INTRODUCTION
Type 2 diabetes mellitus (T2DM), affecting approximately 463 million people in 2019, is a global public health concern—particularly in low-income and middle-income countries (LMICs). A conglomeration of modifiable risk factors including physical inactivity, unhealthy dietary patterns, increased blood pressure, dyslipidemia, and obesity, alongside nonmodifiable risk factors such as an aging population, family history of diabetes, and ethnicity are driving the current rise of T2DM and its complications in the Middle East and North Africa (MENA) and Africa (AFR) region. Of the top 20 countries with the highest prevalence of diabetes, 7 are from the MENA region.
The ripple effect of persistent hyperglycemia and metabolic deviations in T2DM results in organ damage with different microvascular and macrovascular complications. Microvascular complications, comprising nephropathy, neuropathy, and retinopathy, along with macrovascular complications, including coronary artery disease, peripheral artery disease, and cerebrovascular disease, are the major cause of mortality and morbidity in patients with T2DM. Indeed, cardiovascular (CV) complications such as myocardial infarction (MI), atrial fibrillation, and chronic heart failure (CHF) occur a decade earlier in the MENA and AFR region than in other populations. To prevent CV-related mortality in patients with T2DM, optimum management of cardiorenal risk factors and complications is crucial, along with glycemic control. Screening programs for early detection of T2DM, compounded by timely utilization of safe and effective therapies, may help prevent complications, thus reducing morbidity and mortality.
The prevalence of cardiorenal complications in patients with T2DM is rising in the MENA and AFR regions. The cross-sectional Turkish Diabetes Epidemiology (TURDEP)-II survey involving 26 499 adults (≥20 years) showed an alarming rise in the prevalence of T2DM and associated cardiometabolic risk factors, highlighting an urgent need to address this major public health burden. Similarly the Dyslipidemia International Study (DYSIS)-Middle East registry showed that 61.8% of very high-risk patients (T2DM with atherosclerotic cardiovascular disease [ASCVD]) failed to achieve control of cardiometabolic risk factors. Moreover, the DYSIS-II showed a progressive increase in the incidence of T2DM and simultaneously challenges in glycemic and cardiometabolic risk factor control in this growing population. To identify the current challenges for the management of cardiorenal complications in T2DM in MENA and AFR, we convened a panel of experts to provide insights on the regional gaps with strategic recommendations for treatment. In addition, we aimed to foster the development of real-world evidence that can support patients with T2DM, encourage patient-centric projects for cardiorenal complications, and improve patient outcomes.
CONSENSUS METHODOLOGY
A multidisciplinary panel of 13 members representing the specialties of endocrinology, cardiology, and internal medicine across the MENA and AFR region (Saudi Arabia = 2, United Arab Emirates [UAE] = 2, Egypt = 2, South Africa = 1, Lebanon = 1, Jordan = 1, Iraq = 1, Morocco = 1, and Turkey = 2) provided insights on practical challenges and recommendations to overcome the gaps in prevention and care. This manuscript is an outcome of literature review, expert group discussion, and consensus recommendations for the management of cardiorenal complications in patients with T2DM in MENA and AFR.
BURDEN AND ASSOCIATED RISK FACTORS FOR CARDIORENAL COMPLICATIONS IN MENA AND AFR
Globally, the MENA and AFR region had the highest (18.1%) prevalence of T2DM in 2021 (Figure ). The majority (90%) of people with T2DM in MENA and AFR are overweight or obese, with poor control of low-density lipoprotein cholesterol levels, resulting in increased CV risk. T2DM is a major risk factor for the development of cardiorenal complications—58% of individuals with T2DM develop chronic kidney disease (CKD), which concurrently increases the risk of heart failure (HF) and MI. The multicountry DISCOVER study among patients initiating a second-line glucose-lowering therapy reported that only 1 in 10 individuals in MENA and AFR had glycosylated hemoglobin (HbA1c) < 7.0%, alongside a high burden of cardiometabolic risk factors including hypertension and dyslipidemia. A similar trend in high cardiometabolic risk factors was reflected by the DISCOVER Global Registry. Cardiovascular registries from MENA and AFR, including but not limited to Gulf RACE (acute coronary syndrome [ACS]), Gulf Coast (ACS), and Gulf CARE (CHF), have consistently demonstrated the large burden of T2DM, obesity, hypertension, and dyslipidemia leading to premature cardiovascular disease (CVD) in spite of the young age of patients enrolled. The DISCOVER program illustrated a substantial burden of microvascular complications (including CKD and albuminuria) and macrovascular complications (primarily coronary artery disease, HF, and stroke). Another multinational study (CAPTURE) showed that people with T2DM and established CVD (33%) have a higher burden of renal dysfunction (microalbuminuria [31.8% vs 20.6%], macroalbuminuria [10.8% vs 6.8%], and estimated glomerular filtration rate [eGFR] of ≤ 59 mL/min/1.73 m2 [30.7% vs 15.4%]) compared to those without CVD. CKD (44.3%) and CVD (17.3%) are the most prevalent comorbidities in T2DM. People with T2DM have almost quadruple the risk (hazard ratio [HR] 3.77, P = .001), while those with coronary heart disease are 2.47 (P = .004) times more likely to develop CKD stages 3-5. A multinational registry of T2DM reported that cardiorenal disease was consistently the most frequent first manifestation (60%), stemming from 24% HF and 36% CKD, with HF being associated with a 2-fold risk of CKD and vice versa. The combination of HF and CKD is associated with the highest CV risk (HR 3.91; 95% CI, 3.02-5.07) and all-cause mortality risk (HR 3.14; 95% CI, 2.90-3.40). Table provides an overview of the cardiorenal burden and associated risk factors in MENA and AFR. Reliable and consistent approaches are needed to measure routine cardiorenal parameters to guide clinical decision-making in T2DM. Alongside the substantial burden, cardiorenal diseases incur the highest short- and long-term health care costs in T2DM and are important parameters associated with increased health care resource utilization. The Take CaRe of Me program has been initiated to create an end-to-end management model focusing on early prevention of cardiorenal complications of T2DM in the primary care setting. With the increasing prevalence of cardiorenal comorbidities in the MENA and AFR region, it is critical to identify the gaps and solutions for optimal management. Herein, we present the real-world challenges and recommendations suggested by the experts for the management of cardiorenal complications in T2DM in the MENA and AFR region.
[IMAGE OMITTED. SEE PDF]
EXPERT DISCUSSION: CHALLENGES AND RECOMMENDATIONS IN MANAGEMENT OF CARDIORENAL COMPLICATIONS OF
Patient level
Challenges
Lower education level of patients is an independent determinant of poor glycemic control in T2DM. There are voids in awareness pertaining to glycemic control, implications of suboptimal glycemic control, and subsequent cardiorenal complications of T2DM in most patients from MENA and AFR. Poor access to diabetic educators or certified nurses, deficient infrastructure for patient education, and lack of educational tools are barriers for optimal care of T2DM in MENA and AFR. Sociocultural barriers such as preference for female educators by women, stigma related to the use of glucometers in public, and noncompliance with diet (likely during fasting in Ramadan) lead to challenges for appropriate management.
Recommendations
Enhanced patient awareness of risk factors and early identification of diabetic complications are fundamental to improve quality of life. To this end, the development of simple and structured learning tools with education campaigns for physicians and patients can be crucial. Due to variability in traditional sociocultural factors throughout the MENA and AFR region, risk assessment in primary care is warranted. Enhanced involvement of diabetic educators and nurses who understand the local sociocultural barriers can potentially influence patient engagement—thus encouraging frequent visits to educators for better care.
Physician level
Challenges
Lack of awareness among primary care physicians (PCPs) and family doctors regarding the identification of risk factors for diabetic complications, screening asymptomatic cardiac and vascular disease, systematic screening for renal disease, and microalbuminuria in a standardized fashion remains a crucial challenge in MENA and AFR. Moreover, the use of antidiabetic medications for T2DM in the MENA and AFR region is driven by glycemic control, rather than cardiorenal risk reduction. As PCPs are the first-contact care providers, awareness and knowledge of risk factors regarding cardiorenal complications in T2DM among PCPs are crucial. The majority of patients with T2DM are treated by generalists lacking expertise in treating such patients, leading to gaps in patient selection for the right antidiabetic medications. In addition, lack of systematic communication between different specialists, endocrinologists, cardiologists, or nephrologists, leading to a delay or nonreferral of patients to the specialists by PCPs further hinders T2DM management. Failure to reduce complexity and intensity of glycemic control in the older and frail population is another significant concern reported in 1 in 10 older adults with diabetes.
- Therapeutic inertia: Barriers to appropriate care including therapeutic inertia appears to be an important contributor to poor glycemic control in MENA and AFR, with prescribers often willing to tolerate extended periods of “mild” hyperglycemia leading to delays in initiating or intensifying glucose-lowering therapy when needed. Treatment inertia exposes patients with T2DM to long periods of raised blood glucose, predisposing them to complications and a reduced quality of life. Despite suboptimal metabolic control, almost half of the patients with T2DM were using injectable regimens in Turkey, with metformin, secretagogues, and dipeptidyl peptidase IV inhibitor (DPP-IVi) being the most common oral antidiabetic drugs. The Saudi Arabia cohort of the DISCOVER study demonstrated that metformin (with or without sulfonylureas) was the most common first-line treatment, while DPP-IVis were the most common second-line drugs for patients managed either in governmental institutions or in the private sector, irrespective of drug affordability. This underlines the presence of clinical inertia at the initiation of second-line therapy, thus emphasizing a need for more aggressive risk factor screening with treatment intensification at early disease stages. Although data on the novel antidiabetic drugs are still evolving, there is a gap between evidence-based management suggested by international guidelines and real-life practice in different regions.
