Managing diabetes: The drivers of change

The challenge

Diabetes management is a challenging proposition. Recent advances in the etiology and pathophysiology of the disease have changed it from a simple disease of insulin deficiency, to a bifactoral model of insulin deficiency and resistance, to a multifactorial condition. The earlier moniker of the Ominous Octet[1] is now being replaced by the Dirty Dozen[2] as potential candidates for the elusive etiology of type 2 diabetes line up.

The advances in pathophysiology have been accompanied by improvements in pharmacology, and we now have a wide array of anti-diabetic drugs to choose from, These drugs, both oral and injectable, both non-insulin and insulin, can be prescribed in multiple combinations and permutations, separately as well as in fixed dose combinations.

While it may be a challenge for the endocrinologist to understand, remember and use these therapies, this is the least of his or her problems.

The diabetes pandemic shows no sign of abating[3] and not only developing nations such as India but developed countries such as USA[4] also report a shortage of trained endocrinologists and other professionals, who are qualified to tackle the large number of patients needing diabetes care.

In spite of various physiological, biochemical, and therapeutic advances in diabetology control remains poor. Data from all parts of the globe reports poor control of diabetes. The largest observational trial done in diabetes until date, the A1chieve trial, reports an average HbA1c of 9.5% globally, at the time of insulin initiation.[5] It seems that medical advances alone are not enough to fight the challenge of the diabetes pandemic. Had they been so effective, we would not be reporting the same HbA1c levels worldwide that were reported a decade ago.

• References

• 1 Defronzo RA. Banting Lecture. From the triumvirate to the ominous octet: A new paradigm for the treatment of type 2 diabetes mellitus. Diabetes 2009; 58: 773-795
• 2 Kalra S. Recent advances in pathophysiology of diabetes: Beyond the dirty dozen. J Pak Med Assoc 2013; 63: 277-280
• 3 International Diabetes Federation. Diabetes and impaired glucose tolerance. IDF Diabetes Atlas. 5. Brussels, Belgium: International Diabetes Federation; 2011
• 4 Stewart AF. The United States endocrinology workforce: A supply-demand mismatch. J Clin Endocrinol Metab 2008; 93: 1164-1166
• 5 Home P, Naggar NE, Khamseh M, Gonzalez-Galvez G, Shen C, Chakkarwar P. et al. An observational non-interventional study of people with diabetes beginning or changed to insulin analogue therapy in non-Western countries: The A1chieve study. Diabetes Res Clin Pract 2011; 94: 352-363
• 6 Available from: http://www.en.wiktionary.org/wiki/change [Last accessed on 2012 May 26].
• 7 Kalra S, Kumar S, Kalra B, Unnikrishnan A, Agrawal N, Sahay R. Patient-provider interaction in diabetes: Minimizing the discomfort of change. Internet J Fam Pract 2010; 8: 2
• 8 Conference Report: 2nd International DAWN Summit. a call-to-action to improve psychosocial care for people with diabetes. Pract Diabetes Int 2004; 21: 201-208
• 9 Peyrot M, Rubin RR, Lauritzen T, Snoek FJ, Matthews DR, Skovlund SE. Psychosocial problems and barriers to improved diabetes management: Results of the Cross-National Diabetes Attitudes, Wishes and Needs (DAWN) Study. Diabet Med 2005; 22: 1379-1385
• 10 Available from: http://www.dawnstudy.com/dawn2/newsandevents.asp [Last accessed on 2013 Feb 06].
• 11 Kalra S, Unnikrishnan AG, Skovlund SE. Patient empowerment in endocrinology. Indian J Endocrinol Metab 2012; 16: 1-3
• 12 Kalra S, Kalra B. Using analogy-building to initiate insulin. Internet J Fam Pract 2010; 8: 1