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05-30-2018 | Insulin | Editorial | Article

Hit early, hit hard: The EADSG insulin guidelines

Authors:
Sanjay Kalra, Silver Bahendeka

Author bios | Disclosures

Introduction

Diabetes knows no borders, and no region of the world is immune to this pandemic. Each country, however, has a unique healthcare system that influences the local approach to diabetes care. Such features, whether subtle or obvious, create a need for local recommendations to guide diabetes management.

The challenges in East Africa

The East African Diabetes Study Group (EADSG) has taken the lead in producing such guidance [1]. This evidence-based consensus considers the reality of diabetes care on the ground in East Africa, and suggests a pragmatic approach to the use of insulin therapy. The common challenges of diabetes in various developing countries mean that this document will find welcome usage beyond East Africa as well. 

Diabetes is a challenging syndrome to manage, but this challenge becomes even greater in certain regions. East Africa faces the so-called ABCDE barriers, which create hurdles in diabetes care (Box 1).

Box 1: The barriers to diabetes care in East Africa
Availability, accessibility, affordability of diagnostics, monitoring, therapeutic requirements
Behavior of patients and community with regards to acceptance of traditional versus Western medicine
Complications of diabetes, both acute and chronic, at presentation
Delayed diagnosis of diabetes and its complications 
Experienced diabetes care provider shortage

Comprehensive targets

The EADSG has adhered to internationally accepted grades of evidence while crafting these guidelines. The aims of therapy have been kept in concordance with current global recommendations [2,3]. All children with type 1 diabetes should aim for a glycated hemoglobin (HbA1c) <7.5%, while most adults with type 2 diabetes should target an HbA1c <7.0%. However, individuals with newly diagnosed diabetes, long life expectancy, and no cardiovascular complications must aim for tighter control (HbA1c <6.5%), while those with severe hypoglycemia, advanced vascular complications, limited life expectancy, and “difficult” diabetes should have their goals relaxed to <8.0% .

The guidelines highlight the concept of the glycemic pentad and hexad [4], and support the need to move beyond HbA1c centricity. The guidelines state the importance of achieving fasting, postprandial, and HbA1c control, while minimizing the risk of hypoglycemia, nocturnal hypoglycemia, and glycemic variability. In these regards, the EADSG encourages safety and efficacy of the highest standards.

Sensible regimens

Keeping in mind the unique challenges of diabetes in East Africa, formulating a sensible regimen becomes a herculean task. To achieve the twin aim of efficacy and safety, in the face of a relatively late and complicated clinical presentation of diabetes, is not easy. To do so, the EADSG recommends initiation of insulin in newly diagnosed type 2 diabetes with symptoms and/or severe hyperglycemia. Insulin may be initiated with basal or premixed/co-formulation, or in combination with glucagon-like peptide-1 receptor agonists/oral antidiabetic drugs. The organization also specifies the use of basal–bolus regimens as the initial choice in life-threatening or organ-/limb-threatening clinical situations [5]. This advice reflects the reality on the ground in East Africa, where patients often present with severe hyperglycemia, symptoms of diabetes, or acute complications [6]. The American Diabetes Association/European Association for the Study of Diabetes guidance to initiate treatment with basal insulin may not be appropriate in circumstances characterized by a high burden of hyperglycemia or its acute complications.

Flexible strategies

The EADSG has constructed its guidelines to strike a balance between science and sensibility in many ways (Table 2). The guidelines acknowledge the advantages of insulin analogs compared with human insulin preparations, especially in regards to the reduced risk of hypoglycemia [7]. The guidelines call for consideration of the cost–benefit ratio when choosing insulin preparations. While accepting that basal–bolus insulin is the standard of care for type 1 diabetes [8], the guidelines allow the use of premixed insulin and premixed insulin analogs if no other insulin is available.

Table 1: Unique features of EADSG guidelines on insulin
STRATEGY
  • Focus on education, psychosocial aspects
  • Focus on avoidance of hypoglycemia
  • Focus on health economics
  • Hit early, hit hard
GOALS
  • Person-centered HbA1c goals
  • Comprehensive glycemic pentad/hexad
  • Efficacy and safety
INSULIN INITIATION
  • At presentation
  • Symptomatic hyperglycemia
  • Severe hyperglycemia
  • In oral antidiabetic drug failure
REGIMEN
  • Initiation with basal/premixed insulin od/bid
  • Intensification to premixed bid/tds or basal bolus
  • Use of premixed insulin (analogs) in type 1 diabetes, if other insulins are not available
DELIVERY
  • Insulin technique
  • Delivery devices
  • Storage and transport
  • Insulin site reactions, including insulin tattoos (scarification)
SPECIAL SITUATIONS
  • Fasting, including Ramadan
  • Acute febrile illness
  • HIV and related comorbidities
  • Renal/hepatic impairment
  • Chronic complications
bid: Twice daily; od: Once daily; tid: Three times daily

Self-care and special situations

A strong emphasis on education, self-management skills, and insulin titration (to avoid hypoglycemia) is evident in the EADSG guidelines. The call to individualize therapy is underscored multiple times in the document. Mention is made of appropriate insulin regimens and preparations in special situations and complications. Special focus on fasting states, acute febrile illness, HIV infection and comorbidities, and ketosis-prone diabetes is concordant with the morbidity profile of East Africa.

Insulin delivery issues

The practical aspects of insulin delivery such as insulin technique, transport, and storage are also addressed in the comprehensive EADSG guidelines. The availability of insulin pens and syringe needles is discussed, and the phenomenon of needle reuse analyzed in a patient-centric manner. Furthermore, insulin site reactions such as insulin tattoos (scarification), which occur more frequently in the African population, are also covered. The need to debunk common myths surrounding insulin usage, information on biosimilar insulin, and the health economic considerations help to round out the comprehensive coverage of the issues that affect the delivery of insulin therapy in East Africa.

Summary

The EADSG guidelines on insulin are a comprehensive resource that will appeal to readers across the world. Their detailed coverage of the various aspects of insulin usage, shared in a reader-friendly format, make them a valuable companion for the clinician and student, alike.

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