Recommendations
It is imperative to shift the focus from a glycemic control-centric approach to adopting a holistic risk-based strategy, considering adverse effects and patient preferences. There is a critical need to address treatment inertia through early commencement of medications or escalation/de-escalation, whenever required, to avert complications. Physicians should be well versed in the different types of pharmacotherapy for T2DM and select the accurate, effective, and safe drugs that patients can tolerate. Simplified treatment algorithms to recommend universal utilization of novel cardiorenal therapies in the earlier stage of diabetes is essential. Empowering nonphysician providers such as pharmacists, nurses, and diabetes educators to initiate and intensify treatment, supported by appropriate guidelines, might be an effective approach for mitigating therapeutic inertia. In Turkey, the Consensus Statement of Endocrinology, Cardiology, and Nephrology (ENCARNE) Experts on Prevention, Diagnosis, and Management of Cardiovascular and Renal Complications of Diabetes was formulated by collaborative body to provide a multidisciplinary platform for guiding PCPs through collective discussions on prevention, diagnosis, and management of cardiorenal complications, such as the need for referral to a specialist, frequency of visiting a specialist, and type and frequency of testing. Targeted screening using simple, sensitive, and cost-effective tools can facilitate early identification and intervention of high-risk populations, thus delaying the onset or progress of cardiorenal complications. A patient-centric approach for the management of T2DM and related complications is elucidated in Figure . Hence, continuous medical education of PCPs and family doctors on screening for T2DM, identifying complications, using guideline-recommended antidiabetic medications, and addressing lifestyle and sociocultural issues is pivotal.
- Risk stratification and early diagnosis: Risk stratification traditionally used for dyslipidemia management is now equally important for the selection of diabetic therapy in T2DM patients with three or more risk factors like obesity, smoking, older age, or hypertension and those with established target organ damage. Diagnosis of early complications of T2DM may require additional cardiac and renal investigations as well as assessment of target organ damage. ENCARNE illustrates diagnostic algorithms in T2D including assessment of serum creatinine, eGFR, urine albumin-to-creatinine ratio (UACR), and annual follow-up for renal disease, alongside cardiac evaluation by electrocardiogram (ECG) every 1 or 2 years. Early diagnosis of left ventricular hypertrophy (LVH), nephropathy, retinopathy, and diabetic peripheral neuropathy is especially important in MENA and AFR. The earliest complications of T2DM including diastolic dysfunction, metabolic inflammatory cardiomyopathy, and HF with preserved ejection fraction can be effectively diagnosed with a combination of abnormal ECG and natriuretic peptide levels (B-type natriuretic peptide [BNP] ≥35 pg/mL] or N-terminal pro-B-type natriuretic peptide [NT-proBNP] ≥125 pg/mL]). An echocardiogram should be requested in patients who present with new cardiac symptoms to assess silent cardiac abnormalities in the early stages. Assessment of UACR before progression to microalbuminuria and any abnormality in eGFR can predict early stage diabetic renal complications. Among T2DM patients with established complications, regular and systematic monitoring through ECG, UACR, eGFR, body mass index, fundus examination, and foot physical examination is imperative. Early diagnosis in an outpatient setting by PCPs can facilitate prompt addition of novel agents such as sodium glucose cotransporter 2 inhibitors (SGLT2is) and/or glucagon-like peptide 1 receptor agonists (GLP-1RAs) that can arrest the progression and symptomatology of the CHF phenotype and have an impact on normalization of eGFR with reduction of microalbuminuria at the earliest stages.
- Novel cardiorenal therapies: Novel antidiabetic agents like SGLT2is and GLP-1RAs have been proven to have cardiorenal benefits in robust evidence-based clinical trials, leading to their expansion to nondiabetic patients. A recent meta-analysis showed that SGLT2is were associated with a reduced risk of major adverse cardiovascular events (MACE); the greatest benefit was a reduction in the risk of hospitalization for heart failure (HHF) and kidney outcomes. Similarly, GLP-1RAs, have been reported to reduce the risk of individual MACE components, HHF, and worsening kidney function in T2DM. Dapagliflozin (compared with placebo) was associated with the greatest reduction in risk of developing composite kidney outcome, followed by empagliflozin, canagliflozin, semaglutide, and liraglutide. Tables provide a broad overview of major randomized controlled trials, real-world studies, and meta-analyses for SGLT2is, GLP-1RAs, and thiazolidinediones. The benefits of dapagliflozin and empagliflozin that they lower the risk of CV events, HHF, and all-cause mortality have been evidenced through real-world studies in routine clinical care and nationwide registries. Combination therapy is also a recommended clinical practice for improving glycemic control. The long-term efficacy of insulin sensitizer thiazolidinedione (pioglitazone) plus a GLP-1RA caused a greater decrease in HbA1c (−1.1%, P < .0001) and produced a greater improvement in insulin secretion with a lower risk of hypoglycemia in patients with poorly controlled T2DM. However, despite the CV benefits, pioglitazone should be used judiciously in clinical settings due to the definite increase in HF, bone fractures, weight gain, edema, and anemia.
- Utilization of guideline-recommended therapy: Based on cardiovascular outcome trials (CVOTs), recent guidelines strongly recommend the use of novel antidiabetic therapies for T2DM with high-risk factors or established ASCVD, CKD, or HF. Traditionally, the American Diabetes Association (ADA) guidelines recommend metformin with lifestyle modifications as first-line therapy. However, in patients with high-risk factors or established cardiorenal disease, the ADA recommends the following strategies, independent of baseline HbA1c or individualized HbA1c target or metformin use: (a) ASCVD or indicators of high risk: either GLP-1RA or SGLT2i with proven CVD benefit; (b) HF: SGLT2i with proven benefit (empagliflozin, canagliflozin, dapagliflozin); and (c) CKD: either GLP-1RA or SGLT2i with proven benefits. The recent guidelines also recommend recognition of subclinical diabetic cardiomyopathy/CHF in people with early stage T2DM, CKD, or very high CV risk. A consistent approach was elaborated by the expert consensus recommendations in ENCARNE. The 2019 European Society of Cardiology (ESC) guidelines also recommend that patients with T2DM with either three or more major risk factors (T2DM, obesity, smoking, age, and hypertension) or established target organ damage (albuminuria, GFR, LVH, retinopathy, and neuropathy) may require SGLT2i or GLP-1RAs, along with standard therapy. Adoption of early utilization of novel antidiabetic medication with metformin may be more practical in T2DM, particularly for addressing the management of glycemic control while simultaneously reducing cardiorenal and metabolic disorders. This approach may also overcome the problem of treatment inertia at the time of diagnosis, instead of progression to cardiorenal complications. Key recommendations from major guidelines for the management of T2DM and cardiorenal complications are illustrated in Table and Table . The Dapagliflozin Effect on Cardiovascular Events-Thrombolysis in Myocardial Infarction 58 (DECLARE-TIMI 58) study has supported the expansion of SGLT2is for primary prevention of HF outcomes and reduction in atrial fibrillation. Evidence from the SGLT2is CVOTs lay the foundation for a change in focus from the traditional glycemic control to the reduction in cardiorenal complications in a cost-effective manner.
[IMAGE OMITTED. SEE PDF]
TABLE 1 Summarization of key recommendations from major guidelines for management of type 2 diabetes mellitus and cardiorenal complications
| Screening: Impaired glucose tolerance testing in asymptomatic individuals | Glucose monitoring: Self-monitoring of blood glucose and/or continuous glucose monitoring | Lifestyle: Maintain body weight by adopting healthy diet and at least 150 min a week of moderate-intensity physical activity | Risk-based therapy: Personalized treatment based on hyperglycemia, diabetes duration, drug characteristics (efficacy, side effects, CV safety, contraindications, hypoglycemia risk, and cost), complications/comorbidities, life expectancy, patients' preferences | Pathway of care: Newly diagnosed T2DM: initial metformin with lifestyle modifications
|
|
| International guidelines | |||||
| USA | + Beginning at age 45 years; all overweight/obese adults with at least one risk factor at 3-year interval; earlier and frequently with risk factors |
+ Behavior change program to achieve/maintain 7% loss of initial body weight |
+
|
||
| Europe |
|
+
|
|||
| Regional guidelines | |||||
| Turkey | +Beginning at age 40 years, testing for all individuals with BMI ≥ 25 kg/m2 at 3-year interval; earlier and frequently in presence of risk factors |
||||
| South Africa | +Beginning at age 45 years, all overweight/obese adults with at least one risk factor; frequency depends on individual risk range (3 months to 3 years) |
+
|
|||
| Emirates | + Beginning at age 45 years, all adults with BMI ≥ 25 and ≥1 risk factor at least once every 3 years, or 6-monthly if prediabetic |
+
|
HEALTH SYSTEM LEVEL
Challenges
The mean health care expenditure per person with diabetes complications per year in the UAE is more than US$5000. However the cost of medications is a small component of this. High cost and poor drug accessibility are among the many factors hindering health care. In MENA and AFR, insufficient access to novel medications in the public health sectors and the high cost of antidiabetic medications are the primary contributing reasons, together with country-wise inequalities in health care financing, restricting the selection of a certain class of medications. The use of SGLT2is has been studied to be highly cost-effective in preventing the cost of CV complications in LMICs.
Shortage of regional data, poor adherence to international or regional guidelines, and inequalities in health care between private and public sectors are other challenges in the management of cardiorenal complications in MENA and AFR. Unavailability of medications in the public sector, insufficient care, and disparities of services contribute to patient flow to the private sector. Nearly 60% of patients with T2DM are not assessed by a specialist in MENA and AFR, with PCPs being the main first-line treating physician. Absence of electronic medical records (EMRs) may hinder sharing of patients' status and current therapies, leading to duplication of T2DM and other concomitant therapies. User resistance, lack of awareness, and gaps in strategic implementation are the common barriers for adopting EMRs in developing countries. A survey-based study of medical documentation in LMICs showed that the majority of the participating institutions used paper charting (64.2%) followed by institutional electronic health care record software (25.9%) for data entry during a patient visit. Capturing reliable patient data is challenging in most of the developing countries, including Iraq. The data collected during a routine patient visit may not be stable due to lack of attention to documentation and may hamper the physicians' ability to provide useful diagnosis to patients. Hence, it is imperative to emphasize the robust collection of physical patients records for diagnosis and prescribed drugs, followed by adequate maintenance at the physician and patient level in LMICs with gaps in systematic EMRs. As the world is transitioning to adopt the EMR system, with ongoing efforts toward making EMRs the preferred way of data collection, robust physical patient records can be the foundation stone for providing appropriate patient care in LMICs.
