Asher Fawwad

Ramadan Prospective Diabetes Study: the role of drug dosage and timing alteration, active glucose monitoring and patient education.

Diabet. Med. 29, 709–715 (2012)

Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in the Punjab Province of Pakistan.

AIMS The prevalence of diabetes mellitus and impaired glucose tolerance (IGT) and their relationship to age and obesity were estimated in Punjab, Pakistan by a population-based survey done in 1998. METHODS Oral glucose tolerance tests were performed in a stratified random sample of 1852 adults aged >or=25 years. The diagnosis of diabetes and IGT were made on the basis of WHO criteria. RESULTS The prevalence of diabetes was 12.14% in males and 9.83% in females. Overall total glucose intolerance (diabetes and IGT) was present in 16.68% males and 19.37% females. Central obesity, hypertension and positive family history were strongly associated with diabetes. CONCLUSIONS These results indicate that the prevalence of glucose intolerance is high in the studied population and comparable with the published data from the other three provinces of Pakistan i.e. Sindh, Baluchistan and North West Frontier Province, studied by the same group.

Glimepiride: evidence-based facts, trends, and observations

Type 2 diabetes mellitus is characterized by insulin resistance and progressive β cell failure; therefore, β cell secretagogues are useful for achieving sufficient glycemic control. Glimepiride is a second-generation sulfonylurea that stimulates pancreatic β cells to release insulin. Additionally, is has been shown to work via several extra pancreatic mechanisms. It is administered as monotherapy in patients with type 2 diabetes mellitus in whom glycemic control is not achieved by dietary and lifestyle modifications. It can also be combined with other antihyperglycemic agents, including metformin and insulin, in patients who are not adequately controlled by sulfonylureas alone. The effective dosage range is 1 to 8 mg/day; however, there is no significant difference between 4 and 8 mg/day, but it should be used with caution in the elderly and in patients with renal or hepatic disease. In clinical studies, glimepiride was generally associated with lower risk of hypoglycemia and less weight gain compared to other sulfonylureas. Glimepiride use may be safer in patients with cardiovascular disease because of its lack of detrimental effects on ischemic preconditioning. It is effective in reducing fasting plasma glucose, post-prandial glucose, and glycosylated hemoglobin levels and is a useful, cost-effective treatment option for managing type 2 diabetes mellitus.

Vitamin D for the treatment of painful diabetic neuropathy

Objective To assess the effect of high-dose vitamin D in patients with painful diabetic neuropathy. Methods A single intramuscular dose of 600 000 IU vitamin D was administered, and the effects on metabolic parameters and neuropathic pain assessed over 20 weeks. Results 143 participants with predominantly type 2 diabetes, aged 52.31±11.48 years, with a Douleur Neuropathique 4 (DN4) score (3.0±1.8), total McGill pain score (21.2±14.9), and Short Form McGill Pain Questionnaire (SFMPQ) score (2.1±0.9), were enrolled. The baseline 25-hydroxyvitamin D (25(OH)D) level was 31.7±23.3 ng/mL and 58 (40.5%) patients showed evidence of vitamin D deficiency (25(OH)D<20 ng/mL). Intramuscular administration of vitamin D resulted in a significant increase in 25(OH)D (46.2±10.2 ng/mL, p<0.0001) and a reduction in positive symptoms on the DN4 (p<0.0001), total pain score (p<0.0001), and SFMPQ (p<0.0001). Conclusions Treatment with a single intramuscular dose of 600 000 IU of vitamin D in patients with painful diabetic neuropathy is associated with a significant decrease in the symptoms of painful diabetic neuropathy. Trial registration number BIDE-12/2014.

Implementation of Ramadan-specific diabetes management recommendations: a multi-centered prospective study from Pakistan

BackgroundTo observe the outcome of implementation of Ramadan-specific diabetes management recommendations in fasting individuals with diabetes through health care providers.MethodsThis multi-centered prospective study was conducted at nine diabetes specialist centers in four provinces of Pakistan. The study was carried out in two phases; pre-Ramadan recruitment interview (visit A) and post-Ramadan follow up interview (visit B) of the same patients. Pre-Ramadan individual counseling was given and educational material provided to each patient by health care providers during visit A.ResultsOut of 388 patients with diabetes, blood glucose level was checked by all patients with type 1 and 71.43% patients with type 2 diabetes when they developed hypoglycemic symptoms during Ramadan. Of patients with type 1 and type 2 diabetes, 33.33% and 48% discontinued their fast when they felt hypoglycemic symptoms, respectively. None of the patient with type 1, while 18.87% patients with type 2 diabetes discontinued fast on the development of hyperglycemic symptoms. Drug dosage and timing were altered in 80% patients with type 1 and 90.5% patients with type 2 diabetes during Ramadan. Majority of the patients with type 2 diabetes changed from moderate/severe levels of physical activity before Ramadan to light physical activity during Ramadan (p<0.000). None of the patients required hospitalization when they developed symptomatic hypoglycemia or hyperglycemia and none developed diabetic ketoacidosis and hyperglycemic hyperosmolar state during Ramadan.ConclusionWe observed that it is practicable to implement Ramadan-specific diabetes management recommendations through health care providers.

