Pfizer South Africa held its 6th annual Hidden Faces of Diabetes Summit on the 27th July 2019 at the Maslow Hotel in Johannesburg. The meeting was opened by Dr Niraksha Jithoo, SSA Medical Lead from Pfizer and the programme was chaired by Dr Zaheer Bayot. The Summit programme addressed key issues impacting the evolving diabetes epidemic in South Africa as well as globally. The aim of the Summit was to share knowledge and best practices from experts in the field of diabetes management through an environment that facilitated medical education. The delegates included a host of local South African doctors as well as representatives from Kenya, Swaziland and Zimbabwe.

Scientific talks were presented by Dr Zaheer Bayot, Professor Solomon Tesfaye, Professor Rayaz Malik, Professor Hoosen Vawda, Professor Adam Mohomed, Dr Elna Rudolph. A summary of the scientific talks follows.

In his talk “The Evolving Face of Diabetes Epidemic” Dr Zaheer Bayat, Endocrinologist in private practice as well as Acting Head, Department of Internal Medicine, Helen Joseph Hospital, South Africa confirmed that diabetes is a complicated combination of what the patient thinks he/she needs, basic science and medicine and what the doctor thinks he/she knows. A sedentary lifestyle escalates the risk of disease, which is compounded by a poor nutritional diet and a lack of exercise.

Some South African statistics discussed around diabetes mellitis (DM)

  • South Africa is ranked 28 in the world for number of people living with diabetes
  • Ranked 1 in the African region with 1 in 14 adults affected
  • Diabetes is the 2nd leading cause of death in South Africa
  • A 48% increase in the number of diabetic patients in South Africa by 2040 is predicted (from 2.3m to 3.4m)
  • The prevalence will rise from 7% to 8.1% by 2040 in South Africa
  • Africa has the highest prevalence of undiagnosed diabetes, with over two thirds (66.7 %) of people with diabetes unaware they have the disease.

The “rule of halves” states that only 6 % of people with diabetes are estimated to achieve well-managed diabetes and desired health outcomes. Cardiovascular Disease (CVD) remains the major cause of morbidity and mortality in DM. Diabetes is the leading cause of Chronic Kidney Disease. Diabetes is a complicated disease with various treatment options available. This is changing the way patients are treated and diabetes management is evolving. There are multiple treatment guidelines available globally, however the SEMDSA 2017 guidelines are still relevant. The holy grail remains to prevent diabetes.

 Diabetic Neuropathy: A Personalised Approach”

Presented by Prof RA Malik from Weill Cornell Medicine, now practicing in Qatar

  • A combination of typical symptomatology and symmetrical distal sensory loss, or typical signs in the absence of symptoms, in a patient with diabetes is highly suggestive of distal symmetric polyneuropathy (DSPN) and does not require referral.
  • Referral should be initiated for atypical signs: motor deficits > sensory deficits, asymmetry, atypical symptoms (initial symptoms in the upper extremities), rapid progression.
  • Approximately 10 % of neuropathies in patients with diabetes may be due to a treatable cause, including: chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), vitamin B12 deficiency, hypothyroidism. An analysis of a patient’s history is critically important.
  • Necrotising vasculitis – can be diagnosed using a nerve biopsy.
  • Diabetic neuropathic cachexia – can resolve on its own after two years, with precipitous weight loss, no motor signs (primarily sensory).

Non-Alcoholic Steatohepatitis and Type 2 Diabetes Mellitus

Presented by Prof Adam Mahomed practicing at Charlotte Maxeke Johannesburg Academic Hospital and Donald Gordon Medical Center

Non-alcoholic fatty liver disease (NAFLD) is characterised by excessive hepatic fat accumulation, associated with insulin resistance and defined by the presence of steatosis in >5 % of hepatocytes.

NAFLD includes two distinct conditions with different prognoses: non­ alcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis (NASH); NASH covers a wide spectrum of disease severity, including fibrosis, cirrhosis and a higher risk of hepatocellular cancer.

In patients with T2DM it is important to identify the unique histopathological features of NAFL in order to stage the disease progression but also to help understand the impact of diabetes in progression of NAFLD.

There are various non-invasive tools available. However liver biopsy is still regarded as the gold standard for measurement of histopathological features of NAFLD.

(NAFLD) includes a histological spectrum of liver diseases ranging from simple steatosis to NASH and NASH can progress to cirrhosis in patients without significant alcohol consumption.

T2DM is being increasingly recognized as on important risk factor in NAFLD progression, with NAFLD being regarded as on extension of metabolic syndrome. There is a lock of definite predictors for NASH among NAFLD patients with T2DM highlighting the need to obtain liver histopathology for accurate determination of NASH and fibrosis.

All individuals with steatosis should be screened for features of Metabolic Syndromes (MetS), independent of liver enzymes. All individuals with persistently abnormal liver enzymes should  be  screened  for  NAFLD, because NAFLD is the main reason for unexpectedly elevated liver enzymes. In subjects with obesity or Mets, screening for NAFLD by liver enzymes and/or ultrasound should be port of routine work-up. In high risk individuals (age> 50 years, T2DM, MetS) case finding of advanced disease (i.e. NASH with fibrosis) is advisable.

Surrogate markers of fibrosis (NFS, FIB-t., ELF or FibroTest) should be calculated for every NAFLD patient, in order to rule out significant fibrosis. If significant fibrosis cannot be ruled out, patients should be referred to a Liver Clinic; if significant fibrosis is confirmed, the final diagnosis should be made by liver biopsy.

The assessment of dietary and physical activity habits is port of comprehensive NAFLD screening. Obesity should prompt the inclusion of the patient in a structured weight loss program and / or referral to an obesity specialist. All cases should receive comprehensive cardiovascular disease (CVD) work-up.

 Diabetes Mellitus and Sexual Dysfunction: A Rational Approach

Presented by Dr Elna Rudolph, Medical Doctor and Sexologist

 Diabetes Mellitis (DM) is associated with decreased sexual desire, decreased sensation and delayed, premature and retrograde ejaculation as well as anejaculation.

Sexual dysfunction preceded the diagnosis of DM in 30 % of patients witht.5.3 % of patients with DM and sexual dysfunction had never consulted about sexual dysfunction. Inflammation, pain, and discharge related to fungal balanitis have been shown to have adverse somatic and psychological effects on erection and intercourse.

Phimosis is more common in DM patients and 32 % of men diagnosed with phimosis were found to have DM. Pain with intercourse in men and women is more common and Peyronie’s disease is more common in T2DM patients.

The prevalence of erectile dysfunction (ED) is threefold with those without DM and on overall prevalence of 75 % in adult primary core population. ED is the first sign of DM in 12 % – 30 % men and a warning sign for existing or impending CVD in DM patients. ED is a stronger predictor of CV events in DM than hypertension, HbA1c, lipids and microalbuminuria.

The 7 principles of Erectile dysfunction treatment:  AUA Guidelines of 2018

  • All ED patients of all age groups should be screened for CVD and DM
  • All men with ED should be screened for hypogonadism
  • All men with ED should be screened and monitored for depression. A patient does not have to beg for ED treatment or jump through multiple hoops to get it
  • Always ask psychosocial and relationship factors and always refer to a sexologist.
  • Offer all treatment options to all men – it is their choice what they want to start with.
  • Use a validated scale to determine ED severity before treatment and monitor efficacy of treatment 

  *Content provided by Pfizer