Recommendations
Robust systems of EMRs along with the utilization of other novel digital technologies are needed to improve monitoring of glycemic control, the therapeutic landscape, and early detection of cardiorenal complications. The panel shed light on the importance of adhering to international and regional management guidelines and suggested regulators to encourage the use of guidelines by general practitioners. Raising awareness of policy makers for enhanced utilization of novel antidiabetic drugs for preventing cardiorenal complications is central to T2DM management. Timely identification and resolution of barriers for utilization of guideline-recommended therapies in clinical practice should be emphasized. In addition, the formulation of risk stratification tools tailored to different regions of MENA and AFR can be crucial to better inform treatment and policy-level decisions. Patient support programs, advocacy groups, national diabetes registries, and national awareness campaigns are cornerstones for improving patient outcomes. Mandatory systemic audits, application of key performance indicators, and public health models to streamline the management process are recommended. Collaboration between different specialists, the establishment of cardiometabolic clinics to identify the differences in practice, and creating a simple questionnaire to assess the clinical need and track risk patterns among different specialists were considered essential to deliver the appropriate care and improve quality of life in T2DM. Additionally, assessment surveys at all levels of care with a subsequent formulation of regional cardiorenal guidelines should be endorsed by regulators and payers.
Economic perspective
From a global public health perspective, implementation of the World Health Organization (WHO) Best Buys refers to cardiometabolic risk reduction in terms of treatment of diabetes, dyslipidemia, and hypertension. Most of the MENA region has been classified as a very high-risk region based on the ESC risk stratification. The targeted use of CV and renal risk-reducing SGLT2is and GLP-1RAs has a clear public health implication, especially in the populations at higher CV risk. In addition, the involvement of national regulatory health authorities for the wider utilization of these novel antidiabetic medications has significant implications in the reduction of cardiorenal events in broad segments of the population. It also has significant health economic benefits as demonstrated in high-income countries through reduction of downstream costs, such as hospitalization due to MI, HF, and renal replacement therapy. The cost-effectiveness of the novel antidiabetic therapies, particularly SGLT2is, has been widely reported in the literature. The cost-effective benefit is likely to have an even greater significance in resource-limited countries, as utilization of complication-preventing therapies would have an impact on population productivity and overall health care costs. Recent data including nationally representative surveys from 67 LMICs reported that using novel antidiabetic agents in a glycemia-agnostic pathway produced a 92% reduction (SGLT2is) and 72% reduction (GLP-1RA) in incremental cost-effectiveness ratios in T2DM. The study elaborated that, consistent with the choice to include SGLT2is in the WHO Essential Medicines List, SGLT2is hold particular promise for reducing T2DM complications and meeting common price targets, particularly when used among people with established CV or kidney disease.
Challenges and key recommendations suggested at all levels—patient, physician, and health system—are tabulated in Table . Recognizing this urgent need for the creation of integrated cardiometabolic clinics in the UAE was highlighted in the long-term multidisciplinary project UNITE inaugurated by the Emirates Diabetes Society and Emirates Cardiac Society (with collaboration from the American College of Cardiology [ACC] and ADA). This has resulted in the first cardiometabolic clinic in the region, which began operations in June 2021, and an official implementation pilot to the health care regulatory authorities for a population health initiative using this model of care. The growing prevalence of T2DM complications and the subsequent economic burden in the MENA region call for an urgent need and strategic response at all spheres of health care, including targeted interventions at the policy level.
TABLE 2 Challenges and key recommendations for management of type 2 diabetes mellitus and cardiorenal complications in the Middle East and Africa
| Patient level |
|
|
| Physician level |
|
|
| Policy level |
|
|
Policy shaping for effective care of
With approximately one out of every seven people in MENA and AFR countries suffering from T2DM, coherent region-wide approaches are warranted, alongside the currently existing short-scale responses. Many countries such as UAE, Turkey, Oman, and South Africa have developed region-specific guidelines for T2DM tailored to the needs of their population. Predominantly targeting obesity, many countries have formulated programs such as reducing salt intake in food, raising taxes on tobacco and alcohol, or promoting public awareness for diet and physical activity. By 2019, 10 of the region's countries had policies relating to trans-fatty acids, 13 countries had fully or partially implemented national salt reduction policies, and 8 countries had introduced taxes on carbonated or sugar-sweetened beverages. With respect to diabetes care, Turkey has made steady progress undertaking initiatives such as the Diabetes Program of Turkey 2015-2020 and the Multisectoral Action Plan of Turkey for Noncommunicable Diseases 2017-2025, listing out priority approaches for strategic implementation. In the UAE, the Early Action in Diabetes policy, the “drive-in” awareness-raising initiative for improving quality of life of patients with T2DM, along with the Diabetes Prevention Program 2020 are noteworthy. In Saudi Arabia, the Ministry of Health established specialized centers for the prevention, treatment, and rehabilitation of patients with T2DM through a network of integrated facilities. Other initiatives like the National Awareness Program for Diabetes 2013, the Antidiabetes Education National Program, and the National Executive Plan of Diabetes Control (2010-2020) are crucial for primary and secondary prevention. Countries like Oman and the UAE have initiated screening programs that can be instrumental for the early detection of noncommunicable diseases (NCDs). On the same lines, the Egypt National Multisectoral Action Plan for Noncommunicable Diseases 2017-2021 was formed with emphasis on the following strategic areas: governance, risk reduction, health promotion, early detection and management, surveillance, monitoring and evaluation, and research. Similar initiatives for T2DM are ongoing in AFR with the aim to improve detection rates, address issues of lifestyle changes, and improve care monitoring and adherence to prescribed medicines.
Notwithstanding the steady progress in policy shaping, only eight countries (Afghanistan, Islamic Republic of Iran, Kuwait, Saudi Arabia, Bahrain, Iraq, UAE, and Qatar) have an operational national strategy/action plan that integrates the major NCDs and their shared risk factors as of 2018. Only nine countries (Bahrain, Iran, Jordan, Kuwait, Lebanon, Oman, Saudi Arabia, UAE, and Palestine) have a provision of drug therapy and counseling to prevent CVD. Health expenditure on diabetes is still less in MENA and AFR countries, with a disparate standard of care across different regions. A recent pooled analysis from 55 LMICs, including MENA and AFR, reported that fewer than 1 in 10 people with T2DM receive coverage of guideline-based comprehensive treatment. The study highlighted lower coverage for glucose-lowering medication (50.5%), antihypertensive medication (41.3%), cholesterol-lowering medication (6.3%), diet counseling (32.2%), exercise counseling (28.2%), and weight-loss counseling (31.5%). Similarly, in AFR universal strengthening of the health system for better access to medicines for the management of cardiorenal complications, focusing on expanding the health technology assessment capabilities to assist with rational choices considering the pressure on resources, is warranted. Despite the formulation of several policies for T2DM in MENA and AFR, many are still in nascent stages of implementation in the real world, with gaps in the evaluation of key indicators for understanding their impact on the control of cardiorenal complications.
Roadmap for driving patient-centric diabetes care in MENA and AFR
Concerted efforts at a wider scale with better screening initiatives are required for effective T2DM care and prevention of cardiorenal complications in MENA and AFR. Higher investments to raise health care capabilities, particularly in the underserved primary care, can be pivotal to channel better diabetes management. Cross-governmental approaches including different ministries, alongside engagement of the wider community can raise awareness and help navigate better patient-centric care across the trajectory of T2DM. Implementation of chronic care models for T2DM and task-sharing interventions with nonphysician health care workers can be instrumental in improving diabetes-related outcomes. Wider use of innovative digital technology, such as mobile health through telemedicine, may facilitate comprehensive treatment at a lower cost. As chronic complications pose the biggest challenge, enhancing the capacity of health systems to deliver glucose-lowering treatment and alongside addressing cardiorenal factors through timely and judicious use of novel antidiabetic agents with pleiotropic effects, are urgent priorities for diabetes care in the region.
CONCLUSION
This consensus document identified challenging areas and outlined strategic recommendations for the effective management of cardiorenal complications in MENA and AFR. The use of antidiabetic medications for T2DM is driven by glycemic control rather than cardiorenal risk reduction. As PCPs are the first-contact care providers, enhancing their knowledge on risk factors for cardiorenal complications and identification of high-risk patients is crucial. Early diagnosis with regular and systematic monitoring of cardiorenal parameters, development of region-specific care pathways for timely referral to a cardiologist or nephrologist, followed by guideline-recommended care with novel antidiabetic agents are imperative. There is a critical need to address treatment inertia through early commencement of cardiorenal medications or the escalation/de-escalation, whenever required, to avert complications. Early utilization of novel antidiabetic medication with metformin may be a pragmatic dual-pronged approach for glycemic control while simultaneously reducing cardiorenal disorders in a cost-effective manner, especially in resource-limited countries. Despite the guideline recommendations, deficiencies in real-world adoption of cardiorenal-protective therapies should be identified and addressed for optimum management of cardiorenal complications in MENA and AFR.
ACKNOWLEDGEMENT
The authors thank Kanchan Birajdar and Piyalee Pal from Covance Scientific Services and Solutions Pvt Ltd, India, for medical writing support that was funded by AstraZeneca FZ LLC in accordance with Good Publication Practice (GPP) 3 guidelines ().
