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Alikhanova Nadira Mirshavkatovna, PhD in Medicine, Academic Secretary of RSSPMC of Endocrinology MH of Uzbekistan E-mail: nodi200468@mail.ru Ismailov Said Ibragimovich, MD (DMSc.), Professor, Director of RSSPMC of Endocrinology MH of Uzbekistan E-mail: endocrin@uzsci.net Akbarov Zairkhodja Sobirovich, MD (DMSc.), Professor, Head of Diabetology Laboratory
Evaluation of medical and preventive care of patients with diabetes mellitus according to the register in Fergana region
Аbstract: Clinical courses of DM 1 and 2 were analyzed from of 10 436 register-cards in Fergana region. It was established that most of the patients were in decompensation stage that result from poor management of diabetes and increases rate of diabetic complications. Based on the results, conclusions were made about the necessity of reviewing current treatment modalities and on increasing general awareness among healthcare personnel.
Keywords: diabetes mellitus, register, cards, decompensation, treatment.
Urgency. At present, cardiovascular diseases, cancer and make it possible to solve both the practical problems faced by the other diseases of non-infectious origin became major causes of healthcare authorities and carry out a scientific analysis of the pecu-morbidity, disability and early mortality. The problem of diabetes liarities of clinical course and manifestation of DM in Uzbekistan. mellitus (DM) is acquiring ever-increasing importance among The study was aimed at analyzing the clinical course of type 1
them. According to the World Health Organization, that global prevalence of DM increased during the last decade more than twofold, reaching some 387 million to the end of 2014 and it was estimated to affect 9 % of adults aged 18 and over. WHO projects that diabetes will be the 7th leading cause of death in 2030 [14]. In the absence of a well-organized health and social care to patients, DM leads to early disability, increased mortality and reduced life expectancy of affected individuals. Uzbekistan encounters a sharp growth in the prevalence of DM, like many other countries. Currently, the number of registered patients with diabetes in Uzbekistan has exceeded 157 000 people. However, epidemiological studies of the prevalence of diabetes suggest that actual prevalence is several times greater than the officially registered and, by estimates comprises 5.2-9.1 % of population [2; 7; 8; 13].
Establishment of a national registry is an essential step towards optimization of care provided to diabetic patients. The data of register
and type 2 diabetes in the last 12 months (2007) in Fergana region.
Materials and methods of research. Analysis Clinical course of DM was studied with aid of register-cards in Fergana region. The register-cards were unified forms of national register, elaborated by employees of the center with account taken ofEASD recommendations and experience of other countries [1; 4; 5; 9; 10].
10 436 register-cards of same numbered patients, including 9 384 patients with type 2 DM, 1 052 of type 1 DM and 1 — gestational diabetes, were filled in Fergana region; the data of clinical course and treatment were processed with aid of computer.
The age of patients with 1 type DM ranged mainly from 1 to 14, up to 80 and included 560 men, 492 women.
The age of patients with type 2 DM was 14 to 80 years, 4 086 men and 5 297 women. The number of patients who were on constant follow-up or what is called dispensary observation comprised 11 659, filling in of register-cards comprised 89.51 %.
Table 1. - The age and sex composition of patients with DM type 1 and type 2 in Fergana region
Values Total number Age
1-14 15-18 19-29 30-39 40-49 50-59 60-69 70-79 80-89
DM type 1 Men 560 10 21 95 120 132 106 47 28 1
Women 492 14 22 70 107 119 93 42 20 5
Total 1 052 24 43 165 221 251 199 89 48 6
DM type 2 Men 4 086 1 4 30 121 756 1588 1003 503 80
Women 5 297 2 3 34 120 865 1923 1403 761 186
Total 9 383 3 7 64 241 1621 3511 2406 1264 266
DM and pregnancy 1
Total 10 436 27 50 229 468 1872 3710 2495 1312 272
As seen from table 1, the number of women exceeded that of men for almost 1.02 times. It is known that the prevalence indicators of type 2 diabetes increases with age and the obtained data comply with such pattern. Thus, the prevalence of type 2 diabetes, according to the register reached its maximum values in individuals 50-59 years of age, being: 1 588 men and 1 923 women, whereas there were only 121 men and 120 women in the age group of 30-39 years.
Disposing data on the prevalence of diabetes, it becomes possible to plan activities of therapeutic and preventive care. However, the data on the prevalence only would be deficient without information on the prevalence of complications of diabetes and information about types of hypoglycemic agents used in the treatment of these patients, and finally, how high are the morbidity and mortality of patients with diabetes.