Role of platelet indices, glycemic control and hs-CRP in pathogenesis of vascular complications in type-2 diabetic patients

Objectives: Alteration in platelet morphology and functions are associated with pathological processes and increased risk of vascular complications in patients with diabetes. The purpose of the study was to find the correlation between platelet indices with fasting blood glucose, HbA1c and hs-CRP level in pathogenesis of vascular complications in type 2 diabetic patients. Methodology: The study has been carried out on 51 Type 2 Diabetics and 55 age and sex matched healthy control subjects. Fasting blood glucose (FBG), Glycosylated hemoglobin (HbA1c), high sensitivity C- reactive protein (hs-CRP) level and platelet indices including Platelet count (PLT), Plateletcrit (PCT), Mean platelet volume (MPV), Platelet distribution width (PDW) were estimated and compared with normal subjects. The results were evaluated statistically. Results: The study demonstrated that FBG, HbA1c, MPV, PDW and hs-CRP were statistically higher in diabetics in comparison with control subjects (P is less than 0.05). Positive correlation of FBG with HbA1c (r is equal to 0.993, P is equal to 0.0001), PLT with PCT (r is equal to 0.922, P is equal to 0.0001) and MPV with PDW (r is equal to 0.332, P is equal to 0.024) was found in diabetics. Conclusion: The poor glycemic control is positively correlated with high HbA1c level. The increased values of MPV, PDW and elevated hs-CRP level may also serve as confirmatory test in finding risk of developing complications.

Temporal changes in the prevalence of diabetes, impaired fasting glucose and its associated risk factors in the rural area of Baluchistan

AIMS To observe temporal changes in the prevalence of diabetes, impaired fasting glucose and its associated risk factors in the rural area of Baluchistan province of Pakistan according to American Diabetes Association criteria by comparing the two surveys done in 2002 and 2009. METHODOLOGY This community based survey of 1264 subjects aged 25 years and above was conducted from February 2009 to February 2010 in sixteen villages of southern Baluchistan. The temporal changes were assessed in comparison with a similar survey conducted seven years previously. Data from 2002 survey was also re-analyzed according to the latest ADA criteria. RESULTS A two-fold increase in the prevalence of diabetes (from 7.2% to 14.2%) was seen in 2009 survey and the prevalence of impaired fasting glucose also increased significantly (6.5-11.0%). An important finding was the number of hypertensives and subjects with positive family history of diabetes also increased significantly (p<0.000) from the previous survey. CONCLUSION Coordinated National Programs for primary prevention to counteract the increasing prevalence of diabetes are the need of time. Further large scale studies with proper risk factor assessment are needed to ascertain the reasons of rising prevalence of glucose intolerance.

Trends of type 1 diabetes in Karachi, Pakistan.

Objective:  Our study aims to assess the presentation, prevalence, and associations of acute and chronic complications in subjects with type 1 diabetes mellitus (T1DM) at their first visit to outpatient departments.

Evaluation of Diabetes Conversation Map™ Education Tools for Diabetes Self-Management Education

Objective. To evaluate the efficacy of Diabetes Conversation Maps™ education tools for people with type 2 diabetes attending a diabetes self-management education program. Design and methods. This cross-sectional study was conducted with patients with type 2 diabetes who were recruited from Baqai Institute of Diabetology & Endocrinology, a tertiary care diabetes center of Karachi, Pakistan, from May 2010 to June 2011. Groups of 10–12 participants were given a pre-session questionnaire. Four sessions using Diabetes Conversation Maps™ education tools were conducted, and the same questionnaire was then completed again. Results. A total of 172 people (82 males, 90 females, mean age 60 years, average duration of diabetes 15 ± 4 years) participated in the study. Confidence in diabetes self-management: before the sessions, 52.3% of participants believed that the doctor is the most influential person in the management of their type 2 diabetes, whereas after the sessions, 97.1% acknowledged that they were responsible for diabetes self-management. Before, 15% said they knew what to do to manage their diabetes, whereas 75% indicated this after the sessions. Empowerment: before the sessions, 32% said they understood those aspects of their diabetes self-management that were in need of improvement, whereas 75.6% indicated this after the sessions. Willingness, ability, and preparedness for diabetes self-management: before the sessions, 22% said they understood the importance of diabetes self-management; this increased to 63.4% afterward. Before, 20.3% agreed that they will start making changes in their lives, whereas 65.7% agreed with this after the sessions. Satisfaction: 61% found the map sessions very effective, 72.1% found this format to be better than individual education, and 52.8% agreed that map tools helped in goal-setting. Conclusion. Diabetes Conversation Maps™ education tools are effective for diabetes self-management education and facilitating behavior change in people with type 2 diabetes. This, in turn, may improve patients’ chances of attaining desirable diabetes control.

Characteristics of a large cohort of patients with diabetes having at-risk feet and outcomes in patients with foot ulceration referred to a tertiary care diabetes unit

To identify in a large population cohort the clinical and biochemical characteristics of patients with diabetes at risk of foot ulceration and outcomes in those with foot ulcers. All patients with diabetes attending Baqai Institute of Diabetology and Endocrinology from January 2004 to April 2012 included in the study. Clinical, biochemical and socio‐demographic data were collected and patients were categorised into those at no risk of ulceration, at risk of ulceration and those with foot ulcer, according to the University of Texas classification. Patients with foot ulceration followed for their final outcome, that is complete healing, persisted non‐healed ulcer, lower extremity amputation, lost to follow‐up or death. A total of 18 119 patients with diabetes underwent assessment, 3576 (19·7%) patients defined as at high risk for foot ulceration and 3731 (20·6%) presented with foot ulcer. Age, male gender, hypertension, higher glycated haemoglobin (HbA1c), history of smoking and presence of neuropathy were risk factors (P < 0·000) for foot ulceration. Amputation rate in patients with foot ulceration was significantly related to severity of ulceration at presentation. Preventive foot care practices were followed by 19·02% patients. One thousand eight hundred seventy three (50·2%) patients completely healed, 293 (11%) patients underwent amputation and 397 (10·1%) patients continued to be treated in the foot clinic. All patients with diabetes should be screened for neuropathy to identify those at risk of foot ulceration, as it is the major contributory factor for foot ulceration. The final outcome of foot ulceration was determined by the severity and grade of ulcer at presentation.