This was the message from Dr Sundeep Ruder and Prof Joel Dave of Groote Schuur Hospital (GSH). The newly opened diabetes centre, which Prof Dave heads at GSH, is a great example of what we can do in South Africa, and it will help improve access to care for many South Africans.
HYPERGLYCAEMIA IN HOSPITALISED PATIENTS IN A NON-CRITICAL CARE SETTING
Prof Dave addressed the wider aspect of hyperglycaemia in hospitalised patients in a non-critical care setting, mainly focusing on patients with type 2 diabetes (T2D) requiring admission to hospital. He emphasised that there is no one option that fits all, and we must individualise treatment if we are going to get the best outcomes for our patients.
There is an excess of 450 million people globally living with diabetes. By 2045 this is expected to grow to over 700 million people. Prof Joel stated that at GSH Hospital at any one time, 25% to 30% of all admissions are patients with diabetes. This means that about 300 people with diabetes are admitted in the hospital. Hypoglycaemia is a common comorbidity in medical surgery patients. Hyperglycaemia is a pro-inflammatory, pro-oxidative and pro-coagulant. All these mechanisms are known to increase mortality and morbidity in acutely ill patients. In experimental models, correction of hyperglycaemia reverses all the above abnormalities. In the presence of euglycaemia. insulin may have direct anti-inflammatory, anti-oxidative and anticoagulant effects.
In the ICU setting, for antihypoglyceamic therapy we have access to oral antidiabetic agents, which are generally not recommended. Instead, we have access to intravenous insulin and subcutaneous insulin. Intravenous insulin in the wards has been shown in many studies to increase morbidity and mortality. Insulin needs quite intensive monitoring and adjusting, so intravenous insulin should only be attempted rarely in the wards.
Managing these patients in the hospital is challenging. “Across the board, there is variable access to different type of insulins, various monitoring and different experience of doctors and nurses. We are dealing with vulnerable patients who are dehydrated, septic, not eating, have comorbidities, and are probably on drugs that could interfere with the medications they are on and worsen their hyperglycaemia.
There are no large, randomised controlled trials to guide us. It is important to individualise treatment according to the patient, the setting and according to the treating doctors. We need to watch the space in terms of the incretins, we know that in the non-hospital setting they are quite safe agents with a very low risk of hypoglycaemia and good in terms
of postprandial glycaemic control,” Prof Dave stated.
ACCESS TO T1D DIABETES CARE
Dr Angela Murphy, a physician in private practice in Johannesburg, presented on access to diabetes care in type one diabetes (T1D). Insulin has progressed from being an animal source to human insulin to analogue insulins. Even though we have had good treatment for 100 years now, we are still not seeing the level of control that we thought we would have. Data have shown that only 21% of adults with T1D are achieving the HbA1c target of less than 7%.
“There are over 20 insulins available in South Africa now and we know there are more to come. We have seen the rise in concentrated insulins. Studies have shown that insulin glargine 300U/ml demonstrated low risk of any time and nocturnal hypoglycaemia versus glargine 100U/ml. Insulin glargine 300 U/ML demonstrated lower incidence and rates of hypoglycaemia versus insulin degludec 100U/ML in the titration period,” she said.
In terms of dosing, Dr Murphy commented that we need to get patients to inject 20 to 30 minutes before meals to give their prandial insulin time to work. The huge leap that has come with using insulin pumps is the advent of the artificial pancreas. This allows a continuous glucose monitoring device to talk to the pump, which can then make decisions about changes in basal insulin and giving correction basal insulin doses that has really revolutionised the management of T1D. It goes without saying that diet and exercise have a big role to play. When having a consultation with a patient, remember to address their mental health. Do they have diabetes burnout or are they not achieving their HbA1c targets because they ran out of insulin? When giving advice to patients, deal with three steps being hypoglycaemia, fasting blood glucose and then prandial insulin.
