr Mamdoo, a Cardiologist and Specialist Physician, explored the serious implications that diabetes has for cardiac health. Heart failure (HF) carries an incredibly poor prognosis. “In a developing country like ours, we won’t be able to deal with the burden that is going to hit us,” he said. HF is a multifactorial problem and there are multiple steps in the development of HF in a patients living with diabetes. DM is an independent risk factor for cardiovascular disease.
Primary prevention strategies most effective are targeting HbA1c levels, lipid levels and BP to <140/90 but not lower than 130. Aspirin prevention should be considered in those with appropriate risk. Asymptomatic patients with goal level of BP, HbA1c, lipogram and lifestyle modification do not need routine expensive coronary imaging. The investigation of diastolic dysfunction should be implemented early especially if retinopathy is present as it carries an adverse prognosis and may influence risk assessment.
Diagnosis and management of painful diabetic neuropathy – Prof Roy Freeman
Prof Freeman who is a Professor of Neurology at Harvard Medical School delved into painful diabetic neuropathy (pDPN) – a global epidemic. Painful symptoms including burning, aching, painful tingling, painful numbness, stabbing were present in 26% of patients without neuropathy. He explained that pain is an early manifestation of diabetic peripheral neuropathy. According to a 2005 ADA survey, only one in four patients with symptoms of diabetic neuropathy is diagnosed with the condition.
Neuropathy gets trivialised, and it shouldn’t. It is a combination of excruciating pain and insensitivity. “Vascular disease is the final assassin but neuropathy is the real killer. The impaired healing is all rooted in peripheral nerve function,” he said. In treatment-induced neuropathy, pain is severe and its distribution varies – proximal or generalised to 33% of individuals.
There is evoked pain (hyperalgesia and allodynia) in up to 60% of patients. The condition is reversible or self-limited. In generalised diabetic peripheral neuropathy, we find a range of pain scores, distal pain distribution, evoked pain is infrequent and the condition is progressive.
Pregabalin is an analogue of gabapentin with the same mechanism of action but manifests linear pharmacokinetics. Evidence-based guideline support its use in the treatment of diabetic peripheral neuropathy neuropathic pain.
- Atypical presentations are frequent
- Exclude other causes even in patients living with diabetes
- Different neuropathic pain from other pains
- Treatment should treat risk factors and underlying disease
- Thoughtful evidence-based approach to the treatment of neuropathic pain
- Individualised therapy
- Be mindful of undertreatment
- More personalised glycaemic control
- Lifestyle management is important.
Case studies: diagnosing and treating pDPN
Drs Joel Dave and P Naiker presented case studies focusing on the diagnosis and treatment of painful diabetic peripheral neuropathy (pDPN). Diabetic neuropathy screening should be repeated annually and must include sensory examination of the feet and ankle reflexes. From history and examination, 60%-70% of the time you can make the diagnosis of pDPN. Tests increase your yield by an extra 10%, and another 20%-30% remain idiopathic. So, history and examination are essential components of making the diagnosis and trying to determine a cause of the peripheral neuropathy.
We are probably underestimating the significance of diabetic neuropathy and we should therefore be screening earlier and once we detect it, treat the diabetes more aggressively to get to the individualised targets,” said Dr Dave.