Results and discussion. From the surveying of diabetic patients it was found that patients did not comply with due diet well and more or less frequently violated it.
353 (33.8 %) patients with type 1 diabetes were on intensified insulin therapy, the rest — on traditional.
Among patients with type 2 diabetes solely on diet were 4 (0.44 %) patients, 8 735 (83.69 %) on combination of diet and oral hypoglycemic drugs, including 7 883 (75.53 %) on sulfonylureas, 96 (0.92 %) on meglitinides, 1 559 (14.4 %) on biguanides, 149 (1.43 %) on tiazolindiones, 889 (8.52 %) on sulfonamides plus biguanides. It is worthy of note that there were no patients registered with type 2 diabetes on insulin therapy.
The incidence of complications in surveyed type 1 diabetes patients was as following: presence of changes in nervous system in 781 of cases (74.23 %), including sensory neuropathy — 465 (44.2 %), autonomic neuropathy — 33 (3.14 %), orthostatic hypotension — 123 (11.69 %), diarrhea — 66 (6.27 %), impotence — 91 (8.65 %), amyotrophy — 3 (0.29 %); diabetic ulcers were in 54 patients (5.13 %), 52 patients had angina (4.94 %), arterial hypertension — 240 (22.81 %), MI — 11 (1.05 %), patients with diabetic ophtalmopathy — 523 (49.71 %), cataract — 60 (5.70 %), complete absence of vision in 1 or 2 eyes — 8 (0.76 %), proteinuria — 366 (34.79 %), CKD 19 (1.81 %) patients. Acute complications of diabetes occurred with the following frequency: comas altogether comprised 36 (3.742 %), of which 16 (1.52 %) were ketoacidotic, in 1 case (0.10 %) hyperosmolar, lactic acidosis — 3 (0.29 %), hypoglycemic — 14 (1.33 %).
Among 9 384 patients with type 2 diabetes, 3 400 (32.58 %) had sensory neuropathy, 2 844 (27.22 %) had macroangiopathy of lower extremities, 211 (2.25 %) — autonomous neuropathy, 431 (4.523 %) — orthostatic hypotension, 287 (3.06 %) — diarrhea, 524 (7.66 %) — impotence, 13 (0.10 %) — amyotrophy. Patients with diabetic ulcers amounted to 150 (2.2 %), amputation was carried out in 276 (2.94 %), MI — 131 (1.44 %), recurrent MI in — 4 (0.04 %), CVA — 129 (1.37 %), hypertension — 2 732 (29.11 %),
angina — 675 (7.19 %), retinopathy — 3 644 (38.83 %), absence of vision in 1 or 2 eyes — 114 (1.21 %), cataract — 705 (7.51 %), proteinuria — 2 196 (23.4 %), CKD — 45 (0.48 %), none of patients was receiving hemodialysis. Acute complications of diabetes occurred with the following frequency: all comas — 41cases (0.44 %), including of which ketoacidotic — 18 (0.19 %), hyperosmolar — 3 (0.03 %), lactic acidosis — 1 (0.01 %), hypoglycemic — 18 (0.19 %).
Analysis of the prevalence of complications, considering the type of diabetes, showed that the prevalence of specific complications of diabetes is significantly higher in patients with type 1 diabetes than in type 2. Thereby, comparison of the shares of diabetic retinopathy in type 1 and 2 were respectively 49.7 % and 38.83 %, diabetic nephropathy — 34.79 % and 23.4 %, autonomic neuropathy 3.14 % and 2.25 %, sensory neuropathy — 44.3 % and 27.22 %.
Reverse trend had place in the prevalence of various forms of macroangiopathy in the two compared groups. CAD, MI, hypertension and others were significantly more common in type 2 diabetes than in type 1. The share of CAD in type 1 and type 2 were respectively 4.94 % and 7.193 %, MI — 1.05 % and of 1.44 %, hypertension — 22.81 % and 29.11 %. However, it should be noted, that compared with the registered data, the prevalence of all of the above complications at early stages in epidemiological studies of a row of authors [3; 6; 7; 12] was much higher.
The quality of glycemic control plays an essential role in the development and progression of complications. The following data were received upon biochemical studies conducted: FBG < 6.5 mmol/L was found in 95 (0.92 %), PPG < 9.0 mmol/L in 278 (2.69 %) of patients with type 1 diabetes. In type 2 diabetes patients the figures: FBG < 6.5 mmol/L in 1 265 (12.23 %), PPG < 9.0 mmol/L in 3 113 (30.09 %), glycated hemoglobin < 7 % in 72 (0.7 %). These figures demonstrate significant decompensation among patients of both types, due to inadequate provision of antidiabetic agents, insufficient self-control, and low detectability of the disease, especially in the early stages.
