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International Diabetes Federation Congress 2019, Busan, Korea, 2nd-6th December 2019 (IDF 2019)

by | Dec 11, 2019 | Conference Update | 0 comments

Take Home message 

  1. Among the seven IDF regions, North America and the Caribbean has the highest crude prevalence of diabetes (13.3%), followed by the Middle East and North Africa (12.9%), Western Pacific (9.6%), South and Central America (9.4%), Europe (8.9%) and South East Asia (8.8%) while Africa has the lowest prevalence at 3.9%
  2. Youth onset of diabetes is no longer a rare entity population burden, regional variation-needs more research
  3. Benefits of SGLT- 2 inhibitors in terms of SBP, weight and HbA1c reduction are usually greatest in the first 3 months and maintained thereafter
  4. Metformin has the potential of being an additive combination therapy to enhance the bactericidal effect of anti-TB on DM-TB co-infection patients
  5. There are substantial differences in real-world prescribing patterns of second-line glucoselowering drugs after metformin among patients with type 2 diabetes
 

1. Prevalence of Depression in Diabetes

  • Depression increases risk of developing diabetes complications like cerebrovascular disease, retinopathy, coronary artery disease, nephropathy, sexual dysfunction, peripheral vascular disease, peripheral neuropathy and first foot ulcer
  • There is higher prevalence and incidence of (sub) clinical depression in people with diabetes compared to the general population
  • Depression seems related to the burden of the diabetes
  • Depression is associated with lower diabetes self-management, and increased risk of complications and mortality
  • Yet, depression is often undiagnosed and, consequently, remains untreated

 

2. Youth-Onset Diabetes in India

  • The inclusion criteria for all the cases of diabetes reporting (to a designated center of the Registry) on or after 01st January 2000 is: Age at onset/diagnosis <25 years with fasting plasma glucose >126 mg/dL and /or 2-hour post-load plasma glucose > 200 mg/dL
  • Malnourished young individuals from poor socioeconomic background from tropical countries and patients secondary to idiopathic non-alcoholic chronic pancreatitis are individuals who are generally affected by fibre-calculus pancreatic diabetes (FCPD)
  • Prevalence of FCPD is decreased from 1.6% (1991-1995) to 0.2% (2006-2010)
  • Ketosis resistant diabetes of young is a distinct clinical syndrome described in many areas of Asia and Africa
  • Impoverished and markedly underno-urished young adults develop insulin required but ketosis resistant diabetes
  • Clinical and biochemical evidence of blunted beta-cell functional zone
  • Hyperglycemia improves with sustained insulin therapy but not with oral agents
  • A single study from North India, mortality rate of T1DM was 1.1 per 100 patients-year over 2549 patients’ years of follow-up
  • Median duration of death due to diabetes was 102 months
  • Out of 16 cases, 10 cases were directly related to diabetes and its complication
  • Death of six cases were due to chronic renal failure (diabetic nephropathy), and four cases were due to septicaemia
  • Prevention: Youth onset of diabetes is no longer a rare entity population burden, regional variation-needs more research (capture recapture- “SEARCH”)
  • Early Detection: 50% T1DM and T2DM registered <1 year of diagnosis >60% registered were diagnosed <20 years of age.
  • Family history of strong predictor-especially T2DM
  • Optimal Management: High prevalence of Optimal Management: High prevalence of co-morbidities and hospitalisation, high rate of incidence of complications, and T2DM are at higher risk compared to T1DM

 