CONFLICT OF INTEREST
M.H., A.E., A.M.R., A.M.A., F.S.S., F.H.H., H.I., S.A., Z.B., and Z.O.S. declare no competing interests. A.S. reports participation in advisory boards of AstraZeneca, Novo Nordisk, Novartis, Eli Lilly, and Sanofi; meeting and travel support from AstraZeneca, Novo Nordisk, Amgen, and Sanofi; honoraria for educational lectures from Novo Nordisk, Boehringer Ingelheim, and Sanofi, and being the principal investigator in studies by Novo Nordisk and Novartis. I.E. reports participation in advisory boards of Abbott, AstraZeneca, Boehringer Ingelheim, Merck Sharp & Dohme, Novartis, Eli Lilly, Servier, Janssen, Novo Nordisk, Sanofi, EVA Pharma, Apex, and Amgen; participation as a speaker at AstraZeneca, Boehringer Ingelheim, Merck Sharp & Dohme, Novartis, Eli Lilly, Servier, Janssen, Merck Serono, Novo Nordisk, Sanofi, Amgen, EVA Pharma, Apex, hikma, Marcyrl, and Abbott; and participation in clinical trial research at Merck Sharp & Dohme, Novartis, Servier, and Novo Nordisk. H.S. reports honoraria for educational lectures and licenses from Novartis, AstraZeneca, Boehringer Ingelheim, Novo Nordisk, MAD, and Merck Sharp and Dohme. S.A. reports speaker honoraria from AstraZeneca, Boehringer Ingelheim, Merck Sharp and Dohme, Merk Serono, Novo Nordisk, Novartis, and Sanofi Aventis. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or editorial, research, and writing support for the development of the recommendations for gaps in the management of T2DM in the MENA and AFR region apart from those disclosed.
IDF Diabetes Atlas 9 Edition 2019. Global diabetes data report 2010 — 2045. Accessed March 12, 2021. https://diabetesatlas.org/data/
Lin X, Xu Y, Pan X, et al. Global, regional, and national burden and trend of diabetes in 195 countries and territories: an analysis from 1990 to 2025. Sci Rep. 2020;10:14790.
Badran M, Laher I. Type II diabetes mellitus in Arabic‐speaking countries. Int J Endocrinol. 2012;2012: [eLocator: e902873].
Alawadi F, Abdelgadir E, Bashier A, et al. Glycemic control in patients with diabetes across primary and tertiary government health sectors in the emirate of Dubai, United Arab Emirates: a five‐year pattern. Oman Med J. 2019;34:20‐25.
Shan PF, Li Q, Khamaisi M, Fen QG. Type 2 diabetes mellitus and macrovascular complications. Int J Endocrinol. 2017;2017: [eLocator: e4301461].
Chatterjee S, Khunti K, Davies MJ. Type 2 diabetes. Lancet. 2017;389:2239‐2251.
Shehab A, Bhagavathula AS, Al‐Rasadi K, et al. Diabetes and mortality in acute coronary syndrome: findings from the Gulf COAST registry. Curr Vasc Pharmacol. 2020;18:68‐76.
Zubaid M, Rashed WA, Alsheikh‐Ali AA, et al. Gulf survey of atrial fibrillation events (gulf SAFE): design and baseline characteristics of patients with atrial fibrillation in the Arab Middle East. Circ Cardiovasc Qual Outcomes. 2011;4:477‐482.
Al‐Jarallah M, Rajan R, Al‐Zakwani I, et al. Impact of diabetes on mortality and rehospitalization in acute heart failure patients stratified by ejection fraction. ESC Heart Fail. 2020;7:298‐306.
Arredouani A. Greater and more focused measures are needed to tackle diabetes and obesity epidemics in the nations of the gulf cooperation council. Int J Endocrinol. 2021;2021: [eLocator: e6661346].
Satman I, Omer B, Tutuncu Y, et al. Twelve‐year trends in the prevalence and risk factors of diabetes and prediabetes in Turkish adults. Eur J Epidemiol. 2013;28:169‐180.
Al Sifri SN, Almahmeed W, Azar S, et al. Results of the dyslipidemia international study (DYSIS)‐Middle East: clinical perspective on the prevalence and characteristics of lipid abnormalities in the setting of chronic statin treatment. PLoS One. 2014;9: [eLocator: e84350].
Al Mahmeed W, Bakir S, Beshyah SA, et al. Prevalence of lipid abnormalities and cholesterol target value attainment in patients with stable and acute coronary heart disease in The United Arab Emirates. Heart Views. 2019;20:37‐46.
IDF. Diabetes Atlas. 10th ed. Accessed December 2, 2021. https://diabetesatlas.org/
Shehab A, Al‐Rasadi K, Arafah M, et al. The management of dyslipidaemia in patients with type 2 diabetes mellitus receiving lipid‐lowering drugs: a sub‐analysis of the CEPHEUS findings. Curr Vasc Pharmacol. 2018;16:368‐375.
Sonmez A, Yumuk V, Haymana C, et al. Impact of obesity on the metabolic control of type 2 diabetes: results of the Turkish Nationwide survey of glycemic and other metabolic parameters of patients with diabetes mellitus (TEMD obesity study). Obes Facts. 2019;12:167‐178.
Parving HH, Lewis JB, Ravid M, Remuzzi G, Hunsicker LG. Prevalence and risk factors for microalbuminuria in a referred cohort of type II diabetic patients: a global perspective. Kidney Int. 2006;69:2057‐2063.
Gomes MB, Rathmann W, Charbonnel B, et al. Treatment of type 2 diabetes mellitus worldwide: baseline patient characteristics in the global DISCOVER study. Diabetes Res Clin Pract. 2019;151:20‐32.
Kosiborod M, Cooper A, Fenici P, et al. The DISCOVER global registry: a long term, large scale patient registry of routine care for people with type 2 diabetes ‐ virtual meeting | EASD. Published 2020. Accessed July 5, 2021. https://www.easd.org/virtualmeeting/home.html#!resources/the-discover-global-registry-a-long-term-large-scale-patient-registry-of-routine-care-for-people-with-type-2-diabetes-cba30e9e-13c4-4341-9bb8-cf5122f8ce8b
Zubaid M, Rashed WA, Almahmeed W, et al. Management and outcomes of middle eastern patients admitted with acute coronary syndromes in the Gulf registry of acute coronary events (gulf RACE). Acta Cardiol. 2009;64:439‐446.
Alhabib KF, Sulaiman K, Al‐Motarreb A, et al. Baseline characteristics, management practices, and long‐term outcomes of middle eastern patients in the second gulf registry of acute coronary events (gulf RACE‐2). Ann Saudi Med. 2012;32:9‐18.
Zubaid M, Thani KB, Rashed W, et al. Design and rationale of gulf locals with acute coronary syndrome events (Gulf Coast) registry. Open Cardiovasc Med J. 2014;8:88‐93.
Sulaiman K, Panduranga P, Al‐Zakwani I, et al. Clinical characteristics, management, and outcomes of acute heart failure patients: observations from the Gulf acute heart failure registry (gulf CARE). Eur J Heart Fail. 2015;17:374‐384.
Kosiborod M, Gomes MB, Nicolucci A, et al. Vascular complications in patients with type 2 diabetes: prevalence and associated factors in 38 countries (the DISCOVER study program). Cardiovasc Diabetol. 2018;17:150.
Mosenzon O, Alguwaihes A, Leon JLA, et al. CAPTURE: a multinational, cross‐sectional study of cardiovascular disease prevalence in adults with type 2 diabetes across 13 countries. Cardiovasc Diabetol. 2021;20:154.
Al‐Ozairi E, Jallo MK, Hafidh K, et al. Prevalence of cardiovascular and renal co‐morbidities in patients with type 2 diabetes in the Gulf, a cross‐sectional observational study. Diabetes Ther. 2021;12:1193‐1207.
Al‐Shamsi S, Regmi D, Govender RD. Chronic kidney disease in patients at high risk of cardiovascular disease in The United Arab Emirates: a population‐based study. PLoS One. 2018;13: [eLocator: e0199920].
Birkeland KI, Bodegard J, Eriksson JW, et al. Heart failure and chronic kidney disease manifestation and mortality risk associations in type 2 diabetes: a large multinational cohort study. Diabetes Obes Metab. 2020;22:1607‐1618.
Al‐Shamsi S, Regmi D, Govender RD. Incidence of cardiovascular disease and its associated risk factors in at‐risk men and women in The United Arab Emirates: a 9‐year retrospective cohort study. BMC Cardiovasc Disord. 2019;19:148.
Kelishadi R, Pour MH, Sarraf‐Zadegan N, et al. Obesity and associated modifiable environmental factors in Iranian adolescents: Isfahan healthy heart program ‐ heart health promotion from childhood. Pediatr Int. 2003;45:435‐442.
Alhabib KF, Batais MA, Almigbal TH, et al. Demographic, behavioral, and cardiovascular disease risk factors in the Saudi population: results from the prospective urban rural epidemiology study (PURE‐Saudi). BMC Public Health. 2020;20:1213.
Afsharian S, Akbarpour S, Abdi H, et al. Risk factors for cardiovascular disease and mortality events in adults with type 2 diabetes ‐ a 10‐year follow‐up: Tehran lipid and glucose study. Diabetes Metab Res Rev. 2016;32:596‐606.
Omar M, Khudada K, Safarini S, Mehanna S, Nafach J. DiabCare survey of diabetes management and complications in the Gulf countries. Indian Endocrinol Metab. 2016;20:219.
Kaplan H, Amod A, Chadli A, et al. IDMPS wave 7 Africa. J Endocrinol Metab Diabetes S Afr. 2021;26:76‐81.
Jelinek HF, Osman WM, Khandoker AH, et al. Clinical profiles, comorbidities and complications of type 2 diabetes mellitus in patients from United Arab Emirates. BMJ Open Diabetes Res Care. 2017;5: [eLocator: e000427].
Al‐Rubeaan K, Youssef AM, Subhani SN, et al. Diabetic nephropathy and its risk factors in a society with a type 2 diabetes epidemic: a Saudi National Diabetes Registry‐Based Study. PLOS One. 2014;9: [eLocator: e88956].
Eriksson JW, Bodegard J, Thuresson M, Mamza JB, Norhammar A. Cardiorenal disease is the costliest CVD in type 2 diabetes: a large long‐term observational study. Metabolism. 2020;104: [eLocator: 154134].
