Diabetes Mellitus in the different countries

Ukrainian version of the PCD Guidelines

Translator's notes about ukrinian perculiarties concerning Diabetes Care

by

Nikolay Khalangot, MD, Ph.D.

Epidemiology

• Traditionally, in Ukraine it is endocrinologists (district endocrinologists and doctors who render primary care to patients with diabetes mellitus  type 2), who are responsible for treating all DM patients. In practice due to a great number of these patients and a relatively small number of endocrinologists (1470 in year 2000 )[1] the situation may lead to an inadequate DM control, therefore the participation of GP or family doctors in treating DM type 2 may become necessary.
• The total number of DM cases in 2000 was 902628, of them 123739 receive insulin and are considered to be patients with DM type 1 [1]. The real Type1-Type2 patients ratio is to be verified [2,3] which can be facilitated by the analysis of the National DM Register [4].
• According to the official data in 2000  13261 lower limb amputations including 3823 amputations associated with DM were performed in Ukraine [1].

Background

Management of diabetes in the GP

treatment of diabetes, here, - reduction of hyperglycemia only 

** community and diabetes nursing personnel  – a visiting nurse who provides medical care to patients at home. Such workers are financed from the local communal budget. 

*** internal medicine specialist, i.e. a consulting doctor, a therapeutist 

**** a podiatrist : a doctor’s assistant who cares for mild lesions and ulcers of feet and assists in selecting foot wear, etc. Such a service is almost absent in Ukraine

Detection

Acording to the latest IDF / WHO guidelines concerning DM diagnosis,  blurring of vision should be considered one of possible DM symptoms. It may result from a disturbed refraction during a significant rise in glycemia    www.staff.ncl.ac.uk/philip.home/guidelines

In key presentations made at the Conference (May 11-12 ,2002) of the PCD –Europe Group the orators stressed the necessity to change their standart : any person over 45 is considered to be in need of DM screening, while in presence of the mentioned risk factors – even earlier

According to the classification of obesity (IOTF WHO, 1997) the body mass index is considered >29 kg/m², therefore, here we mean both obesity and overweight  (25-29 kg /m²).    

Diagnosis of diabetes mellitus

*that is, glycemia was determined in capillary or venous blood. In same  laboratories glycemia is still determined by the Hagedorn – Yensen  technique which should be taken into account while evaluatory of the results (obtained by this technique these results are by 10% higher than usially). 

** The given standard is based mainly on the position of the ADA .  According to the latest IDF guidelines concerning DM diagnosis, the glucose tolerance test may be successfully used (www.staff.ncl.ac.uk/philip.home/guidelines ) .

*** According to previous data on the analysis of one of hospital’s database’s in Ukraine (BSTD), the fraction of patients with a problematic diagnosis of their DM type may be 1-2 %. For this category of patients, who in the course of time are required for the DM type diagnosis, according to International Disease Classification 10-th revision, can be coded as E-14 (DM unspecified type), it is advisable to use GADA diagnostic assays [2,3].     

Risk assesment

*chiefly hyperglycemia with poliuria are a mention

** that is the diabetic foot syndrome

*** a device used to take a photograph of the fundus of the eye. Unfortunately, this photo fails to show some details of retinal pathology, particulary, the presence of macular oedema  

Treatment Policy Guidelines

Oral hypoglycaemic agents

*   We mean the plan of treatment only by the means of oral hypoglycemic agents (OHA), i.e., in case when nonmedicamentous treatment fails     

• New OHA that have appeared recently: they are derivates of benzoic acid (repaglinide),  D-phenilalanine (nateglinide), and thiazolidine diones (rosglitazone, pioglitazone). Repaglynide and nateglinide lead to a rapid and relatively short-term increase in insulin, which makes it possible to use them to control postprandial (post- meal) hyperglycemia, considered to be an independent factor of developing chronic complication of DM

Another significant property actively used in advertising new OHA is selectivity of “secretogogues” to the pancreatic receptors themselves, as compared to the cardiac ones. Such a selectivity was theoretically proved in experiments, paricullary, to glyclazide [5], it can decrease a potential risk of a negative effect of OHA produced on the atherosclerosis process. We cannot neglect the fact registered in the 70’s by the University Group Diabetes Program (UGDP) in USA that an increased mortalyty due to cardiovascular and cerebrovascular diseases in DM patients in a sulphonylurea (tolbutamide) [6] can be explained by the same non-selective effect of OHA in the receptors of coronary and cerebral arteries which can result in a disturbed reaction to ishemia. However, both  the IDF guidelines

( www.staff.ncl.ac.uk/philip.home/guidelines), and some local guidelines (ex: Sheffield university guidelines as to controlling DM type 2 by GP) demonstrate the absence of reliable proofs of clinical advantages of new OHA’s.

