Prevention and rational treatment of Type 2 Diabetes Mellitus and its complications-II


Prevention and rational treatment of Type 2
Diabetes Mellitus and its complications-II

Lt Gen Prof Emeritus Mahmud Ahmad Akhtar
Former Surgeon General/DGMS (IS) Army
(Note: First part of this write-up was published in February 1, 2015 issue)

Aspirin: Low dose enteric coated aspirin 75 to 81 mg up to the age of 75 years may be used in patients having 7.5% or higher risk of heart attacks and strokes. Diabetic patients should always carry soluble aspirin 325 mg tab to be used on onset of chest pain or stoke. It helps in reducing heart attacks and strokes. Aspirin is a must for secondary prevention, sometime in combination with clopidogrel. When used in combination, it is only used for one year duration then clopidogrel is withdrawn. Unfortunately many times this combination is used for long periods with serious adverse effects due to hemorrhages.

Bariatric Surgery: It has been successfully used in severely obese prediabetes patients from developing into type 2 diabetes. 


The life-style therapy regime described under the heading of “Prevention” is continued vigorously. Those diabetic patients which are not controlled with it, are placed on “pharmacological treatment.

Metformin: This is the most cost-effective drug – cost of a day’s treatment being Rs. One to three per day.  With it HB1Ac reduction from 0.8 to 2.0 percent can be achieved. Furthermore it generally does not cause hypo-glycaemic episodes. It also causes loss of weight, which is beneficial in overweight patients. 

Sulphonylureas: which are the next cost effective group of anti-diabetic drugs, of which the most economical one is glibenclamide – the cost of a day’s treatment of which is Rs. two to five and can achieve HB1Ac reduction from 1.0 to 2.5% on long term therapy. The other drugs are glimeperide, gliclazide and glipizide which may be used in those who get frequent hypoglycaemic episodes with glibenclamide, which is quite rare. 

A combination of metformin and sulphonylureas: This  is recommended for the diabetic patients, who are over-weight, obese and having increased insulin resistance, along with reduced production of insulin. In this combination, metformin reduces insulin resistance and sulphonylureas increase insulin production forming an ideal treatment options for these patients. Moreover this combination achieves substantial reduction of HB1Ac, therefore it is most cost-effective. In pregnancy, these drugs can be used.

Thiazelodenones:  They cost more and have many side effects like increase in weight, fluid retention, precipitation of heart failure in patients suffering from ischaemic heart diseases, liver function disturbances, adverse effects on bones in old age and suspicion of causing urinary bladder carcinoma also. These can achieve HB1Ac reduction from 0.6 to 1.5 percent with logn term therapy. They have a limited application in therapeutics.

Glipitins (DDP4) inhibitors: These are costlier and less potent drugs which may on long term therapy achieve reduction of HB1Ac from 0.4 to 0.7% only. Therefore, they have lesser cost-effectiveness. Unfortunately these are used on a massive scale and that too as primary drugs.

Glucosidase-inhibitors: These can reduce HB1Ac from 0.4 to 0.7 percent only, cause a lot of g.i disturbances therefore have very small utility as an adjunct drug.

GLP I mimetics like Exetanideetc: They are highly expensive and have very restricted use even in prosperous developed countries like England, Scotland and others. Therefore, these have practically no place for use in our country.

Repaglinide and Nateglinide: They are expensive and have very limited use.

Ganalglitflozin and Dapagliflozin. These are new drugs acting on renal tubules inhibiting absorption of glucose – have very limited use even in economically advanced countries.

Insulin: insulin is usually needed by Type II diabetic patients, in the later stages of the disease. Insulin is available as human insulin and its modified version, insulin analogue. Insulin analogue is ten times more expensive than human insulin and has no worth-while advantages. Therefore, it should not be used except in an extremely rare situation when a long acting insulin analogue may be used for a patient who suffers from frequent hypo-glycaemic episodes particularly at night times. It is pathetic to note that it is being abused on a large scale in our poor country.