Gagliardino JJ, Atanasov PK, Chan JCN, et al. Resource use associated with type 2 diabetes in Africa, the Middle East, South Asia, Eurasia and Turkey: results from the international diabetes management practice study (IDMPS). BMJ Open Diabetes Res Care. 2017;5: [eLocator: e000297].
Take Care of Me Clinical Management Model. AstraZeneca launches diagnostics programme to prevent diabetes complications. CodeBlue. Published December 18, 2020. Accessed March 14, 2021. https://codeblue.galencentre.org/2020/12/18/astrazeneca-launches-diagnostics-programme-to-prevent-diabetes-complications/
Sonmez A, Haymana C, Bayram F, et al. Turkish nationwide survEy of glycemic and other metabolic parameters of patients with diabetes mellitus (TEMD study). Diabetes Res Clin Pract. 2018;146:138‐147.
Alanazi FK, Alotaibi JS, Paliadelis P, Alqarawi N, Alsharari A, Albagawi B. Knowledge and awareness of diabetes mellitus and its risk factors in Saudi Arabia. Saudi Med J. 2018;39:981‐989.
Godman B, Basu D, Pillay Y, et al. Review of ongoing activities and challenges to improve the Care of Patients with Type 2 diabetes across Africa and the implications for the future. Front Pharmacol. 2020;11:108.
Ellahham S. Diabetes and its associated cardiovascular complications in the Arabian gulf: challenges and opportunities. J Clin Exp Cardiolog. 2020;11:1‐5.
Alramadan MJ, Magliano DJ, Almigbal TH, et al. Glycaemic control for people with type 2 diabetes in Saudi Arabia – an urgent need for a review of management plan. BMC Endocr Disord. 2018;18:62.
Assaad‐Khalil SH, Arouj MA, AlMaatouq M, et al. Barriers to the delivery of diabetes care in the Middle East and South Africa: a survey of 1,082 practising physicians in five countries. Int J Clin Pract. 2013;67:1144‐1150.
Al‐Alawi K, Al Mandhari A, Johansson H. Care providers' perceptions towards challenges and opportunities for service improvement at diabetes management clinics in public primary health care in Muscat, Oman: a qualitative study. BMC Health Serv Res. 2019;19:18.
Alsairafi ZK, Taylor KMG, Smith FJ, Alattar AT. Patients' management of type 2 diabetes in middle eastern countries: review of studies. Patient Prefer Adherence. 2016;10:1051‐1062.
Bekele H, Asefa A, Getachew B, Belete AM. Barriers and strategies to lifestyle and dietary pattern interventions for prevention and management of TYPE‐2 diabetes in Africa, systematic review. J Diabetes Res. 2020;2020: [eLocator: e7948712].
Assaad Khalil SH, Abdelaziz SI, Al Shammary A, et al. Prediabetes management in the Middle East, Africa and Russia: current status and call for action. Diab Vasc Dis Res. 2019;16:213‐226.
Burke SD, Sherr D, Lipman RD. Partnering with diabetes educators to improve patient outcomes. Diabetes Metab Syndr Obes. 2014;7:45‐53.
Nikitara M, Constantinou CS, Andreou E, Diomidous M. The role of nurses and the facilitators and barriers in diabetes care: a mixed methods systematic literature review. Behav Sci (Basel). 2019;9:61.
Al Rasheed R, Al AF. Diabetic retinopathy: knowledge, awareness and practices of physicians in primary‐care centers in Riyadh, Saudi Arabia. Saudi J Ophthalmol. 2017;31:2‐6.
Johnson J, Carragher R. Interprofessional collaboration and the care and management of type 2 diabetic patients in the Middle East: a systematic review. J Interprof Care. 2018;32:1‐8.
Sonmez A, Tasci I, Demirci I, et al. A cross‐sectional study of overtreatment and Deintensification of antidiabetic and antihypertensive medications in diabetes mellitus: the TEMD overtreatment study. Diabetes Ther. 2020;11:1045‐1059.
Andreozzi F, Candido R, Corrao S, et al. Clinical inertia is the enemy of therapeutic success in the management of diabetes and its complications: a narrative literature review. Diabetol Metab Syndr. 2020;12:52.
Schernthaner G, Shehadeh N, Ametov AS, et al. Worldwide inertia to the use of cardiorenal protective glucose‐lowering drugs (SGLT2i and GLP‐1 RA) in high‐risk patients with type 2 diabetes. Cardiovasc Diabetol. 2020;19:185.
Blonde L, Aschner P, Bailey C, Ji L, Leiter LA, Matthaei S. Gaps and barriers in the control of blood glucose in people with type 2 diabetes. Diab Vasc Dis Res. 2017;14:172‐183.
Haymana C, Sonmez A, Demirci I, et al. Patterns and preferences of antidiabetic drug use in Turkish patients with type 2 diabetes – a nationwide cross‐sectional study (TEMD treatment study). Diabetes Res Clin Pract. 2021;171: [eLocator: 108556].
Azar ST, Echtay A, Amm M, et al. Characteristics and treatment patterns of patients with type 2 diabetes in Lebanon: the DISCOVER study. East Mediterr Health J. 2021;27:509‐515.
Khunti K, Gomes MB, Pocock S, et al. Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: a systematic review. Diabetes Obes Metab. 2018;20:427‐437.
Khunti K, Chen H, Cid‐Ruzafa J, et al. Glycaemic control in patients with type 2 diabetes initiating second‐line therapy: results from the global DISCOVER study programme. Diabetes Obes Metab. 2020;22:66‐78.
Ahmadieh H, Sawaya MT, Azar ST. Management and control of type 2 diabetes mellitus in Lebanon: results from the international diabetes management practices study wave 6. World J Diabetes. 2019;10:249‐259.
Al‐Rubeaan K, Bana FA, Alruwaily FG, et al. Physicians' choices in the first‐ and second‐line management of type 2 diabetes in the Kingdom of Saudi Arabia. Saudi Pharm J. 2020;28:329‐337.
Nicolucci A, Charbonnel B, Gomes MB, et al. Treatment patterns and associated factors in 14 668 people with type 2 diabetes initiating a second‐line therapy: results from the global DISCOVER study programme. Diabetes Obes Metab. 2019;21:2474‐2485.
American Diabetes Association. Pharmacologic approaches to glycemic treatment: standards of medical Care in Diabetes—2021. Diabetes Care. 2021;44:S111‐S124.
Cosentino F, Grant PJ, Aboyans V, et al. 2019 ESC guidelines on diabetes, pre‐diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J. 2020;41:255‐323.
Alawadi F, Abusnana S, Afandi B, et al. Emirates diabetes society consensus guidelines for the Management of Type 2 diabetes mellitus – 2020. Dubai Diab Endocrinol J. 2020;26:1‐20.
The Society of Endocrinology and Metabolism of Turkey (SEMT) Diabetes Mellitus Working Group. Clinical Practice Guideline for Diagnosis, Treatment and Follow‐up of Diabetes Mellitus and Its Complications – 2019. Accessed May 10, 2021. https://temd.org.tr/admin/uploads/tbl_kilavuz/20191107144832‐2019tbl_kilavuz7c65cb4e70.pdf
SEMDSA 2017. Guidelines for the management of type 2 diabetes mellitus. J Endocrinol Metabol Diabetes S AF. 2017;22:S1–S196. Accessed March 12, 2021. https://docs.mymembership.co.za/docmanager/d7a3ded1-2f30-4ff2-b566-b69abe5d7a8e/00150685.pdf
Ministry of Health Sultanate of Oman. Diabetes Mellitus Management Guidelines, 2015. Accessed May 10, 2021.
Khunti S, Khunti K, Seidu S. Therapeutic inertia in type 2 diabetes: prevalence, causes, consequences and methods to overcome inertia. Ther Adv Endocrinol Metab. 2019;10:1‐11.
Powell RE, Zaccardi F, Beebe C, et al. Strategies for overcoming therapeutic inertia in type 2 diabetes: a systematic review and meta‐analysis. Diabetes Obes Metab. 2021;23:2137‐2154.
Sönmez A, Özdoğan Ö, Arici M, et al. Consensus statement of endocrinology, cardiology, and nephrology (ENCARNE) experts on prevention, diagnosis, and management of cardiovascular and renal complications of diabetes. Turk J Endocrinol Metab. 2021;25:392‐411.
Khatib OMN, World Health Organization, Regional Office for the Eastern Mediterranean. Guidelines for the Prevention, Management and Care of Diabetes Mellitus. Cairo, Egypt: World Health Organization, Regional Office for the Eastern Mediterranean; 2006.
O'Brien MJ, Bullard KM, Zhang Y, et al. Performance of the 2015 US preventive services task force screening criteria for prediabetes and undiagnosed diabetes. J Gen Intern Med. 2018;33:1100‐1108.
Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the heart failure association (HFA) of the ESC. Eur Heart J. 2016;37:2129‐2200.
Mannucci E, Dicembrini I, Nreu B, Monami M. Glucagon‐like peptide‐1 receptor agonists and cardiovascular outcomes in patients with and without prior cardiovascular events: An updated meta‐analysis and subgroup analysis of randomized controlled trials. Diabetes Obes Metab. 2020;22:203‐211.
Giugliano D, Longo M, Scappaticcio L, Caruso P, Esposito K. Sodium–glucose transporter‐2 inhibitors for prevention and treatment of cardiorenal complications of type 2 diabetes. Cardiovasc Diabetol. 2021;20:17.
Zelniker TA, Wiviott SD, Raz I, et al. SGLT2 inhibitors for primary and secondary prevention of cardiovascular and renal outcomes in type 2 diabetes: a systematic review and meta‐analysis of cardiovascular outcome trials. Lancet. 2019;393:31‐39.
McGuire DK, Shih WJ, Cosentino F, et al. Association of SGLT2 inhibitors with cardiovascular and kidney outcomes in patients with type 2 diabetes: a meta‐analysis. JAMA Cardiol. 2021;6:148‐158.
