Can HbA1c Alone Be Safely Used to Guide Insulin Therapy in African Youth with Type 1 Diabetes?

Introduction: The relationship of HbA1c versus the mean blood glucose (MBG) is an important guide for diabetes management but may differ between ethnic groups. In Africa, the patient's glucose information is limited or unavailable and the management is largely guided by HbA1c. We sought to determine if the reference data derived from the non-African populations led to an appropriate estimation of MBG from HbA1c for the East African patients. Methods: We examined the relationship of HbA1c versus MBG obtained by the continuous glucose monitoring in a group of East African youth having type 1 diabetes in Kenya and Uganda (n = 54) compared with the data obtained from A1c-derived average glucose (ADAG) and glucose management indicator (GMI) studies. A self-identified White (European heritage) population of youth (n = 89) with type 1 diabetes, 3-18 years old, living in New Orleans, LA, USA metropolitan area (NOLA), was studied using CGM as an additional reference. Results: The regression equation for the African cohort was MBG (mg/dL) = 32.0 + 16.73 × HbA1c (%), r = 0.55, p < 0.0001. In general, the use of the non-African references considerably overestimated MBG from HbA1c for the East African population. For example, an HbA1c = 9% (74.9 mmol/mol) corresponded to an MBG = 183 mg/dL (10.1 mmol/L) in the East African group, but 212 mg/dL (11.7 mmol/L) using ADAG, 237 mg/dL (13.1 mmol/L) using GMI and 249 mg/dL (13.8 mmol/L) using NOLA reference. The reported occurrence of serious hypoglycemia among the African patients in the year prior to the study was 21%. A reference table of HbA1c versus MBG from the East African patients was generated. Conclusions: The use of non-African-derived reference data to estimate MBG from HbA1c generally led to the overestimation of MBG in the East African patients. This may put the East African and other African patients at higher risk for hypoglycemia when the management is primarily based on achieving target HbA1c in the absence of the corresponding glucose data.

The Current Situation Regarding Long-Acting Insulin Analogues Including Biosimilars Among African, Asian, European, and South American Countries; Findings and Implications for the Future.

Background: Diabetes mellitus rates continue to rise, which coupled with increasing costs of associated complications has appreciably increased global expenditure in recent years. The risk of complications are enhanced by poor glycaemic control including hypoglycaemia. Long-acting insulin analogues were developed to reduce hypoglycaemia and improve adherence. Their considerably higher costs though have impacted their funding and use. Biosimilars can help reduce medicine costs. However, their introduction has been affected by a number of factors. These include the originator company dropping its price as well as promoting patented higher strength 300 IU/ml insulin glargine. There can also be concerns with different devices between the manufacturers. Objective: To assess current utilisation rates for insulins, especially long-acting insulin analogues, and the rationale for patterns seen, across multiple countries to inform strategies to enhance future utilisation of long-acting insulin analogue biosimilars to benefit all key stakeholders. Our approach: Multiple approaches including assessing the utilisation, expenditure and prices of insulins, including biosimilar insulin glargine, across multiple continents and countries. Results: There was considerable variation in the use of long-acting insulin analogues as a percentage of all insulins prescribed and dispensed across countries and continents. This ranged from limited use of long-acting insulin analogues among African countries compared to routine funding and use across Europe in view of their perceived benefits. Increasing use was also seen among Asian countries including Bangladesh and India for similar reasons. However, concerns with costs and value limited their use across Africa, Brazil and Pakistan. There was though limited use of biosimilar insulin glargine 100 IU/ml compared with other recent biosimilars especially among European countries and Korea. This was principally driven by small price differences in reality between the originator and biosimilars coupled with increasing use of the patented 300 IU/ml formulation. A number of activities were identified to enhance future biosimilar use. These included only reimbursing biosimilar long-acting insulin analogues, introducing prescribing targets and increasing competition among manufacturers including stimulating local production. Conclusions: There are concerns with the availability and use of insulin glargine biosimilars despite lower costs. This can be addressed by multiple activities.

Continuous glucose monitoring assessment of metabolic control in east African children and young adults with type 1 diabetes: A pilot and feasibility study.

BACKGROUND: For individuals with type 1 diabetes (T1D) in East Africa and other low-income regions, the last decade has seen substantial gains in access to insulin and trained healthcare providers, yet metabolic control remains poor. METHODS: The objective was to determine the feasibility of continuous glucose monitoring (CGM) and to gather baseline metabolic data for future power analysis in Ugandan and Kenyan youth with T1D using a Freestyle Libre Pro blinded CGM. RESULTS: Of 78 participants recruited, four sensors fell off and six patients did not return, leaving 68 evaluable subjects. Average age was 16 ± 5 (range 4-26) years, 43% female. Average diabetes duration was 7 ± 5 years, insulin dose 0.9 ± 0.3 U/kg/d, and number of fingerstick glucose levels per day 2.1 ± 1.1. All were on human insulin. Point-of-care HbA1c was 10.9 ± 2.7% (96 ± 30 mmol/mol). Mean number of sensor days was 13 ± 3; >90% wore the sensor for ≥10 days. Mean glucose was 231 ± 86 mg/dL (12.8 ± 4.8 mmol/L). Only 30 ± 19% of time was spent in the target range (70-180 mg/dL; 3.9-10 mmol/L), and 7 ± 8% of time was spent in hypoglycaemia (glucose <55 mg/dL, 3.0 mmol/L). Hypoglycaemia occurred in 81% of participants, averaging five events/wk with an average duration of 140 ± 79 minutes/event. CONCLUSIONS: Despite significant diabetes care improvements, East African youth with T1D have poor metabolic control with chronic hyper- and hypoglycaemia, placing them at high risk for serious acute and chronic complications. This study demonstrates the feasibility of CGM use in this population and provides baseline metabolic data that will be used to inform a future intervention study.

Childhood diabetes in Africa.

PURPOSE OF REVIEW: This review summarizes the current state of diabetes in African children. RECENT FINDINGS: Type 1 diabetes is the most common form of pediatric diabetes in Africa. Significant improvements have been achieved over the last 6 years, including the training of more than 60 pediatric endocrinologists who are now practicing in 14 African nations, greater training of other healthcare providers, increased availability of insulin through the efforts of philanthropic organizations and industry, modestly better availability of testing supplies, and the introduction of patient education materials in native languages. However, there is still a long way to go before the standard-of-care available to children in resource-rich nations is available to children with diabetes in Africa. SUMMARY: Here, we review the known epidemiology, pathophysiology, complications, and treatment of diabetes in children in Africa.