An observational multi-center study on type 2 diabetes treatment prescribing pattern and patient adherence to treatment.

In 2021, the International Diabetes Federation (IDF) reported that the prevalence of diabetes in Pakistan was 9.6%, higher than the global average. However, adherence to treatment guidelines, e.g., American Diabetes Association and Pakistan Endocrine Society and prescription patterns for Oral anti-diabetes (OAD), is poorly understood in Pakistan. Therefore, this study aimed to examine the prescribing practices of anti-diabetic medications, an association of lifestyle modification with drugs prescribed, and their effectiveness in preserving ideal glycemic levels in diabetic patients undergoing treatment in tertiary care teaching hospitals in rural and urban Pakistan. In this cross-sectional study, data were collected from prescriptions of outpatient diabetic patients from different rural and urban tertiary care hospitals between October 2021 and February 2022. 388 participants were enrolled in the study for a detailed interview on prescription evaluation and glycemic control. The coinvestigators conducted an interview with the patient and used a pre-validated questionnaire to collect the data. The relationship between following treatment guidelines and clinical and demographic factors was found using chi-square tests for bivariate analyses. The study reported that out of 388, the mean ages of the patients were 48 ± 12.4, and the majority were female. It was observed that 60.1% and 66.5% have uncontrolled fasting and random blood glucose, respectively. The education level of the study participants was also below par to have a complete understanding of the medical condition and self-management therapy. Even though they were taking the right medications-an average prescription regimen included 5.08 medications-52.1% of the studied people had glycated haemoglobin (HbA1c) levels higher than the therapeutic threshold set by the International Diabetes Federation. In this modern era, it was observed that the prescribing trend was still focused on traditional therapeutic options Biguanides, sulfonylureas, and dipeptidyl peptidase-4 inhibitors were prescribed in 64.6% of the patients. A significant association was found between glycemic control and body mass index, adherence to lifestyle modifications, and the number of medications prescribed (p-value < 0.05). The study reveals that Pakistan's prescribing practices do not align with international and national guidelines, leading to a high prevalence of uncontrolled diabetes and widespread use of polypharmacy among patients. To address this issue, policymakers should prioritize establishing a comprehensive national diabetes action plan. Additionally, there is a pressing need to develop diabetes education and awareness programs emphasizing the importance of lifestyle modifications for effective diabetes management.

Efficacy and safety of combination of empagliflozin and metformin with combination of sitagliptin and metformin during Ramadan: an observational study.

BACKGROUND: Management of diabetes during fasting is a clinical challenge. Sodium glucose co-transporter -2 inhibitors (SGLT2i) are considered safe with a low risk of hypoglycemia. However, studies on SGLT2i are scarce. This study was designed to compare the efficacy, safety, and tolerability of empagliflozin with metformin during Ramadan in comparison with sitagliptin and metformin. METHODS: It was a prospective, observational study, conducted at 11 different sites all across Pakistan on an outpatient basis during Ramadan (May 2021-June 2021). including 132 patients, 88 who received metformin and sitagliptin, and 44 patients who received metformin and empagliflozin. RESULTS: Patients of the SGLT-2i group experienced similar symptomatic hypoglycemic episodes (15.9%) as the sitagliptin group. There was an improvement in blood sugar levels after the use of SGLT-2i (RBS 181 ± 64 before Ramadan vs 162 ± 53 after Ramadan). HbA1c also improved after the use of SGLT-2i before and after Ramadan (7.2 ± 0.8 vs 6.9 ± 0.9 for Metformin + Empagliflozin and 7.8 ± 1.5 vs 7.6 ± 1.6 for Metformin and sitagliptin). Weight and BMI improved after the use of SGLT-2i (BMI 36.5 ± 4.8 before Ramadan and 33.7 ± 2.4 after Ramadan). There were no reported cases of urinary tract infection in the empagliflozin group. CONCLUSION: SGLT-2 inhibitors combined with metformin for patients with diabetes during Ramadan fasting is as effective, safe and well tolerated as DPP4 combined with metformin.

Cost of Illness Analysis of Type 2 Diabetes Mellitus: The Findings from a Lower-Middle Income Country.

BACKGROUND: Diabetes is a major chronic illness that negatively influences individuals and society. Therefore, this research aimed to analyze and evaluate the cost associated with diabetes management, specific to the Pakistani Type 2 diabetes population. Research scheme and methods: A survey randomly collected information and data from diabetes patients throughout Pakistan out-patient clinics. Direct and indirect costs were evaluated, and data were analyzed with descriptive and inferential statistics. RESULTS: An overall of 1839 diabetes patients participated in the study. The results have shown that direct and indirect costs are positively associated with the participants' socio-demographic characteristics, except for household income and educational status. The annual total cost of diabetes care was USD 740.1, amongst which the share of the direct cost was USD 646.7, and the indirect cost was USD 93.65. Most direct costs comprised medicine (USD 274.5) and hospitalization (USD 319.7). In contrast, the productivity loss of the patients had the highest contribution to the indirect cost (USD 81.36). CONCLUSION: This study showed that direct costs significantly contributed to diabetes's overall cost in Pakistan and overall diabetes management estimated to be 1.67% (USD 24.42 billion) of the country's total gross domestic product. The expense of medications and hospitalization mostly drove the direct cost. Additionally, patients' loss of productivity contributed significantly to the indirect cost. It is high time for healthcare policymakers to address this huge healthcare burden. It is time to develop a thorough diabetes management plan to be implemented nationwide.