Ida S, Kaneko R, Imataka K, et al. Effects of oral antidiabetic drugs and glucagon‐like peptide‐1 receptor agonists on left ventricular diastolic function in patients with type 2 diabetes mellitus: a systematic review and network meta‐analysis. Heart Fail Rev. 2020;26:1151‐1158.
Gerstein HC, Colhoun HM, Dagenais GR, et al. Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): a double‐blind, randomised placebo‐controlled trial. Lancet. 2019;394:121‐130.
Sattar N, Lee MMY, Kristensen SL, et al. Cardiovascular, mortality, and kidney outcomes with GLP‐1 receptor agonists in patients with type 2 diabetes: a systematic review and meta‐analysis of randomised trials. Lancet Diabetes Endocrinol. 2021;9:653‐662.
Cha AS, Chen Y, Fazioli K, Rivara MB, Devine EB. Microvascular benefits of new antidiabetic agents: a systematic review and network meta‐analysis of kidney outcomes. J Clin Endocrinol Metab. 2021;106:1225‐1234.
Zinman B, Wanner C, Lachin JM, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med. 2015;373:2117‐2128.
Neal B, Perkovic V, Mahaffey KW, et al. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med. 2017;377:644‐657.
Wiviott SD, Raz I, Bonaca MP, et al. Dapagliflozin and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2019;380:347‐357.
Cahn A, Raz I, Leiter LA, et al. Cardiovascular, renal, and metabolic outcomes of Dapagliflozin versus placebo in a primary cardiovascular prevention cohort: analyses from DECLARE‐TIMI 58. Diabetes Care. 2021;44:1159‐1167.
Heerspink HJL, Stefánsson BV, Correa‐Rotter R, et al. Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020;383:1436‐1446.
Perkovic V, Jardine MJ, Neal B, et al. Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. N Engl J Med. 2019;380:2295‐2306.
McMurray JJV, Solomon SD, Inzucchi SE, et al. Dapagliflozin in patients with heart failure and reduced ejection fraction. N Engl J Med. 2019;381:1995‐2008.
Cannon CP, Pratley R, Dagogo‐Jack S, et al. Cardiovascular outcomes with Ertugliflozin in type 2 diabetes. N Engl J Med. 2020;383:1425‐1435.
Packer M, Anker SD, Butler J, et al. Cardiovascular and renal outcomes with Empagliflozin in heart failure. N Engl J Med. 2020;383:1413‐1424.
Abraham WT, Lindenfeld J, Ponikowski P, et al. Effect of empagliflozin on exercise ability and symptoms in heart failure patients with reduced and preserved ejection fraction, with and without type 2 diabetes. Eur Heart J. 2021;42:700‐710.
Ring A, Brand T, Macha S, et al. The sodium glucose cotransporter 2 inhibitor empagliflozin does not prolong QT interval in a thorough QT (TQT) study. Cardiovasc Diabetol. 2013;12:70.
Nassif ME, Windsor SL, Tang F, et al. Dapagliflozin effects on biomarkers, symptoms, and functional status in patients with heart failure with reduced ejection fraction. Circulation. 2019;140:1463‐1476.
Verma S, Mazer CD, Yan AT, et al. Effect of Empagliflozin on left ventricular mass in patients with type 2 diabetes mellitus and coronary artery disease: the EMPA‐HEART CardioLink‐6 randomized clinical trial. Circulation. 2019;140:1693‐1702.
Hernandez AF, Green JB, Janmohamed S, et al. Albiglutide and cardiovascular outcomes in patients with type 2 diabetes and cardiovascular disease (harmony outcomes): a double‐blind, randomised placebo‐controlled trial. Lancet. 2018;392:1519‐1529.
Holman RR, Bethel MA, Mentz RJ, et al. Effects of once‐weekly Exenatide on cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2017;377:1228‐1239.
Marso SP, Daniels GH, Brown‐Frandsen K, et al. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016;375:311‐322.
Husain M, Birkenfeld AL, Donsmark M, et al. Oral Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2019;381:841‐851.
Marso SP, Bain SC, Consoli A, et al. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2016;375:1834‐1844.
Pfeffer MA, Claggett B, Diaz R, et al. Lixisenatide in patients with type 2 diabetes and acute coronary syndrome. N Engl J Med. 2015;373:2247‐2257.
Tonneijck L, Muskiet MHA, Twisk JW, et al. Lixisenatide versus insulin Glulisine on fasting and Postbreakfast systemic hemodynamics in type 2 diabetes mellitus patients. Hypertension. 2018;72:314‐322.
Satirapoj B, Watanakijthavonkul K, Supasyndh O. Safety and efficacy of low dose pioglitazone compared with standard dose pioglitazone in type 2 diabetes with chronic kidney disease: a randomized controlled trial. PloS One. 2018;13:e0206722.
Abdul‐Ghani M, Migahid O, Megahed A, DeFronzo RA, Al‐Ozairi E, Jayyousi A. Combination therapy with pioglitazone/exenatide improves beta‐cell function and produces superior glycaemic control compared with basal/bolus insulin in poorly controlled type 2 diabetes: a 3‐year follow‐up of the Qatar study. Diabetes Obes Metab. 2020;22:2287‐2294.
Abdul‐Ghani M, Migahid O, Megahed A, et al. Combination therapy with Exenatide plus pioglitazone versus basal/bolus insulin in patients with poorly controlled type 2 diabetes on sulfonylurea plus metformin: the Qatar study. Diabetes Care. 2017;40:325‐331.
Young LH, Viscoli CM, Schwartz GG, et al. Heart failure after ischemic stroke or transient ischemic attack in insulin‐resistant patients without diabetes mellitus treated with pioglitazone. Circulation. 2018;138:1210‐1220.
Vaccaro O, Masulli M, Nicolucci A, et al. Effects on the incidence of cardiovascular events of the addition of pioglitazone versus sulfonylureas in patients with type 2 diabetes inadequately controlled with metformin (TOSCA.IT): a randomised, multicentre trial. Lancet Diabetes Endocrinol. 2017;5:887‐897.
Kosiborod M, Cavender MA, Fu AZ, et al. Lower risk of heart failure and death in patients initiated on sodium‐glucose Cotransporter‐2 inhibitors versus other glucose‐lowering drugs. Circulation. 2017;136:249‐259.
Norhammar A, Bodegard J, Nystrom T, et al. Dapagliflozin is associated with lower risk of hospitalization for heart failure, major adverse cardiovascular events and all‐cause death compared to DPP‐4i in T2D patients: CVD‐REAL Nordic. Can J Diabetes. 2017;41:S51.
Kosiborod M, Lam CSP, Kohsaka S, et al. Cardiovascular events associated with SGLT‐2 inhibitors versus other glucose‐lowering drugs: the CVD‐REAL 2 study. J Am Coll Cardiol. 2018;71:2628‐2639.
Patorno EE, Pawar A, Franklin JM, et al. Empagliflozin and the risk of heart failure hospitalization in routine clinical care: a first analysis from the EMPagliflozin compaRative effectIveness and SafEty (EMPRISE) study. Circulation. 2019;139:2822‐2830.
Patorno E, Goldfine AB, Schneeweiss S, et al. Cardiovascular outcomes associated with canagliflozin versus other non‐gliflozin antidiabetic drugs: population based cohort study. BMJ. 2018;360: [eLocator: k119].
Birkeland KI, Bodegard J, Banerjee A, et al. Lower cardiorenal risk with sodium‐glucose cotransporter‐2 inhibitors versus dipeptidyl peptidase‐4 inhibitors in patients with type 2 diabetes without cardiovascular and renal diseases: a large multinational observational study. Diabetes Obes Metab. 2021;23:75‐85.
Tanaka H, Soga F, Tatsumi K, et al. Positive effect of dapagliflozin on left ventricular longitudinal function for type 2 diabetic mellitus patients with chronic heart failure. Cardiovasc Diabetol. 2020;19:6.
Baviera M, Genovese S, Lepore V, et al. Lower risk of death and cardiovascular events in patients with diabetes initiating glucagon‐like peptide‐1 receptor agonists or sodium‐glucose cotransporter‐2 inhibitors: a real‐world study in two Italian cohorts. Diabetes Obes Metab. 2021;23:1484‐1495.
Tonneijck L, Muskiet MHA, Smits MM, et al. Effect of immediate and prolonged GLP‐1 receptor agonist administration on uric acid and kidney clearance: post‐hoc analyses of four clinical trials. Diabetes Obes Metab. 2018;20:1235‐1245.
Longato E, Camillo BD, Sparacino G, Gubian L, Avogaro A, Fadini GP. Cardiovascular outcomes of type 2 diabetic patients treated with SGLT‐2 inhibitors versus GLP‐1 receptor agonists in real‐life. BMJ Open Diabetes Res Care. 2020;8: [eLocator: e001451].
Dave CV, Kim SC, Goldfine AB, Glynn RJ, Tong A, Patorno E. Risk of cardiovascular outcomes in patients with type 2 diabetes after addition of SGLT2 inhibitors versus sulfonylureas to baseline GLP‐1RA therapy. Circulation. 2021;143:770‐779.
Chang YH, Hwu DW, Chang DM, An LW, Hsieh CH, Lee YJ. Renal function preservation with pioglitazone or with basal insulin as an add‐on therapy for patients with type 2 diabetes mellitus. Acta Diabetol. 2017;54:561‐568.
Strongman H, Christopher S, Majak M, et al. Pioglitazone and cause‐specific risk of mortality in patients with type 2 diabetes: extended analysis from a European multidatabase cohort study. BMJ Open Diabetes Res Care. 2018;6: [eLocator: e000481].
Miao S, Dong X, Zhang X, et al. Detecting pioglitazone use and risk of cardiovascular events using electronic health record data in a large cohort of Chinese patients with type 2 diabetes. J Diabetes. 2019;11:684‐689.
Chewcharat A, Prasitlumkum N, Thongprayoon C, et al. Efficacy and safety of SGLT‐2 inhibitors for treatment of diabetes mellitus among kidney transplant patients: a systematic review and meta‐analysis. Med Sci (Basel). 2020;8:47.