3. Impact of SGLT‐2 Inhibitors: An Observational Study in the Real‐World Setting

  • This is a one-year retrospective analysis of a cohort of 377 consecutive patients with T2DM initiated on SGLT2 inhibitors (empagliflozin and dapagliflozin) on follow up at a tertiary hospital in Singapore
  • The cohort was 51% male with a mean (±SD) age of 57 ± 12 years; 60.5% were Chinese, 14.6% Malays, 14.9% Indians, and 10.1% other ethnicities
  • At the end of 3 months, the mean weight had reduced by 1.3kg from 80.4kg to 79.1kg but plateaued at 12 months (p < 0.001)
  • Similarly, SBP reduced by 2.4 mmHg from 137.5 mmHg at baseline to 135.1 mmHg at 3 months but plateaued at 12 months (p = 0.018)
  • HbA1c reduced by 0.7% from 9.4% at baseline to 8.7% at 3 months but only decreased by a further 0.1% at 12 months (p < 0.001)
  • 89 patients (23.6%) had discontinued SGLT-2 inhibitors by 1 year, of which 42 patients had stopped within 3 months
  • Amongst those who discontinued by the first year, 21.3% had genital or urinary infections, 10.1% had worsening renal impairment, 3.4% had severe postural giddiness, 2% had significant polyuria and 3.4% stopped due to the cost
  • Euglycemic DKA did not occur during the study period
  • Compared to those who discontinued SGLT2 inhibitors at 3 months, those who continued had a significant reduction of HbA1C values from baseline (+0.07 vs. -0.86, p< 0.001)
  • This study showed that the benefits of SGLT- 2 inhibitors in terms of SBP, weight and HbA1c reduction are usually greatest in the first 3 months and maintained thereafter
  • Subjects who continued SGLT-2 inhibitors showed significant metabolic advantages
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4. Metformin as a Potential Enhancer for Anti‐tuberculosis Efficacy in Diabetes Mellitus‐tuberculosis Co‐infection Patients

  • In 2015, the incidence of new tuberculosis (TB) cases in East Java Provence Indonesia, reached 647 from 100,000 population
  • The risk ratio (RR) of TB infection in diabetes mellitus (DM) was increased 2.39 times and the risk of failure in TB treatment was also increased 1.69 times
  • The aim of an observational clinical study was to understand the clinical effect of metformin use in type 2 DM-TB coinfection
  • The study evaluated metformin therapy, at least 2 months, accompanying with insulin and anti-TB regimens and compared to non-metformin group
  • As conclusion, metformin is a mTOR inhibitor, by the activation of adenomonophospate kinase (AMPK)
  • Metformin in silico, in vitro and animal’s in vivo, expressed that metformin is a potential adjunct for anti-TB therapy
  • Metformin improves autophagy and it results 100% Acid Fast Basil (AFB) smear reversion rate
  • Metformin has ability in improving SOD level during inflammation and SOD contributes to the INH’s mycobactericid effect by increasing INH active drug and inducing autophagy
  • Metformin is also relatively safe for DM-TB co-infection patients due to its result in not elevated lactate levels
  • Therefore, developing new drug in host immune directed therapy that has similar function to metformin is a prospective project
  • Metformin has the potential of being an additive combination therapy to enhance the bactericidal effect of anti-TB on DM-TB co-infection patients
  • Metformin has several potential effect in enhance anti-TB, its side effect remains unpleasant

 

5. Global and Regional Diabetes Prevalence Estimates for 2019 and Projections for 2030 and 2045

  • The International Diabetes Federation (IDF) Diabetes Atlas has, since 2000, been providing essential information on the estimated and projected prevalence of diabetes worldwide
  • Both estimates and projections have drawn attention to the importance and growing impact of diabetes in all countries and regions
  • The quality of suitable studies was assessed based on their representation, study year, sample size and method of diagnosis
  • Data sources, published between January 1990 and December 2018, were identified and data were extracted from 255 of these sources, representing 138 countries
  • The global diabetes prevalence in 2019 is estimated to be 9.3%, equal to 463 million people living with diabetes
  • This number is projected to reach 578 million by 2030 and 700 million by 2045
  • The diabetes prevalence is higher in urban (10.8%) than rural (7.2%) setting
  • Furthermore, diabetes prevalence is significantly higher in high-income (10.4%) compared to low-income countries (4.0%)
  • Among the seven IDF regions, North America and the Caribbean has the highest crude prevalence of diabetes (13.3%), followed by the Middle East and North Africa (12.9%), Western Pacific (9.6%), South and Central America (9.4%), Europe (8.9%) and South East Asia (8.8%) while Africa has the lowest prevalence at 3.9%
  • In terms of the number of people living with diabetes, the countries with the largest number are China (116.4 million) and India (77.0 million), while the highest country prevalence are those of the Marshall Islands (33.8%) and Mauritius (25.3%)
  • One in two people in the world do not know that they are living with diabetes
  • The region with the highest prevalence of undiagnosed diabetes is Africa, where 59% of all people living with diabetes are unaware of their condition
  • In North America and the Caribbean the level of undiagnosed diabetes is the lowest, yet, even here, one in three people living with diabetes still do not know about their condition
  • The recent diabetes estimates and future projections confirm that a large number of people are living with the condition worldwide
  • It has also once more become obvious that there is a considerable variation in diabetes estimates across IDF regions
  • Even though high-income countries have the highest prevalence of diabetes, special attention should be paid to regions undergoing demographic and epidemiological transition to ensure the availability of appropriate prevention and treatment options to reduce the impact of diabetes