• recommendations given by firms manufacturing new OHA’s do not foresee a combined use of repaglinide or nateglinide with other secretogogues, that is with sulphonylurea derivates. 
• Thiazolidindiones (PRAR - receptors agonists) are one new OHA group, the mechanism of their action being based not on an increased secretion, but an improved insulin reception. The first representative of this group, troglitazone, was forbidden in USA due to its hepatotoxicity. Now in Europe they use rosglitazone, administration of which do not result in hepatic lesion  ( Salcman A., Collegeville P.A., 1999).
• Researches in Sweden determined a rise in the morbidity and mortality in patients on a combinatioin of sulphonylurea derivates and metformin [7]. The causes of this phenomenon, and therefore the proper conclusions, require some specification and further study. Unfortunately, these fundings have caused no changes in the majority of national diabetologic guidelines. Foundation of diabetic registers and its analysis may possibly soon clarify the question of advisability of using a combination of sulphonylurea derivates and metformin.  

Table 4:   Dosage of oral blood glucose lowering agents

*We mean the so-called “generics”, that is primary a non-commercial name.

In Ukraine the present-day practice of treating with OHA is somewhat different : 

1-st generation of sulphonylurea  is almost out of current use;

in case of renal dysfunction one of sulponylureas, glicvidone, is available, it being chiefly excreted by the liver   On the Ukrainian drug market there are repaglinide and nateglinide.

Repaglinide doses are from 1.5 mg to 15 mg per 24 h; those for nateglinide – from 180 to 540 mg per 24 hrs., these tablets are administered before/during each meal;

According to the previous analysis of DM Register, the use of glybenclamide (possibly, due to its low cost) is most common;   

The current commercial names of OHA’s in the Ukrainian market are : glibenclamid, maninil (glibencklamide); glurenorm (glicvidone); amaryl (glimeperide); diabeton (glyclazide); minidiab (glipizide); siofor, dianormet (metformin ); novonorm (repaglinide);  starlix (natheglinide)   

Avandia (rosiglitazon)  has been only recently registered in the Ukrainian market and we have limited experience with its use. Here we give recommendations as to its use received from Sheffield University diabetologists (“Sheffield university guidelines as to controlling DM type 2 by GP”) in the course of carrying out our joint research project in the field of DM :

rosiglitazone

• in combination with metformin in obese patients
• in combination with sulphonylurea in patients intolerant of metformin, or if metformin contra-indicated.
• dose 4mg once daily, may be increased to 8mg (8mg od or 4mg bd)
• contra-indicated in severe renal impairment (creatinine >= 700 ?mol/L), liver dysfunction (ALT x 2.5. normal), cardiac failure/LV dysfunction.
• liver function tests should be checked 2 monthly for 12 months then annually

Reference belong to translater’s notes

1. ??????? ????????? ?????????? ????????????????? ?????? ??????? ?? 2000 ?. ???????? ?????????????? ?? ?????? ??????? ?? . ?.?. ??????????? ??? ???????, ????. - 2000 , c. 31
2. ???????? ?.?. , ????????? ?.?. , ??????????? ?.?. , ?????? ?. ?????????? ????? ????????????? ????????? ??????? ? ????????, ??????????? ??? ???????? ??????????? ??? ?????? ? ???????? ??????? // ??????? ??????? ? ?????????????,  2002 , -  6, ?1, - ?. 78-86.
3. ???????? ?.?. ????? ?., ????????? ?.?., ?????? ?. ???????? ?????????? ???? ????????? ??????? ?? ?????? ??????? ?????? ???????? ?????? ?? ??????//??????????????, 2003, - 8, ?1. – ?.12-17  
4. ????? ??? ??????? ??? ????????? ??????? ?????? ?? ???????? ?????? ??????????????, 2001. – 6, ?2        ?. 246-251.
5. Gribble F.M., Ashcroft F.M.J. Differential sensitivity of ?-cell and extrapancreatic K – ATP channels to gliclazide. Diabetologia.1999; 42:845-848
6. Asvold BO, Jonsbu M, Grill V.  [Increased cardiovascular risk in patients with type 2 diabetes treated with sulfonylurea?] Tidsskr Nor Laegeforen.2000 Sep 10;120(21):2560-4.
7. Olsson J, Lindberg G, Gottsater M, et al. Increased mortality in Type 2 diabetic patients using sulphonurea and metformin in combination: a  population-based study.  Diabetologia 2000 May; 43(5):558-60)