Gilbert RE, Thorpe KE. Acute kidney injury with sodium‐glucose co‐transporter‐2 inhibitors: a meta‐analysis of cardiovascular outcome trials. Diabetes Obes Metab. 2019;21:1996‐2000.
Chambergo‐Michilot D, Tauma‐Arrué A, Loli‐Guevara S. Effects and safety of SGLT2 inhibitors compared to placebo in patients with heart failure: a systematic review and meta‐analysis. Int J Cardiol Heart Vasc. 2021;32: [eLocator: 100690].
Salsali A, Kim G, Woerle HJ, Broedl UC, Hantel S. Cardiovascular safety of empagliflozin in patients with type 2 diabetes: a meta‐analysis of data from randomized placebo‐controlled trials. Diabetes Obes Metab. 2016;18:1034‐1040.
Tang H, Fang Z, Wang T, Cui W, Zhai S, Song Y. Meta‐analysis of effects of sodium‐glucose cotransporter 2 inhibitors on cardiovascular outcomes and all‐cause mortality among patients with type 2 diabetes mellitus. Am J Cardiol. 2016;118:1774‐1780.
Malik AH, Yandrapalli S, Goldberg M, Jain D, Frishman WH, Aronow WS. Cardiovascular outcomes with the use of sodium‐glucose Cotransporter‐2 inhibitors in patients with type 2 diabetes and chronic kidney disease: an updated meta‐analysis of randomized controlled trials. Cardiol Rev. 2020;28:116‐124.
Usman MS, Siddiqi TJ, Memon MM, et al. Sodium‐glucose co‐transporter 2 inhibitors and cardiovascular outcomes: a systematic review and meta‐analysis. Eur J Prev Cardiol. 2018;25:495‐502.
Zannad F, Ferreira JP, Pocock SJ, et al. SGLT2 inhibitors in patients with heart failure with reduced ejection fraction: a meta‐analysis of the EMPEROR‐reduced and DAPA‐HF trials. Lancet. 2020;396:819‐829.
Ryan PB, Buse JB, Schuemie MJ, et al. Comparative effectiveness of canagliflozin, SGLT2 inhibitors and non‐SGLT2 inhibitors on the risk of hospitalization for heart failure and amputation in patients with type 2 diabetes mellitus: a real‐world meta‐analysis of 4 observational databases (OBSERVE‐4D). Diabetes Obes Metab. 2018;20:2585‐2597.
Arnott C, Li Q, Kang A, et al. Sodium‐glucose cotransporter 2 inhibition for the prevention of cardiovascular events in patients with type 2 diabetes mellitus: a systematic review and meta‐analysis. J Am Heart Assoc. 2020;9: [eLocator: e014908].
Giugliano D, Nicola LD, Maiorino MI, et al. Preventing major adverse cardiovascular events by SGLT‐2 inhibition in patients with type 2 diabetes: the role of kidney. Cardiovasc Diabetol. 2020;19:1‐6.
Alfayez OM, Almutairi AR, Aldosari A, Al Yami MS. Update on cardiovascular safety of Incretin‐based therapy in adults with type 2 diabetes mellitus: a meta‐analysis of cardiovascular outcome trials. Can J Diabetes. 2019;43:538‐545.e2.
Wu S, Cipriani A, Yang Z, et al. The cardiovascular effect of incretin‐based therapies among type 2 diabetes: a systematic review and network meta‐analysis. Expert Opin Drug Saf. 2018;17:243‐249.
Dicembrini I, Nreu B, Scatena A, et al. Microvascular effects of glucagon‐like peptide‐1 receptor agonists in type 2 diabetes: a meta‐analysis of randomized controlled trials. Acta Diabetol. 2017;54:933‐941.
Giugliano D, Maiorino MI, Bellastella G, Longo M, Chiodini P, Esposito K. GLP‐1 receptor agonists for prevention of cardiorenal outcomes in type 2 diabetes: An updated meta‐analysis including the REWIND and PIONEER 6 trials. Diabetes Obes Metab. 2019;21:2576‐2580.
Yamada T, Wakabayashi M, Bhalla A, et al. Cardiovascular and renal outcomes with SGLT‐2 inhibitors versus GLP‐1 receptor agonists in patients with type 2 diabetes mellitus and chronic kidney disease: a systematic review and network meta‐analysis. Cardiovasc Diabetol. 2021;20:14.
McKee A, Al‐Khazaali A, Albert SG. Glucagon‐like Peptide‐1 receptor agonists versus sodium‐glucose cotransporter inhibitors for treatment of T2DM. J Endocr Soc. 2020;4:1‐17.
Zhou Y, Huang Y, Ji X, Wang X, Shen L, Wang Y. Pioglitazone for the primary and secondary prevention of cardiovascular and renal outcomes in patients with or at high risk of type 2 diabetes mellitus: a meta‐analysis. J Clin Endocrinol Metab. 2020;105:dgz252.
Liao HW, Saver JL, Wu YL, Chen TH, Lee M, Ovbiagele B. Pioglitazone and cardiovascular outcomes in patients with insulin resistance, pre‐diabetes and type 2 diabetes: a systematic review and meta‐analysis. BMJ Open. 2017;7: [eLocator: e013927].
de Jong M, van der Worp HB, van der Graaf Y, Visseren FLJ, Westerink J. Pioglitazone and the secondary prevention of cardiovascular disease. A meta‐analysis of randomized‐controlled trials. Cardiovasc Diabetol. 2017;16:134.
Lee M, Saver JL, Liao HW, Lin CH, Ovbiagele B. Pioglitazone for secondary stroke prevention: a systematic review and meta‐analysis. Stroke. 2017;48:388‐393.
Sinha B, Ghosal S. Assessing the need for pioglitazone in the treatment of patients with type 2 diabetes: a meta‐analysis of its risks and benefits from prospective trials. Sci Rep. 2020;10:15781.
McEwan P, Bennett H, Khunti K, et al. Assessing the cost‐effectiveness of sodium–glucose cotransporter‐2 inhibitors in type 2 diabetes mellitus: a comprehensive economic evaluation using clinical trial and real‐world evidence. Diabetes Obes Metab. 2020;22:2364‐2374.
Babar ZUD, Ramzan S, El‐Dahiyat F, Tachmazidis I, Adebisi A, Hasan SS. The availability, pricing, and affordability of essential diabetes medicines in 17 low‐, middle‐, and high‐income countries. Front Pharmacol. 2019;10:1375.
Moucheraud C, Lenz C, Latkovic M, Wirtz VJ. The costs of diabetes treatment in low‐ and middle‐income countries: a systematic review. BMJ Glob Health. 2019;4: [eLocator: e001258].
Global Health & Population Project on access to Care for Cardiometabolic Diseases (HPACC). Expanding access to newer medicines for people with type 2 diabetes in low‐income and middle‐income countries: a cost‐effectiveness and price target analysis. Lancet Diabetes Endocrinol. 2021;9:825‐836.
Abushanab D, Al‐Badriyeh D, Liew D, Ademi Z. First‐line treatment with empagliflozin and metformin combination versus standard Care for Patients with type 2 diabetes mellitus and cardiovascular disease in Qatar. A cost‐effectiveness analysis. Curr Probl Cardiol. 2021; [eLocator: 100852]. In Press.
Moshel S, Vexberg MH, Shavit O, Toledano Y. PDB78 ‐ economic evaluation of dapagliflozin as add‐on to metformin for T2DM treatment in the Israeli healthcare setting. Value Health. 2018;21:S131.
Al‐Rubeaan KA, Al‐Manaa HA, Khoja TA, et al. Health care services provided to type 1 and type 2 diabetic patients in Saudi Arabia. Saudi Med J. 2015;36:1216‐1225.
Azzam MM, Ibrahim AA, Abd El‐Ghany MI. Factors affecting glycemic control among Egyptian people with diabetes attending primary health care facilities in Mansoura District. Egypt J Intern Med. 2021;33:33.
Neamah AF, Ghani M, Ahmad A, Alomari ES, Nuiaa RR. E‐health STATE in MIDDLE EAST countries: an overview. Turkish Online J Design, Art Commun. 2018;17:2974‐2990.
Afrizal SH, Hidayanto AN, Handayani PW, Budiharsana M, Eryando T. Narrative review for exploring barriers to readiness of electronic health record implementation in primary health care. Healthc Inform Res. 2019;25:141‐152.
Ferry AM, Davis MJ, Rumprecht E, Nigro AL, Desai P, Hollier LH. Medical documentation in low‐ and middle‐income countries: lessons learned from implementing specialized charting software. Plast Reconstr Surg Glob Open. 2021;9: [eLocator: e3651].
Alanzi T. mHealth for diabetes self‐management in the Kingdom of Saudi Arabia: barriers and solutions. J Multidiscip Healthc. 2018;11:535‐546.
Zghebi SS, Rutter MK, Ashcroft DM, et al. Using electronic health records to quantify and stratify the severity of type 2 diabetes in primary care in England: rationale and cohort study design. BMJ Open. 2018;8:e020926.
WHO. ‘Best Buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. 2017. Accessed December 21, 2021. https://www.who.int/ncds/management/WHO_Appendix_BestBuys_LS.pdf
SCORE2‐OP Working Group and ESC Cardiovascular Risk Collaboration. SCORE2‐OP risk prediction algorithms: estimating incident cardiovascular event risk in older persons in four geographical risk regions. Eur Heart J. 2021;42:2455‐2467.
Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC guidelines on cardiovascular disease prevention in clinical practice: developed by the task force for cardiovascular disease prevention in clinical practice with representatives of the European Society of Cardiology and 12 medical societies with the special contribution of the European Association of Preventive Cardiology (EAPC). Eur Heart J. 2021;42:3227‐3337.
Willis M, Nilsson A, Kellerborg K, et al. Cost‐effectiveness of Canagliflozin added to standard of Care for Treating Diabetic Kidney Disease (DKD) in patients with type 2 diabetes mellitus (T2DM) in England: estimates using the CREDEM‐DKD model. Diabetes Ther. 2021;12:313‐328.