“In terms of hypoglycaemia this often leads to the opposite, being hyperglycaemia so don’t just look at the high sugars and think that the patient needs more insulin. The patient might need less basal insulin and more prandial insulin,” she recommended. Patients want small, incremental changes that lessen the burden of care. “As practitioners as we need to help the patients create balance in terms of controlling their diabetes and still having a quality of life. It is useful to look at the patient’s daily habits. Good patient support groups can be extremely helpful to the patient in this regard. Make the consultation satisfying for the patient so that they understand that having control of their diabetes will lead to a better life,” she said.
In closing, Dr Murphy stated: “We’ve got the insulin, we’ve got the glucose monitoring, which now links with insulin pump therapy and many incredible benefits in this age of technology … but we still need to look at the patient. We’ve got to integrate all this data, the medications, patient monitoring systems and delivery systems, and translate that into what will work best for the patient sitting in front of us. For the next 100 years, I sincerely hope that we can see the prevention of type one diabetes and possibly a cure,” she said.
A PRACTICAL APPROACH TO CKD/DKD
Dr Ismail Randeree, a nephrologist based in KwaZulu-Natal looked at a practical approach to chronic kidney disease (CKD) and diabetic kidney disease (DKD).
He discussed that there is evidence of sodium-glucose cotransporter 2 (SGLT2) inhibitors as a class, for improvement of hyperglycaemia, prevention in people with T2D and established subclinical cardiovascular disease and those with multiple risk factors. They can also be used to prevent progression of CKD in both patients with and without T2D. Looking at SGLT2 inhibitors and the kidney, the benefits of SGLT2 inhibitors are independent of glucose control. SGLT2 inhibitors may prevent progression of CKD and cardiovascular disease. There is low risk of hypoglycaemia unless combined with insulin or sulfonylurea. When adding an SGLT2 inhibitor, reduce dose of sulfonylurea or insulin.
If you have a patient with acute kidney injury or acute tubular necrosis, one needs to monitor them annually. Those with diabetes, hypertension and coronary artery disease patients with eGFR under 45 should be referred to a nephrologist. Do not ignore the role of contrast-induced nephropathy such as an MRI scan, CT scan or PET scan. The patient must have renal assessment pre-test, post-test and six weeks later. CKD going into end-stage kidney failure is at a great cost to morbidity and mortality, family, work and social life. Chronic NSAID usage commonly leads to intestinal nephritis or chronic kidney disease. Be more proactive in looking at renal decline as patients come back to us.
GLYCAEMIC CONTROL IN OLDER PEOPLE WITH DIABETES
Dr Jay Narainsamy, a private practice endocrinologist at the CDE Centre in Houghton presented on glycaemic control in older people with diabetes.
BRIGHT study: U300 vs Degludec
BRIGHT was the first direct comparison of GLa-300 vs IDeg-100. It showed similar glycaemic control for HbA1c and fasting self-measured plasma glucose (SMPG). There was similar variability in 24-hour SMPG and fasting SMPG. During the full study and maintenance periods, anytime and nocturnal confirmed hypoglycaemia were comparable.
During the titration (0-12 weeks), the rate of anytime and nocturnal confirmed hypoglycaemia were lower with Gla-300 versus IDeg-100. Improving glycaemic control to protect cognitive function while avoiding hypoglycaemia may minimise diabetes-related complications in older people. Improved glycaemic control may prevent complications and reduce impact on physical impairment and frailty.
The older population has an increased risk for diabetes, hypertension, dyslipidaemia, and other NCDs. There is a high risk for falls, cognitive impairment and other age-related issues. There is increased risk of hypoglycaemia. We must balance hyperglycaemia complications versus hypoglycaemia risk. What remains the cornerstone of treatment is for us to individualise treatment in our patients.
There is no hard and fast HbA1C targets, although some might be preferable. Choose therapy that reduces risk of hypoglycaemia and side effects. Avoid polypharmacy. Our main aim as physicians is to avoid the vicious cycle of hypoglycaemia vs hyperglycaemia in our older patients.