Poor BP, Diabetes control, smoking are known risk factors for Diabetic Retinopathy - Sue Jones

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Diabetic Retinopathy Workshop at UHS
Poor BP, Diabetes control, smoking are
known risk factors for Diabetic
Retinopathy - Sue Jones
People with T1DM will develop Diabetic 
Retinopathy in 15-20 years’ time
For treatment Metformin remains the first
choice while SGLT2 should be started early

LAHORE: Poor Blood Pressure, Diabetes control, smoking are some of the well-known risk factors for developing diabetic retinopathy. People suffering from Type-1 diabetes mellitus will develop diabetic retinopathy (DR) in 15-20 years’ time. For treatment, Metformin remains the drug of first choice but SGLT2 should also be started early. This was stated by Dr. Sue Jones Consultant Physician in Diabetes, Endocrinology at University Hospital of North Tees & Senior Clinical Lecturer at Newcastle University, UK. She was speaking at a workshop on Diabetic Retinopathy organized at University of Health Sciences Lahore on February 11, 2020.

Dr. Sue Jones, it may be mentioned here was visiting Pakistan in connection with the arrangements for starting Final Paces Exam for MRCP which the Royal Colleges are planning to start very soon. During her presentation she also referred to the complications of diabetes like loss of eye sight, diabetic foot, hypertension and diabetic management at CKD. Hemodialysis, she pointed out is very common with us even today. Other risk factors for DR include aging, family history of diabetic nephropathy, male gender. Low birth babies, tend to develop obesity in adulthood as parents are eager to make them fat considering it healthy, hence start overfeeding them which then develop metabolic syndrome leading to diabetes mellitus. The overall worldwide prevalence of LBW babies is 15.5% but a study done in Rawalpindi Pakistan had reported the prevalence of LBW babies of 27.4% and these do not include those children who died before six months of age. She pointed out that lean LBW will not develop diabetes mellitus.


Justice (Retd) Tussadaq Hussain Jillani Chairman Board of Governors of UHS Lahore
presenting a memento to Dr. Sue Jones Consultant Physician in Diabetes, Endocrinology
from Newcastle University, UK who conducted a workshop on Diabetic Retinopathy at UHS
during a dinner reception hosted by UHS in honour of the visiting delegation
from IUMS Iran on February 10, 2020.

Continuing Dr. Sue Jones said that while examining the patients look in the eyes of the patients. Speaking about measurement of eGFR she said if it is less than 60, go for disease monitoring. Poor medication and diet also play a role in renal diseases. She then discussed a few case studies and how they should be managed. She also pointed out that we always under estimate these patients suffering from depression and anxiety. These people with diabetes are good patients with bad disease. Prof. Javed Akram opined that ideally some of these patients should be put on dual antiplatelet therapy but if that is not possible, at least they must be prescribed low dose Aspirin. Some patients who do not tolerate ACE Inhibitors can be prescribed ARBs. In Type-1 diabetes, more than one gene is involved. We are currently involved in gene editing at UHS. We have also noted that almost 35% patients respond to Statins and the rest 65% do not, hence why they all should be taking Statins. We need to screen out these patients and only those who will responds should be put on statin therapy. He also pointed out that sulfonylureas work better and they can be replaced with Insulin. If sulfonylureas are prescribed early on, it might save them from lifelong Insulin therapy. When we prescribe Insulin, patients go to quacks and they put sulfonylureas in their mixtures and they respond and feel better that is how we lose these patients to quacks. Hence why we should prescribe sulfonylureas ourselves. These patients may be suffering from auto immune disease, MODI can be treated by sulfonylureas. Early life style modifications can prevent Type-2 diabetes. Prof. Javed Akram felt that we should not restrict the diet of patients suffering from T1DM but adjust their Insulin dose. All patients who develop T1DM or Type2 DM at young age need to be looked after carefully.

In diabetes it is also important as to what to eat and when to eat. If we practice fast twice a week, it will be very helpful. Studies have also showed that use of black coffee is beneficial as beta cells have protective effect of coffee. Tea, Prof. Javed Akram said, might have a similar effect but no one is interested to invest money in research in the use of Tea as it is used more in the East. He clarified that it is the black coffee which should be preferred. Dr. Sue Jones remarked that elderly population should also be screened as they are usually neglected. Responding to a question Dr. Sue said that a 3KG baby is normal but anything less than 2.5 KG is abnormal. For management of T2DM Metformin and Sulfonylureas are best and preferred as it metformin makes insulin work better. SGLT2 Inhibitors lowers the HbA1c, reduce blood pressure, weight loss. Its side effects include UITI and increase in urinary glucose excretion. Metformin leads to weight reduction, improves cardiovascular protection but has some GI side effects. They are also contra indicated if eGFR is less than 30, otherwise they are safe and well researched drug. Side effects of SGLT2 also include candidiasis, DKA, toe ischemia and vaginal infection. SGLT2 are the way forward if they are added in medications early. If declining eGFR is more than 30 one should stop ARBs.

Diabetes in 2020

Later she delivered a lecture on Diabetes in 2020 at a meeting organized by Pakistan Society of Internal Medicine at UHS. She discussed the diagnostic criteria in detail, obesity, low birth weight, hypertension which all should be checked to diagnose diabetes. Family history of diabetes is an important risk factor. Aging population will have T2DM. The prevalence of LBW in Asians is between 18.6-35.2%. Patients should be advised to RUN for healthy life. Bariatric surgery was another treatment modality. For treatment Metformin remains the first choice. Acarbose is under used. She also referred to the efficacy of GLP1 analogues i.e. DPP4 inhibitors. Metformin is a low cost medication and proven track record of safety and efficacy, weight reduction, improvement in CVD outcome. However it is contra indicated if eGFR is less than30. Insulin comes in short acting, intermittent acting and pre-mixed insulin’s. She also pointed out that Human Insulin was still available in UK as it is very economical. She also talked about new generation of Insulin analogues. SGLT2 have benefits in heart failure patients.

Dr. Sue Jones concluded her presentation by stating that prevention remains better than cure. Dietary and life style modifications should always be preferred. Metformin is cheap and effective. GLP1 are expensive hence should be used carefully. SGLT2 Inhibitors shows promise and should be used early. Bariatric surgery can be recommended in obesity to patients suffering from T2DM.

Earlier Dr. Somia Iqtidar welcomed the guest speaker and participants. Prof. Tariq Waseem Senior Vice President of PSIM also briefly addressed the participants.

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