Yoshida Y, Cheng X, Shao H, Fonseca VA, Shi L. A systematic review of cost‐effectiveness of sodium‐glucose cotransporter inhibitors for type 2 diabetes. Curr Diab Rep. 2020;20:12.
Ehlers LH, Lamotte M, Monteiro S, et al. The cost‐effectiveness of Empagliflozin versus Liraglutide treatment in people with type 2 diabetes and established cardiovascular disease. Diabetes Ther. 2021;12:1523‐1534.
Bagepally BS, Gurav YK, Anothaisintawee T, Youngkong S, Chaikledkaew U, Thakkinstian A. Cost utility of sodium‐glucose cotransporter 2 inhibitors in the treatment of metformin monotherapy failed type 2 diabetes patients: a systematic review and meta‐analysis. Value Health. 2019;22:1458‐1469.
Pawaskar M, Bilir SP, Kowal S, Gonzalez C, Rajpathak S, Davies G. Cost‐effectiveness of intensification with sodium‐glucose co‐transporter‐2 inhibitors in patients with type 2 diabetes on metformin and sitagliptin vs direct intensification with insulin in the United Kingdom. Diabetes Obes Metab. 2019;21:1010‐1017.
Sherif S, Sumpio BE. Economic development and diabetes prevalence in MENA countries: Egypt and Saudi Arabia comparison. World J Diabetes. 2015;6:304‐311.
Bos M, Agyemang C. Prevalence and complications of diabetes mellitus in northern Africa, a systematic review. BMC Public Health. 2013;13:387.
Al‐Jawaldeh A, Hammerich A, Doggui R, Engesveen K, Lang K, McColl K. Implementation of WHO recommended policies and interventions on healthy diet in the countries of the eastern Mediterranean region: from policy to action. Nutrients. 2020;12:3700.
Kilic B, Kalaca S, Unal B, Phillimore P, Zaman S. Health policy analysis for prevention and control of cardiovascular diseases and diabetes mellitus in Turkey. Int J Public Health. 2015;60(Suppl 1):S47‐S53.
Kontsevaya A, Farrington J, Balcılar M, Ergüder T, Ministry of Health of Turkey by WHO Regional Office for Europe. Prevention and control of noncommunicable diseases in Turkey, 2018. Accessed December 2, 2021. https://www.euro.who.int/__data/assets/pdf_file/0009/387162/bizzcase-tur-eng.pdf.
World Health Organization. Multisectoral Action Plan of Turkey for Noncommunicable Diseases, 2017–2025. Ankara: Ministry of Health Publication Number; 2017. Accessed December 2, 2021. https://www.euro.who.int/__data/assets/pdf_file/0005/346694/BOH_ENG.pdf
Early Action in Diabetes. United Arab Emirates Policy Road‐Map. Accessed December 2, 2021. http://earlyactionberlin.com/Country-Posters/AZCountry-poster_UAE.pdf.
Ministry of Health & Prevention. United Arab Emirates. MoHAP launches Drive in initiative and Diabetes Prevention program. Accessed December 2, 2021. https://www.mohap.gov.ae/en/MediaCenter/News/Pages/2660.aspx
Ministry of Health, Saudi Arabia. MOH's efforts regarding raising people's awareness of diabetes. Accessed December 2, 2021. https://www.moh.gov.sa/en/Ministry/MediaCenter/Publications/Pages/Publications‐2013‐06‐09‐004.aspx
Alharbi N, Alotaibi M, de Lusignan S. An analysis of health policies designed to control and prevent diabetes in Saudi Arabia. Glob J Health Sci. 2016;8:233.
Busaidi NA, Shanmugam P, Manoharan D. Diabetes in the Middle East: government health care policies and strategies that address the growing diabetes prevalence in the Middle East. Curr Diab Rep. 2019;19:1‐10.
Policy ‐ Egypt National Multisectoral Action Plan for Prevention and Control of Noncommunicable Diseases (EgyptMAP‐NCD). Global database on the Implementation of Nutrition Action (GINA). Accessed July 8, 2021. https://extranet.who.int/nutrition/gina/en/node/25915
Fouad H, Latif NA, Ingram RA, Hammerich A. Scaling up prevention and control of noncommunicable diseases in the WHO eastern Mediterranean region. East Mediterr Health J. 2018;24:52‐62.
Al‐Rubeaan K. The impact of diabetes mellitus on health and economy of gulf cooperation council countries. Diabetes Management. 2014;4:381‐390.
Flood D, Seiglie JA, Dunn M, et al. The state of diabetes treatment coverage in 55 low‐income and middle‐income countries: a cross‐sectional study of nationally representative, individual‐level data in 680 102 adults. Lancet Healthy Longev. 2021;2:e340‐e351.
Kong JX, Zhu L, Wang HM, et al. Effectiveness of the chronic care model in type 2 diabetes Management in a Community Health Service Center in China: a group randomized experimental study. J Diabetes Res. 2019;2019:1‐12.
Maria JL, Anand TN, Dona B, Prinu J, Prabhakaran D, Jeemon P. Task‐sharing interventions for improving control of diabetes in low‐income and middle‐income countries: a systematic review and meta‐analysis. Lancet Glob Health. 2021;9:e170‐e180.
Correia JC, Meraj H, Teoh SH, et al. Telemedicine to deliver diabetes care in low‐ and middle‐income countries: a systematic review and meta‐analysis. Bull World Health Organ. 2021;99:209‐219B.
You have requested "on-the-fly" machine translation of selected content from our databases. This functionality is provided solely for your convenience and is in no way intended to replace human translation. Show full disclaimer
Neither ProQuest nor its licensors make any representations or warranties with respect to the translations. The translations are automatically generated "AS IS" and "AS AVAILABLE" and are not retained in our systems. PROQUEST AND ITS LICENSORS SPECIFICALLY DISCLAIM ANY AND ALL EXPRESS OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, ANY WARRANTIES FOR AVAILABILITY, ACCURACY, TIMELINESS, COMPLETENESS, NON-INFRINGMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. Your use of the translations is subject to all use restrictions contained in your Electronic Products License Agreement and by using the translation functionality you agree to forgo any and all claims against ProQuest or its licensors for your use of the translation functionality and any output derived there from. Hide full disclaimer
© 2022. This work is published under http://creativecommons.org/licenses/by/4.0/ (the "License"). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.
Abstract
摘要
2型糖尿病是中东及北非(MENA)和非洲(AFR)地区的一大公共卫生问题，心肾并发症(CRC)是过早发病和死亡的主要原因。心脏代谢危险因素的高发、患者和医生缺乏认识、基础设施不足以及经济限制导致MENA和AFR患者的CRC年龄显著提前。在这篇综述中，我们提出了MENA和AFR地区专家的共识和建议，强调了区域特有的挑战和潜在的区域控制中心管理解决方案。了解社会文化障碍的卫生专业人员可以通过简单的教育工具显著提高患者的意识并鼓励寻求健康的行为。增加医生在早期识别CRC和基于风险分层的个性化治疗方面的知识，同时更好地控制血糖，从而减轻治疗的惰性。必须对高危人群进行早期诊断，对心肾功能进行定期和系统的监测，制定特定区域的护理路径，及时转诊至专家，然后根据指南建议的治疗，使用新型抗糖尿病药物。遵循指南推荐的治疗可以使用钠葡萄糖共转运体2抑制剂和胰高血糖素样肽1受体激动剂，它们已被证明对心肾有好处，从而以经济高效的方式为治疗技术的鸿沟铺平道路。利用数字技术，如电子病历，可以辅助生成真实世界的数据，以填补对较新的抗糖尿病药物效果观察的空白。以患者为中心的方法、不同专科医生之间的协作护理以及政策制定者的参与是改善MENA和AFR地区患者结局和治疗质量的关键。
You have requested "on-the-fly" machine translation of selected content from our databases. This functionality is provided solely for your convenience and is in no way intended to replace human translation. Show full disclaimer
Neither ProQuest nor its licensors make any representations or warranties with respect to the translations. The translations are automatically generated "AS IS" and "AS AVAILABLE" and are not retained in our systems. PROQUEST AND ITS LICENSORS SPECIFICALLY DISCLAIM ANY AND ALL EXPRESS OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, ANY WARRANTIES FOR AVAILABILITY, ACCURACY, TIMELINESS, COMPLETENESS, NON-INFRINGMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. Your use of the translations is subject to all use restrictions contained in your Electronic Products License Agreement and by using the translation functionality you agree to forgo any and all claims against ProQuest or its licensors for your use of the translation functionality and any output derived there from. Hide full disclaimer
Details
; Sabbour, Hani 2
; Echtay, Akram 3 ; Rahmah, Abbas Mahdi 4 ; Alhozali, Amani Matook 5 ; Sabaan, Fahad Sulman 6 ; Haddad, Fares H. 7 ; Iraqi, Hinde 8 ; Elebrashy, Ibrahim 9 ; Assaad, Samir N. 10 ; Bayat, Zaheer 11 ; Osar Siva, Zeynep 12 ; Hassanein, Mohamed 13 1 Department of Endocrinology and Metabolism, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
2 Brown University Warren Alpert School of Medicine, Providence, Rhode Island, USA
3 School of Medicine, Lebanese University, Hadath, Lebanon
4 National Centre for Diabetes, College of Medicine, Al‐Mustansriya University, Baghdad, Iraq
5 Department of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
6 Security Forces Hospital, Riyadh, Saudi Arabia
7 Endocrine & Diabetes, Abdali Hospital/Endocrine & Diabetes Clinic, Amman, Jordan
8 Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
9 Faculty of Medicine, Cairo University, Cairo, Egypt
10 University of Alexandria, Alexandria, Egypt
11 Division of Endocrinology and Metabolism, Department of Internal Medicine, Helen Joseph Hospital, Rossmore, Johannesburg, South Africa
12 Turkish Diabetes Association, Turkey
13 Cardiff University, Cardiff, UK