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A study on management of type 2 diabetic patients with complications

Lack of awareness on the importance of glycaemic control, importance of adherence to medications, financial constraints or self-negligence could be the common causes that may lead to complications in these individuals. Similarly, the uncontrolled glycaemic state on a long run results into the development of co morbid conditions which further worsen the health state and adds to the expense in health management.


INTRODUCTION
Diabetes, a major non-communicable disease has been a problem of both developing and non-developing countries. [1][2][3] Long standing uncontrolled diabetes is known to cause microvascular and macrovascular complications affecting the major organs like eyes, kidney and brain along with the cardiovascular complications like hypertension and dyslipidemia. 4 Lack of awareness on the importance of glycaemic control, importance of adherence to medications, financial constraints or self-negligence could be the common causes that may lead to complications in these individuals. Similarly, the uncontrolled glycaemic state on a long run results into the development of co morbid conditions which further worsen the health state and adds to the expense in health management. [4][5][6][7][8] treatment guidelines to treat and prevent the related complication of diabetes. Irrational use of medicines remains a major concern in practice applicable to diabetes as well, where patients are invariably suffering with comorbid conditions requiring more than one medication thus landing in to practice of polypharmacy.
Similarly, with the compromised immunity, the diabetic individuals who are more prone for infections succumb to the antibiotic resistance and adverse effects in cases where irrational or inappropriate antimicrobials are used, thus resulting into economic burden in their health management. 5 Such situations further contribute to non-adherence of medications and worsen the diabetic control. Hence, the study has been taken up to evaluate the drug pattern or the prescription pattern in patients of type 2 diabetes with associated complications.

METHODS
The study was initiated after obtaining the approval from the Institutional Ethic Committee (SVIEC). Considering the inclusion and exclusion criteria, the type 2 diabetic patients with complications aged 18 and above and willing to give inform consent were included while the type 2 diabetic patients without complications, patients with type-1 diabetes and pregnancy induced diabetes were excluded from the study.
The prospective non-interventional study was conducted in a total of 100 diabetic patients with presence of complications at Dhiraj Hospital, a tertiary care teaching rural hospital affiliated to SBKS MI and RC, run under Suman deep Vidyapeeth, an institution deemed to be University over a period of 15 months from November 2012 to May 2014. After explaining the purpose and nature of the study to the enrolled patients, their demographic details like age, gender, occupation, medical, personal, family and past history along with the treatment details obtained from the patients' case files were recorded in the case record form and subjected for percentage wise data analysis.

Study type
This was a prospective, observational and noninterventional study.

Study site
The study was conducted at Dhiraj Hospital, a tertiary care teaching rural hospital affiliated to SBKS MI and RC, run under Sumandeep Vidyapeeth, an Institution Deemed to be University.

Study population and Inclusion and Exclusion Criteria
The study was carried out in 100 diabetic patients with presence of other complications and admitted in medicine wards of Dhiraj Hospital, Sumandeep Vidyapeeth.

RESULTS
The study included total 100 diabetic participants; out of them 10 (10%) participants were falling in group of 50-60 kg of weight, followed by 52 (52%) in 61-70 kg, 36 (36%) in 71-80 kg and only 2 (2%) in 81-90 kg of weight. All the patients had past history of diabetes. Out of them, 58 (58%) had past history of diabetes less than five years and 37 (37%) patients had diabetes for more than 5 and less than 10 years, while only 5 (5%) patients had suffered with diabetes for more than 10 years.
Authors observed that of the 100 patients, 89 (89%) patients were regularly taking the medication for the diabetes management, while 10 (10%) patients were irregular and 1 (1%) patient was not aware about it. Out of 89 patients who were regular with their medications, 35 patients were on Metformin, 14 patients were on Metformin in combination with Glimepiride, Pioglitazone or Sitagliptin while 40 patients were only on insulin preparations. It was observed that, only 62 (62%) patients were having control on intake of diet, while 38 (38%) were not having diet control or unaware of diet control and its importance in Diabetes Mellitus.
Among the 100 patients who received insulin, it was observed that most commonly prescribed insulin was short acting insulin (e.g. regular) (40%) followed by rapid acting insulin (eg. aspart, lispro) (13%), intermediate acting insulin (eg. isophane) (5%), and long acting insulin (eg. glargine, lantus) (5%). Overall the study focused on drug utilization in diabetic patients having complications.   Considering gender, the mean S. Cr was 0.81mg/dl and 0.93mg/dl in female and male respectively in AM group. In GM group the mean S.Cr values were 0.82mg/dl and 0.93mg/dl in female and male respectively. There was no significant difference in initial S.Cr levels ( Table 2 and Figure 2).

DISCUSSION
The present study focussed on the management of diabetes and the associated complications where, it was found that maximum patients were aged above 60 years, which was similar to the observations found by Brahmbhatt S et al. 5 In contrast to this, a study conducted by Singh et al, and Das. S et al, showed that higher numbers of diabetic patients were falling in the age group of 50-59 years. 3,12 Increased association of Obesity in Diabetes has been observed in last few decades which has been considered as one of the major risk factors for the occurrence of diabetes. 13 In this study, it was found that majority of the patients weighed around 61-70 kgs with very few 2 (2%) patients with overweight (2%).
We have observed that of the enrolled 100 patients, in only 5% diabetes existed for more than 10 years while the remaining individuals suffered for less than 5 years which was in contrast to the observations made by Adhikari et al, who showed that highest number of the patients lived with diabetes for more than 10 years and less number of patients with a period of less than 5 years. 14 It is essential that every diabetic patient is counselled with the importance of lifestyle modifications including diet and exercise along with medication he/she receives. And it has been proved through several studies that sedentary lifestyle and erratic food habits contribute to a great extent in development of obesity and the co morbid conditions including diabetes. We have observed through this study that more than half of the patients, 62 (62%) were aware of the diet and exercise control in diabetes. Further, it was also observed that 2/3 rd of the patients 89 (89%) were observed to be particular about their adherence to intake of medications. 5 On analysing the prescriptions, we observed that majority of diabetic individuals were managed with both oral and parenteral preparations. The preferred oral preparation was Biguanides (Metformin) followed by Sulfonylureas. These observations of this study were similar to that of observations made by Karthikeyan et al. 15 It was also observed that in these hospitalised individuals, regular insulin was preferred the maximum to obtain the glycaemic control, these observations of this study were very much similar to those of S. Das et al. 3 which is also observed in other studies. 16 -18 Further, it was observed that the enrolled diabetic patients were complicated with either hypertension, chronic kidney disease, urinary tract infections, parkinsonism and pleural effusion which were almost similar to the observations made by Karthikeyan et al, and Adhikari et al. Further, it was also observed that most of the patients received multiple drugs adding to the practice of polypharmacy. The highest number of prescribed medicines included antihypertensive drugs, antibiotics, anti-ulcer agents and hypolipidemic agents while, in contrast, the observations made by Adhikari et al, showed that antibiotics and drugs related to gastrointestinal system were less prescribed. 14-15

CONCLUSION
The chronic metabolic disorder with immune compromised state, all diabetic individuals are prone to the complications with uncontrolled glycaemic status resulting in co morbid conditions which forces and the practice of polypharmacy that succumbs the individuals to suffer with problems like adverse drug reaction, drug interactions and drug resistance. Therefore, it has been essential to have proper treatment guidelines along with regular counselling to the diabetic patients pertaining to the importance of adherence to medications and patient compliance that can refrain them from long standing complications and lessening with their economic burden.