WHO recently published guidelines on treating and managing diabetes in low resource settings. Here we bring to you a commentary from Padma Shri Dr. V Mohan, an eminent Indian Diabetologist, who shares his views and opinions on the new guidelines.
I have gone through the new World Health Organization (WHO) Guidelines for diabetes management in low resource settings and would like to congratulate Dr. Roglic and Dr. Norris and the team of experts who put this together. This is a very timely document coming from the WHO and is written in a very balanced manner, keeping the low-income countries and the resource poor set ups and disadvantaged people in high income countries in mind.
With the advent of the newer molecules for treating diabetes including the DPP4 inhibitors, the SGLT2 inhibitors and the GLP1 (Glucagon-like Peptide-1) Analogues and other newer drugs, there is a tendency to prescribe these drugs instead of the older drugs like metformin and sulphonylureas. This report is in that sense, a very timely document.
If we look at the five key recommendations, the first one is to prescribe sulphonylureas as the second-line treatment to patients who display contraindications to metformin or failed to reach glycaemic control with metformin. The recommendation also distinguishes between different sulphonylureas and favours Gliclazide due to the better safety profile and quite rightly emphasizes the need for avoiding very powerful drugs like Gliblanclamide in patients above 60 years of age.
In India, sulphonylureas have been used for the last 50 years. In fact, in a paper which we published in Diabetes Care in 2013, we reported on long term survivors of diabetes who have lived for 50 or more years with diabetes. It is obvious that 50 years ago, only sulphonylureas and biguanides were available and yet these patients lived long to tell us that it is not the drugs that we use but the overall management of the diabetes which is important.
There is a move by the American Diabetes Association (ADA) and few other bodies to downgrade the use of sulphonylureas as in those countries, perhaps the sulphonylureas can be substituted with costlier drugs like the DPP4 inhibitors. But, in India where 80% of patients pay out of pocket, even affording sulphonylureas and metformin may be a problem for some people and hence we should keep these older agents which have stood the test of time, preferring the gentler sulphonylureas with the better safety profile like Gliclazide rather than the long-acting and more powerful drug like Gliblanclamide, particularly in older people.
The second recommendation is to use insulin as the third-line in those who do not achieve sufficient control with the use of sulphonylureas and metformin. This is of course debatable because there are many patients who would be unwilling to go straight on to insulin and in that situation, there are many patients who would be willing to add on a third agent like the DPP4 inhibitors or the SGLT2 inhibitors, if there are no other contraindications. Of course, this means that patients must be able to afford these treatments.
The WHO document talks about cost effectiveness of the newer agents and does not find any of the agents ‘cost-effective’ to justify their use as a third-line agent, and recommends the use of insulin in those who do not respond to sulphonylureas and/or metformin.
This point can be debated and while one can easily see the merit in this view taken by the experts and the authors of the article, in India, there are people who belong to various socio-economic strata and many who can afford these drugs.
There are some states where even in the government-run clinics, the government provides the costlier, newer agents if indicated and deemed necessary by the specialists who work in these clinics. Hence, while this recommendation is applicable to some people in India, our practice patterns have shown that a large number of patients would not mind adding a third oral agent before they go on to insulin.
The third recommendation of the WHO document indeed brings in this point that when insulin proves to be unsuitable to the patient, a DPP4 or SGLT2 or TZD can be used. The usual practice in India except in the very poor, would be to add the third oral agent and then consider insulin.
The fourth recommendation is about using human insulin wherever possible. This point is well taken as the analogue insulins are out of reach of a large number of people in India and human insulin indeed continues to be used extensively in our country. However, there are patients who can afford the analogue insulins and in these patients because of the less frequent hypoglycaemia, the analogue insulins can be considered.
The fifth recommendation talks about using long-acting analogues to patients who have frequent hypoglycaemia. This point is very well taken. Particularly at bed time where one is afraid of nocturnal hypoglycaemia, the long-acting analogues which are ‘peakless and gentler’ can be used and they have indeed helped to achieve better control of blood sugar because of decreased risk of nocturnal hypoglycaemia.
In summary, there is no ‘one size fits all’. Different guidelines recommend different approaches in the use of anti-diabetic drugs. I would say that we are lucky that we have a large armamentarium of anti-diabetic drugs to use and the need of the hour is personalized diabetes care. In other words, the person sitting in front of the doctor should be kept as the central focus point to decide which anti-diabetic drug would be more suitable.
This should definitely be based on cost considerations. However other factors such as the age of the patient, body weight, the type of glucose responses that the patient exhibits, such as whether it is predominantly fasting hypoglycaemia or predominantly postprandial hypoglycaemia, as well as the A1c levels and the presence or absence of diabetic complications and co-morbidities will, finally help decide the best anti diabetic drug for a given patient.
We recently published an article on the Availability and Affordability of essential medicines in diabetes in 18 countries across 5 continents including India. It was encouraging to note that metformin was available in 100% of the pharmacies which were survived as compared to 88% of pharmacies whereas insulin was available only in 76% of pharmacies in India. Particularly in rural areas where refrigerators are not available, many of the pharmacies did not have insulin. The availability of other costlier drugs was not looked at in this study.
In this respect, India fared much better than many other low-income countries in the world which is obviously a reflection of the strong pharma industry in India. This article specifically mentions that the availability and cost of the drugs do influence the patients continuing the treatment and this article is in line with the recent WHO guidelines.