Diabetes in the global Atlas in England
In December 2019, Busan (South Korea) hosted the Congress of the International diabetes Federation (inertnational Diabetes Federation, IDF), which for more than 50 years has been promoting the improvement of specialized care for patients with diabetes, supporting the development and implementation of prevention and treatment methods. The 9th edition of the IDF Diabetes Atlas was presented during the scientific session.
What is the IDF Diabetic Atlas?
Previously, an expanded collection of data on the prevalence of diabetes was conducted in the official languages of the United Nations-Arabic, Chinese, English, French, Russian, Spanish, as well as Danish, German and Portuguese. The new edition of the IDF Diabetes Atlas presents data from 255 sources (epidemiological studies, medical reports) from 138 countries.
The IDF diabetes Atlas is an authoritative source of information on diabetes prevalence, associated mortality, and costs at the global, regional, and national levels. It provides a complete classification of the disease and its diagnostic criteria, presents a General picture of diabetes, including estimates for each of the seven regions, and the role of complications based on current literature, information about specific actions to be taken in relation to diabetes (for example, prevention of type 2 diabetes, treatment of all types of diabetes, etc.).
The IDF diabetes Atlas has been the flagship publication since it was first published in 2000. Since then, the estimated prevalence of diabetes mellitus (types 1 and 2, with and without a diagnosis) among people aged 20-79 years has increased from 151 million to 463 million today. In the absence of effective measures to combat the pandemic, IDF experts predict that by 2030, 578 million people will have diabetes, and by 2045, this number will reach 700 million.
The Diabetes Atlas reflects the medical and social significance of the disease, because diabetes is a serious threat regardless of socio-economic status or national borders. People living with diabetes are at risk of developing a number of serious and life-threatening complications, resulting in increased need for medical care, reduced quality of life, and excessive stress for their families.
In the absence of adequate treatment, diabetes mellitus and its complications are associated with frequent hospitalizations and premature death. Worldwide, diabetes is one of the top 10 causes of death. Who and the United Nations have set global goals for improving health care, including reducing premature deaths from noncommunicable diseases, including diabetes, by 30 % by 2030, as well as developing national diabetes programs. These are very important steps to ensure that affordable quality health care is available to the projected 580 million people with diabetes.
Modern means of glycemic control
Great interest was aroused by the scientific session, which discussed issues of self-control and modern technical means of controlling glycemia. For self-monitoring of blood glucose levels, it is recommended to use individual glucose meters, including those with the setting of the target range of glycemia, which transmit data about glucose levels to a smartphone.
In the conditions of medical and preventive institutions, in addition to laboratory analyzers, it is necessary to use glucose meters for professional use (multi-user, hospital), which have a higher measurement accuracy compared to individual glucose meters and can withstand multiple disinfection cycles in accordance with well-validated methods presented by the manufacturer.
Currently, real-time NMG and flash glucose monitoring are used as an adjunct to traditional self-monitoring of glycemia, without completely replacing it. Their use can be useful for patients with diabetes mellitus of any type, receiving intensive insulin therapy (multiple injections of insulin or an insulin pump), initially conducting self-monitoring of glycemia with a frequency of at least 4 times a day, especially children and adolescents, pregnant women, as well as in cases of impaired recognition of hypoglycemia.
The development of technological means of insulin delivery (continuous subcutaneous insulin injection systems, or pumps) often determines patients ‘ priorities for their use in order to minimize the number of injections and the possibility of dose adjustment. At the same time, the quality and frequency of self-monitoring to determine achievement of optimal compensation in assessment of target levels of HbA1c and a minimum variability of blood glucose when using multiple insulin no less than using of insulin pump therapy.
Continuous glucose monitoring (HMG) systems measure glucose in interstitial fluid continuously at a frequency of 5-15 minutes using subcutaneous sensors. Currently available NMH systems can be divided into three categories.
Permanent NMG in blind mode, or so-called professional NMG, allows you to assess glucose levels in a short period of time (from a few days to 2 weeks) retrospectively. The main purpose of this method is an objective assessment of the glycemic profile, detection of hidden episodes of Hypo- / hyperglycemia in order to correct the treatment, as well as training of patients. While using these systems, the patient should perform parallel self-monitoring of glycemia using glucose meters for subsequent calibration.
Constant NMG in real time reflects the current glucose level, trends in its changes, and a graph for the previous time. The systems activate alarms when glycemia reaches the threshold values, as well as the threshold level of the rate of change in glycemia. When using these systems, the patient should perform parallel self-monitoring of glycemia using glucose meters for subsequent calibration. Some models of NMH systems transmit data to a smartphone in real time. they can be stored on a server and used for remote monitoring.
Periodically scanned / viewed NMG, or flash glucose monitoring, does not display glucose level data automatically, but only when the scanner is close to the sensor. Flash glucose monitoring provides information about the current glucose level, trends in its change, and a graph for the previous time.
Discussion of agreed ESC and EASD recommendations
The scientific sessions actively discussed the agreed recommendations of the European society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD), based on the results of randomized controlled trials EMPA-REG OUTCOME, CANVAS and CREDENCE, DECLARE TIMI 58, LEADER, SUSTAIN-6, Harmony Outcomes, REWIND, PIONEER 6, etc., proven to reduce cardiovascular outcomes when using new classes of glucose-lowering drugs (glucagon-like peptide-1 receptor agonists (AR GPP-1) and sodium co-Transporter glucose-2 inhibitors (INCTG-2)).
The results of these studies have convincingly demonstrated the benefits of these classes of glucose-lowering drugs in patients with type 2 diabetes and high and very high cardiovascular risk, resulting in a reduction in cardiovascular mortality and cardiovascular events.
The main cardiology study of 2019 was named DAPA-HF, which demonstrated sensational results. It is proved that dapagliflozin reduces the primary combined point (cardiovascular mortality, hospitalization due to CHF) of the incidence of worsening heart failure (emergency treatment for worsening CHF) by 26% (p<0.0001), as well as improving the quality of life in patients with and without type 2 diabetes. The results of this study exceeded all expectations and opened a new era in the treatment of patients with heart failure. A similar study is currently being completed to evaluate the effectiveness of empagliflozin.
It is obvious that the cost of drugs of ” new ” classes is a factor limiting their use. The DISCOVER program-a global prospective observational study of patients with type 2 diabetes to evaluate the second line of glucose — lowering therapy after Metformin-included the observation of 15,000 patients in 38 countries with different income levels on six continents. As a result, inertia was reported when making a decision to start using sulfonylurea derivatives, thiazolidinediones, dipeptidylpeptidase-4 inhibitors, AR GPP-1, INCTG-2 and insulin therapy, which leads to non-achievement of compensation and negation of the prognosis.
Along with the above facts, sulfonylurea derivatives, thiazolidinediones (pioglitazone), dipeptidyl peptidase-4 inhibitors are still widely used in clinical practice in many countries, including the United Kingdom (National Institute for Health and Care Excellence), Australia (national guidelines), and others. In patients without cardiovascular pathology, it is possible to use sulfonylurea derivatives, from which gliclazide is isolated as providing neutrality in its effect on body weight, minimal risk of hypoglycemia, and the lowest risk of death in the class. This approach is defined by the 2018 who recommendations for choosing the second and third lines of treatment for type 2 diabetes.