Anti hypertensives:    As far as the use of anti-hypertensive’s is concerned, thiazides are cost-effective unless there is a compelling indication to improve renal function where ACEI/A2A are indicated and beta-blockers may be used for treating Lt ventricular dysfunction and for ischaemic heart disease.

Vaccinations:    Every year diabetic patients should receive the flue vaccination and pneumococcal vaccination one time, Hepatitis B vaccination if not taken earlier and update tetanus toxoid inoculation.

Bariatric surgery: It has been used to severely obese diabetics to reverse the diabetic process.

Irrational drugs:  They should be avoided. A drug ‘TRICADININ’ not approved by any “Drug Regulatory Authority” in the world – not having undergone any valid safety and drug interaction studies and clinical trials is being abused on a large scale due to false aggressive promotional activities of a company – robbing the patients of their health and meager financial resources of the Nation. It is pertinent to point out that in the development of a drug, billions of dollars and expertise are required to carry out valid studies. The companies promoting such drugs, use bogus, fraudulent ghost trial studies. It is also pertinent to note that a similar bogus drug called ‘CARDIOPLANTIN’ was earlier used in Pakistan. European Union Drug Regulatory Authority has repeatedly warned the public of cases of hepatic and renal failures occurring in patients using irrational unapproved drugs, thus requiring renal and hepatic transplants and loss of life.

Patient education: The first and foremost job of a doctor is to educate and motivate the patient about the management of disorders. He should provide information to the patient about “life-style” therapy in detail – about drugs and possible side-effects – about glucose monitoring – blood glucose, lipid and BP levels to be achieved – adjustment of doses of drugs – symptoms of hypoglycemia and its management. Patients should also be provided information about the preventive measures to be adopted by their families. There should be special emphasis, for caring for the eyes, teeth and feet.

Unfortunately many doctors in Pakistan, even many specialists just spend a few minutes in consultation, do not listen to the patient and do not cater for the informational needs of the patients with the result that many patients do not undergo adequate treatment and suffer from complications and their sequlae. There needs to be a change in orientation of medical practice and the role of senior doctors – setting examples by becoming role-models to be emulated by the junior doctors.


Diabetes-mellitus type II has assumed epidemic proportion in Pakistan. The disease has high morbidity and mortality. There is a dire need to adopt preventive measures at the national level to tackle the menace. This needs political will.

It is a life-long disease and causes a large number of complications needing additional treatments. In addition to life-style therapy which forms the foundation stone of its management, there is a need for cost-effective pharmacological treatment. Pakistan is a very poor country with over 40 percent of its population living below the poverty line and another 20 percent touching the poverty line and extremely debt-ridden state with poor economy. The cost effective treatments have added importance.

The most cost-effective drug is metformin following by economical sulphonylureas and their combination in more severe diabetic patients – glucosidase inhibitors have a limited use as an adjunct drug. Thiazeledones have much less utility due to their many undesirable side-effects. Gliptins are expensive and have low potency therefore these are not cost effective. GLPIS like exetanide due to high cost have very low utility even in higher advanced prosperous countries. The efficacy of hypoglycaemic, anti-hypertensive and hypo-lipidaemic drugs can easily be checked by patients themselves.

In those patients losing control on oral drugs, human insulin along with oral drugs or alone may be needed. Human insulin analogues are extremely expensive therefore should seldom be used. In order to achieve good outcomes, good blood sugar control, blood pressure and lipid controls should be achieved and maintained. Statins have special place in the management of D.M patients. Irrational drugs like ‘TRICARDININ’ and others should not be abused.

Complications should be detected earlier and treated vigorously. In addition to physical complications, psycho-somatic and psychiatric disorders should be detected and treated energetically.

Government should adopt policies and specialty organizations should adopt guide-lines which cater for the needs of the common people and are not elite-oriented. These problems can only be tackled by the state becoming a true democratic welfare state, as envisaged by the Quaid-e-Azam. We should set our priorities right – Health and education should be the first and main priority – not the luxurious projects catering mainly to the needs of elites and corrupt.