The level ofblood lipids, included as a criterion of diabetes compensation, is also important in the development ofdiabetic complications and requires an adequate controling. Total cholesterol was measured in 84.72 % ofpatients, triglycerides determined in 158 (1.53 %). Cholesterol over 4.8 mmol/L was revealed in 6 219 (60.12 %) and triglycerides over 1.7 mmol/L in 20 (0.19 %).
Officially registered disability was among 2 176 (20.85 %) patients, 1 785 (17.10 %) of which were due to diabetes and 391 (17.96 %) cases for account of other reasons. 129 (1.24 %) individual were classified as disabled from childhood, 124 (1.19 %) were disabled persons of group 1, 1 907 (18.27 %) of group 2, and 80 (0.77 %) had registered 3rd group of disability.
Overall mortality, for the given year, comprised 18 (from 10 436 records), the share ofvarious causes is provided in table 2.
Table 2. - Mortality of patients with diabetes, by causes in Fergana region
Causes of death Number of deaths by cause
Diabetic coma 1 (5.26)
Hypoglycemic coma
Chronic Renal Failure 8 (42.11)
Congestive Heart Failure 3 (15.79)
Miocardial infarction 1 (5.26)
Cerebrovascular accidents 1 (5.26)
Gangrene complicated by sepsis
Pneumonia
Tuberculosis
Cirrhosis 1 (5.26)
Malignant tumors
Acute infections
Other reasons 3 (15.79)
Overall deaths 18
Information not available
As can be seen from the table, the most frequent causes of death in diabetic patients were CKD — in 8 (42.11 %) cases. The rest of the causes of mortality of patients with diabetes are arranged in decreasing order: diabetic coma (5.26 %), CHF, MI, CVA, cirrhosis and other causes accounted for 3 (15.79 %). Analysis of mortality in diabetic patients showed a high percentage of diabetic comas, which is avoidable with timely adequate treatment. At the same time, the share of deaths due to MI and CVA were 5.26 % and 5.26 % respectively, whereas, according to the world literature, these types of macroangiopathies are the main killers.
According to the analysis, from 9 373 patients with type 2 diabetes, self-control learning courses were taken by 5 262 (88.84 %), regular self-control was carried out by 4 193 (87.81 %). Those who had taken self-control courses amount type 1 diabetes comprised 612 (58.17 %), of whom 533 (87 %) were carrying out self-control.
Hypertension was revealed in 2 973 of patients (28.49 %), 240 (22.81 %) of whom were with type 1 and 2 732 (29.11 %) with type 2 diabetes. Antihypertensive therapy was administered to 4 505 (43.16 %) patients, with 4 179 (40.04 %) taking ACE inhibitors, 93 (0.89 %) — beta-blockers, 256 (2.45 %) — calcium antagonists, 353 (3.38 %) — diuretics, 45 (0.43 %) — other antihypertensive drugs. None of patients received a combination of different antihypertensive drug groups.
Lipid-lowering therapy was implemented with 1 267 (12.14 %) patients, the predominant majority of whom — 641 (6.14 %) where administered nicotinic acid, followed by in fibrates, used in 239 (2.29 %) of cases, statins — 397 (3.8 %), other drugs 10 (0.1 %).
For the whole period of registry, pregnancy was identified in one patient. Figures, taken from the histories of gestation provided the following: from overall 5 790 pregnancies 2 972 (51.33 %) records indicated normal delivery, 25 (0.43 %) miscarriage, and 12 (0.21 %) — premature birth.
The main target of the treatment of patients with diabetes is the prevention of its complications, for which achieving compensation of the disease is necessary. According to the current criteria, compensation includes not only keeping glycemic fluctuations within the normal ranges but also controlling blood pressure and lipid profile. From the register-cards of the overwhelming majority of patients, it is difficult to judge about the state of compensation even based on carbohydrate metabolism (due to insufficient volume of tests monitoring glycemia and almost complete absence of studies
of glycated hemoglobin). The volume of tests of lipid profile is also extremely limited.
In terms of the quality of treatment overwhelming majority of patients with diabetes type 1 remain on conventional insulin therapy (share of IT 33.8 %), and considering the need of the earlier start of insulin therapy in patients with type 2 diabetes, in the light of current recommendation, the fact that none of patients were transferred to insulin therapy appears to be perplexing.
According to the data of register, almost 100 % ofpatients were carrying out self-control, which raises some doubts and requires clarification of the sources from which patients were provided by the means of self-control and reliability of that data on glycemia, obtained by self-control.
