XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

1. Type 1 diabetes (due to b-cell destruction, usually leading to absolute insulin deficiency) 2. Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) 3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes) 4. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis), and drugor chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation)

Classification and diagnosis of diabetes

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Hyperglycemia and Adverse Pregnancy Outcomes

Metformin is a widely-used drug that results in clear benefits in relation to glucose metabolism and diabetes-related complications. The mechanisms underlying these benefits are complex and still not fully understood. Physiologically, metformin has been shown to reduce hepatic glucose production, yet not all of its effects can be explained by this mechanism and there is increasing evidence of a key role for the gut. At the molecular level the findings vary depending on the doses of metformin used and duration of treatment, with clear differences between acute and chronic administration. Metformin has been shown to act via both AMP-activated protein kinase (AMPK)-dependent and AMPK-independent mechanisms; by inhibition of mitochondrial respiration but also perhaps by inhibition of mitochondrial glycerophosphate dehydrogenase, and a mechanism involving the lysosome. In the last 10 years, we have moved from a simple picture, that metformin improves glycaemia by acting on the liver via AMPK activation, to a much more complex picture reflecting its multiple modes of action. More work is required to truly understand how this drug works in its target population: individuals with type 2 diabetes.

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The mechanisms of action of metformin

AIMS/INTRODUCTION
We aimed to evaluate and compare CGMS-based glycemic parameters in women in early pregnancy (<20 weeks of gestation) who were classified as: a) GDM by IADPSG but normoglycemia by alternate (UK NICE, CDA and DIPSI) criteria, and b) normoglycemia by both (IADPSG and alternate) criteria.


MATERIAL AND METHODS
In this cross-sectional study, eligible women underwent standard 75-g OGTT, followed by the placement of a CGMS. Glycemia-related parameters were calculated using the standard approach for CGMS data in pregnancy.


RESULTS
We enrolled 96 women at 14.0 ± 3.2 weeks of gestation. Of the women diagnosed as GDM by IADPSG criteria, 34.2%, 26.3% and 44.7% were classified as normoglycemic by UK NICE, CDA and DIPSI criteria, respectively. Mean 1-h postprandial glucose and time above range were significantly higher in women who were GDM by IADPSG, but normoglycemia by CDA criteria, compared to women with normoglycemia using both criteria. Similarly, mean 1-h postprandial glucose, 2-h postprandial glucose, peak postprandial glucose, 1-hr postprandial glucose excursion and time above range were significantly higher in women who were not identified as GDM by UK NICE criteria. Finally, women missed by DIPSI criteria had significantly higher mean 1-h postprandial glucose, 2-h postprandial glucose, peak postprandial glucose, postprandial glucose excursion, 24-h glucose, and time above range parameters.


CONCLUSIONS
More than a quarter of women diagnosed as GDM by IADPSG criteria are not identified by alternate criteria. Such women are significantly different from normoglycemic women in terms of several CGMS-based glycemic parameters of clinical significance.

CGMS profile of women diagnosed as GDM by IADPSG criteria and labelled as normoglycemic by alternate criteria in early pregnancy.

American Diabetes Association defines gestational diabetes mellitus (GDM) as diabetes which is diagnosed in the 2nd or 3rd trimester of pregnancy and is not clearly overt diabetes. GDM, if missed or not treated properly can result in maternal and foetal complications, short as well as long term. Screening for overt diabetes, especially for high risk women should be done at the earliest in pregnancy and for GDM, universally at 24-28 weeks of gestation. One step screening by IADPSG (75 gram OGTT), has been recently adopted by most of professional bodies to achieve uniformity. IADPSG criteria have resulted in increase in prevalence of GDM, and consequently increase pressure on health care services as well as on patients. This has resulted in discordance of view on universal adoption of the criteria. Many feel this criteria results in over diagnosis without clear benefits. This brief review will provide the answers to some of the important questions pertaining to screening for GDM.

Screening and diagnosis of gestational diabetes mellitus.

In such a situation, it becomes necessary to study the NLEMs of these nations, to assess if adequate provision has been made for essential antidiabetic drugs. An online search was performed to identify the latest NLEMs of the 11 SEARO countries. These are Bangladesh, Bhutan, Democratic People’s Republic of Korea (DPRK), India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor Leste. Two geographically contiguous member countries of the South Asian Association for Regional Cooperation (SAARC), viz. Afghanistan and Pakistan, were also included in the search. National List of Essential Medicines were available for all states except DPRK, for which the WHO has issued a list of life-saving drugs to guide potential donors.

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Essential drugs in diabetes: South and South East Asian perspective

One of the major endpoints to be considered while choosing glucose-lowering therapy is their impact on cardiovascular outcomes. As a corollary, the cardiovascular health assessment of a person with diabetes informs the choice of glucose-lowering treatment. The clinical aspects included in this bidirectional relationship are described in this review as the cardiovascular phenotype. Vital signs, cardiac autonomic function, myocardial health and coronary status influence, and are influenced by, choice of glucose-lowering therapy. Such therapy also has an impact on cerebrovascular and peripheral arterial health. These aspects should be considered while planning treatment for type 2 diabetes mellitus.

The cardiovascular phenotype: impact on choice of glucose- lowering therapy.

In the 26 years since Gruntzig introduced a simple balloon angioplasty technique, percutaneous coronary intervention has made extraordinary progress and has now surpassed bypass surgery in frequency. The area of coronary stenting has been the focus of intense research. One of the major problems encountered after stenting is an exaggerated vascular neointimal proliferation called in-stent stenosis. The evolution of drug-eluting stents has helped in reducing the incidence of in-stent stenosis by almost half. A number of pharmacological agents have been tried in coronary stents with varying degrees of success; many more are being developed and tested. Serious doubts have been expressed about the pharmacoeconomics of drug-eluting stents compared with bare metal stents, because of the huge disparity in costs. Drugeluting stents, which can be grouped under both device and instrument, have thrown up interesting challenges for clinical trials. The future could see the development of more compact devices with the help of diverse fields such as nanotechnology, microelectronics and advanced materials technology.

Yashdeep Gupta

Papers

CGMS profile of women diagnosed as GDM by IADPSG criteria and labelled as normoglycemic by alternate criteria in early pregnancy.

Screening and diagnosis of gestational diabetes mellitus.

Essential drugs in diabetes: South and South East Asian perspective

The cardiovascular phenotype: impact on choice of glucose- lowering therapy.

Drug-eluting stents: a pharmacoclinical perspective.