Essential diagnostics and devices in primary care diabetes.

Medication is essential for diabetes care, and this is reflected in the Essential Medicines lists prepared by the World Health Organization and various countries. The need for essential diagnostics, and essential devices, however, has not been addressed adequately. In this communication, we call for creating a list of the essential diagnostics and devices that are required in primary and secondary/ tertiary diabetes care. We hope that this will encourage policymakers and clinicians to work together, to ensure that these are made available, accessible, and affordable for all patients.

Efficacy and Safety of Dulaglutide in Type 2 Diabetes Patients in Endocrinology Clinics of Islamabad, Pakistan.

Objective: Our objective was to ascertain the efficacy and safety of once weekly Dulaglutide among patients with Type 2 diabetes of Pakistani origin. Methods: This prospective cohort study was conducted at the Endocrinology Clinics of Shifa International Hospital, Islamabad and Umar Diabetes and Foot Care Centre, Islamabad, Pakistan during the period from July 2020 to December 2020. Dulaglutide at the dose of 1.5 mg once weekly was initiated in patients with BMI >28 and suboptimal glucose control in the background of Type 2 Diabetes who were also taking one or more of oral anti-diabetic and/or insulin therapy. Results: Mean age of patient cohort (n = 148) was 49.51 years (SD +/- 12.15) with 53.5% (n = 85) having type 2 diabetes for a duration of over 10 years. Mean weight was 93.2 kg at baseline with end of study mean weight being 90.7 kg. Mean HbA1c at baseline was 9.2%, which improved to 8.05% at the end of study. The main side-effects were nausea in 32%, vomiting in 8%, and diarrhea in 7% with 19% discontinuation rate due to cost and side-effects. Conclusion: Dulaglutide as a therapy demonstrated favorable HbA1c and weight reduction in obese type 2 diabetes patients of Pakistani origin.

Effectiveness, Safety, and Patient Satisfaction of Liraglutide in Type 2 Diabetic Patients.

Background and Objectives Liraglutide, an analog of human glucagon-like peptide 1 (GLP-1), has been approved for the treatment of type 2 diabetes mellitus in Pakistan since 2016. It is a GLP-1 receptor agonist that has shown promising results in terms of not only glycemic control but also weight loss. Our study aimed to provide evidence regarding the safety and effectiveness of liraglutide in Pakistan and to look at the adherence rate and treatment satisfaction of patients using liraglutide. Methods This is an observational retrospective study that recruited patients who were treated with liraglutide. Data were collected at the first visit and follow-up. Morisky Green Levine Adherence Scale and Treatment Satisfaction Questionnaire for Medication (TSQM-9) were used for the determination of adherence and satisfaction with the treatment. Results A total of 70 patients were recruited in the study, The mean difference in weight, body mass index, glycated hemoglobin (HbA1C), systolic blood pressure, and diastolic blood pressure from baseline to follow-up was -5.36 kg, -2.14 kg/m2, -1.76%, -12.38 mmHg, and 5.55 mmHg, respectively. Nausea was the main side effect reported. TSQM-9 scores were compared from baseline, and it was found that patients are satisfied with the treatment and its effectiveness. Conclusions Our study has demonstrated the effectiveness of liraglutide as a monotherapy or combination therapy in the Pakistani population. Liraglutide led to reduction in HbA1C and weight. This is associated with high treatment satisfaction rate and adherence rate. Thus, liraglutide remains an effective though expensive treatment option in a country like Pakistan.

The Outcomes of Dapagliflozin Use in Real-Life Clinical Settings in Endocrinology Clinics of Islamabad, Pakistan.

Introduction Dapagliflozin is a member of a novel class of drugs (sodium-glucose cotransporter-2 inhibitors) used to treat type 2 diabetes mellitus and licensed in Pakistan in 2017. This retrospective observational study evaluated the effects of dapagliflozin on glycated hemoglobin (HbA1c) concentrations in patients treated at endocrinology clinics in Islamabad, Pakistan. The secondary objectives included assessing the effects of dapagliflozin on weight reduction and blood pressure control and to determining its safety. Methodology Patients with type 2 diabetes who were treated with dapagliflozin were identified by screening the electronic medical records at tertiary care hospitals in Islamabad. Data were collected at the first visit and at follow-up. Categorical variables were recorded as frequencies and percentages and compared by McNemar's tests, and continuous variables were recorded as means and standard deviations and compared by paired sample t-tests. Results Mean HbA1C concentration was significantly lower at follow-up than at the first visit (7.57%±0.98% vs. 9.07%±2.07%, respectively; p<0.001). Bodyweight (85.09±15.92 kg vs. 87.07±16.11 kg, respectively; p<0.001) and diastolic blood pressure (80.34±7.12 mmHg vs. 82.34±9.61 mmHg, respectively; p<0.001) were also significantly lower at follow-up than at the first visit, whereas systolic pressure showed a marginally significant reduction (123.5±16.57 mmHg vs. 126.83±19.97 mmHg, p=0.048). Conclusion This first observational study of patients in Pakistan treated with dapagliflozin found that HbA1c concentration, weight, and blood pressure were reduced after initiation of dapagliflozin treatment.