Information on current pregnancies and past pregnancies is incomplete, which makes it difficult to draw any conclusions.
Thus, conducted analysis of the register-cards in Fergana region, demonstrates that the provision of therapeutic and preventive care to patients with diabetes to date does not meet the commonly accepted criteria, whereby there is a high risk of development and progression of cardiovascular disease and chronic microvascular complications of diabetes.
Conclusions:
1. The register involved 10 436 (89.51 %) patients, 1 052 (10.08 %) of which were patients with type 1 diabetes and 9 384 (89.91 %) with type 2 diabetes. The number of women was 1.02 % times higher than of men.
2. It was found from register that the share of compensated, in terms ofthe level offasting plasma glucose, patients with type 1 diabetes comprised 0.92 % and the share of compensated patients with type 2 diabetes — 12.23 %. The level of compensation, in respect to postprandial glycemia comprised in type 1 diabetes — 2.69 % patients and 30.09 % — in type 2 diabetes. This shows a very inadequate compensation of carbohydrate metabolism in patients with diabetes in general.
3. Testing of cholesterol level was performed in glycerides were examined in less than 1.53 % of patients. Lipid-lowering therapy is mainly carried out with ineffective drugs of nicotinic acid.
4. According to register 83.64 % of patients with type 2 diabetes receive oral hypoglycemic agents. The predominant majority of them are administered sulfonylurea drugs — 75.53 %, biguanides were used very rarely — in 14.4 %, tiazolindiones — in 1.43 %, sulfonamides with a Biguanides — in 8.52 %, and Meglitinides — in 0.92 %.
5. Only 33.8 % of patients with type 1 diabetes were on intensified insulin therapy and the rest on conventional. Not even single patient with type 2 diabetes was recorded to be receiving insulin therapy.
6. Analysis of antihypertensive therapy has revealed the following: hypertension was diagnosed in 28.49 % of patients, 40.04 % of whom were administered ACE inhibitors, 0.89 % — beta blockers, 2.45 % — calcium antagonists, 3.38 % — diuretics, 0.06 % — alpha blockers, 0.43 % — other antihypertensive agents. Combinations of different groups of antihypertensive drugs were not used at all.
7. The composition of the complications of type 2 diabetes were as following: retinopathy diagnosed in 38.83 %, cataract — in 7.5 %, nephropathy — in 23.4 %, neuropathy — in 48.5 %, with low rates of registered macroangiopathies: MI -1.37 %, CVA — 1.37 %, macroangiopathy of lower extremities — 27.22 %, arterial hypertension — 28.49 %.
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Alikhanova Nadira Mirshavkatovna, PhD in Medicine, Academic Secretary of RSSPMC of Endocrinology MH of Uzbekistan E-mail: nodi200468@mail.ru
Ismailov Said Ibragimovich, MD (DMSc.), Professor, Director of RSSPMC of Endocrinology MH of Uzbekistan E-mail: endocrin@uzsci.net
Akbarov Z. S.,
MD (DMSc.), Professor, Head of Diabetology Laboratory
E-mail: zair.akbarov@mai.ru
Prevalence of coronary artery disease and miocardial infarction in patients with type 2 diabetes according to the register in Uzbekistan
Abstract: Clinical course of type 2 DM was analyzed based on 61 568 register-cards, taken from National Register of DM, Uzbekistan. 10 130, from the total number of patients, were found to have CAD and 949 MI. From the analysis of management of DM, macrovascular complication and causes of mortality it becomes clear that earlier mortality and disabilities resulted from poor compensation of diabetes. It was found that in the many cases the carried out management did not comply with commonly accepted standards of treatment.
Keywords: diabetes, CAD, MI, register, cards, decompensation, macroangiopathy, management.
Urgency. Angina belongs to a group of common diseases with high prevalence — about 20 thousand cases per million of population. The number of people with angina pectoris in Russia amounts to 2.8-5.6 million and the number of affected with it individuals keeps increasing worldwide due to the aging of population and the improvement of activities aimed at prevention of atherosclerosis. The burden of cost from the treatment of patients with stable CAD
worldwide is high (in EU spending amounts to about 45 billion Euros, which comprises 2.6 % of the total health budget). According to the Division of Epidemiology and Prevention of Republican Specialized Center of Cardiology, in Uzbekistan, the prevalence of CAD in Uzbekistan comprises 8-10.5 %.
It is known that in 40-60 % the cause of death in diabetes is MI, atherosclerosis of main vessels in diabetes develops 4-6 times