 

6. Do Guidelines Guide us Correctly? A Deeper Look into HbA1c Targets and Adverse Outcomes: A Meta‐Analysis

  • Outcomes in type 2 diabetes (T2D) remain poor in spite of advances in treatment, as the variety of glycemic goals set by various bodies contrast widely and confuse the treating physician
  • This meta-analysis was undertaken to analyse HbA1c at end of study (EOS), duration of diabetes and rates of complications and thereby arrive at an accurate and adequate HbA1c target to guide the physician
  • The aim of the study was to assess the relationship between target HbA1c levels and micro- & macro-vascular complications in patients with type 2 diabetes
  • 15 randomised controlled trials were included in this meta-analysis
  • The association of different HbA1c range (<6.5%, 6.6%–7.0%, 7.1%–7.7%) with micro- and macro-vascular complications were assessed and also the combined effect of duration of T2D (< 10 years or ≥ 10 years) and HbA1c levels
  • Each end-point is reported as the effect size (Hazard Ratio [HR] with 95% confidence interval [CI])
  • Intensive glucose-lowering strategy resulted in a statistically significant 13% (p=0.002) reduction in retinopathy, 18% reduction in macroalbuminuria (p=0.000) 32% reduction in end-stage renal disease (ESRD) (p=0.02) and a 13% reduction in non-fatal myocardial infarction (NFMI) (p=0.006)
  • Based on HbA1c achieved at EOS, a statistically significant 46% reduction in newonset or progressive retinopathy (p=0.002), 52% reduction in new-onset or persistent macroalbuminuria (p=0.002), 36% reduction in non-fatal stroke (p=0.008) and a 22% reduction in all-cause mortality (p=0.02) were observed in the group with HbA1c in the 7.1%–7.7% range
  • In the cohort, with diabetes duration of 10 years, reduction of HbA1c to 7.0% resulted in a significant 17% reduction in (p=0.02) with a significant increase (40%) in CV death (p=0.02) and a 20% increase in all-cause mortality (p=0.01)

 

7. Prescribing patterns of Second‐line Drugs After Metformin in Type 2 Diabetes:  Comparison Between the US and Israel

  • The objective of the study conducted by Shin JI, et al. was to compare prescribing patterns of second-line glucose-lowering drugs, after metformin in type 2 diabetes between two health systems in two countries i.e. US and Israel
  • The comparison was made between the proportional share of second-line glucose-lowering drugs in patients who initiated metformin and required a second glucose-lowering drug between the US (Geisinger: 2005-2016) and Israel (Maccabi: 2005-2018)
  • The mean age in the US Geisinger health system was 58 years (N=22,423; 48% female) and in the Israeli Maccabi health system was 59 years (N=57,086; 43% female)
  • Sulfonylurea was the most common second glucose-lowering drug in all years, although its use decreased from 68% to 49% over time
  • DPP4 inhibitor was the most common second glucose-lowering drug since 2010; however, starting in 2015, its use declined concomitant with an increase in SGLT2 inhibitor use
  • In 2016, dipeptidyl peptidase-4 (DPP4) inhibitor (24%) was the second most common glucose-lowering drug, followed by insulin (14%), and sodium-glucose cotransporter- 2 (SGLT2) inhibitor (4%)
  • Compared to the US, sulfonylurea use declined more rapidly: from 77% to 13% over the same period
  • Adoption of novel therapies was remarkably rapid in Israel with DPP4 inhibitor gaining almost 50% of second-line glucose-lowering drug and SGLT2 inhibitor almost 20% already in the third year after introduction
  • Thus, the study concluded that there are substantial differences in real-world prescribing patterns of second-line glucose-lowering drugs after metformin among patients with type 2 diabetes between the US and Israel