1. Vol. 1, No. 1
Diabetes Cases Rapidly
Rising in the Middle East
andWorldwide
Diabetes is on the rise In the Middle East and North
Africa, where there are 34.6 million people with dia-
betes, or about 1 in 10 adults affected, according to the
International Diabetes Federation (IDF).1
That number is
projected to increase to 67.9 million by 2035.
Saudi Arabia has the highest prevalence or percentage
of adults (20 to 79 years) with diabetes in the region at
23.87%, followed by Kuwait (23.09%); Qatar (22.87%);
Bahrain (21.84%); and United Arab Emirates (18.98%).
The five countries in the region with the largest number
of adults with diabetes are Egypt (7.5 million); Pakistan
(6.7 million); Iran (4.4 million); Saudi Arabia (3.6 mil-
lion); and Algeria (1.6 million).
In the Middle East and North Africa, diabetes caused
367,700 deaths in 2013, with half of those occurring in
individuals under age 60. In the region, more women
(221,900) died from diabetes in 2013 compared with
men (145,800).Additionally, IDF estimates that 6.7% of
the region’s population has Impaired Glucose Tolerance
(IGT), a strong risk factor for developing type 2 diabetes.
Worldwide, there were 375 million adults with diabetes in
2013, a number that is projected to grow to 584 million
by 2035.
Benefits of Using
Rapid-Acting Analog
Insulin to Control HbA1c
Using a fast-acting analog insulin at mealtimes, such as
NovoRapid, is generally a way of life for patients with
type 1 diabetes. Increasingly, endocrinologists are also
prescribing fast-acting insulin to manage type 2 diabetes
patients whose glycosylated hemoglobin (HbA1c) levels
cannot be adequately controlled with long-acting analog
basal insulin alone.
By adding a rapid-acting analog insulin such as Novo-
Rapid at mealtimes,“We know we can get many patients
closer to their HbA1c goal,” says David L. Joffe, BSPharm,
CDE, editor-in-chief of diabetesincontrol.com. For pa-
tients whose blood sugar isn’t adequately managed, adding
a rapid-acting analog insulin can provide greater control
by “mimicking what the body does, which is produce
more insulin at mealtimes.”
If patients with type 2 diabetes need to take 50 to 60
units daily of a long-acting basal insulin such as Levemir
to control their blood glucose level,“It’s probably time to
add a rapid-acting insulin,” such as NovoRapid, says Mr.
Joffe, who is also clinical associate professor, University of
Florida College of Pharmacy, St Petersburg, FL, USA. He
notes that by this stage, these patients have likely become
insulin-resistant.
The tricky part is calculating the appropriate mealtime
insulin dose based on the amount of carbohydrates the
patient eats at each meal.There is no one formula that
works for all patients, as individual patient responses vary
widely.As a general rule, Mr. Joffe recommends one unit
of insulin for every 10 grams of carbohydrates consumed
– an amount that can be adjusted later based on patient
response and eating habits as they evolve over time.
Patients also need to monitor their blood glucose levels
regularly.
Many endocrinologists in the United States and the Mid-
dle East choose a step-wise, gradual approach based on
studies showing that this helps maintain control of HbA1c
levels while reducing risk of hypoglycemia.2
David
D’Alessio, MD, chief of the Division of Endocrinology,
Metabolism and Nutrition, Duke University Department
of Medicine, Durham, NC, USA, will typically start a
type 2 diabetes patient on oral medication, then add a
long-acting analog basal insulin later if the patient’s blood
glucose level isn’t controlled. He will generally continue
this regimen for a year or two before adding one or two
injections daily of a short-acting insulin or rapid-acting
analog insulin, such as NovoRapid.“Eventually, many of
these patients will need fast-acting insulin at every meal,”
D’Alessio notes, because of disease progression.
“The fast-acting insulins, such as NovoRapid, provide
more flexibility for patients who are active and who tend
to eat at different times of the day,” D’Alessio explains.
Saher Safarini, MD, consultant endocrinologist and head
of the Diabetes and Endocrine Center, Dallah Hospi-
tal, Riyadh, Saudi Arabia, also uses a stepwise approach
in managing patients with type 2 diabetes. He starts
with oral medications, then adds a long-acting basal
insulin, such as Levemir, eventually adding NovoRapid
at mealtimes “if patients’ blood glucose level still isn’t
controlled.”
Novo Nordisk Best Practices in Diabetes Management:
Spotlight on Rapid-Acting Insulin Analogs
2. 2 | Novo Nordisk Best Practices in Diabetes Management: Spotlight on Rapid-Acting Insulin Analogs
Addressing Hypoglycemia
Risks and Adherence Challenges
NovoRapid is indicated to improve glycemic control in
adults and children with diabetes mellitus.3
It is also clinical-
ly proven to help patients reach their goal with low rates of
hypoglycemia.4
Still, one of the barriers to using fast-acting
insulin is concern about the risk of hypoglycemia.“Hy-
perglycemia will kill you slowly, but hypoglycemia will kill
you fast,” says Mr. Joffe.“Patients tend to blame the insulin
they took instead of what they ate” if this problem occurs,
he explains. Many patients will self-adjust their insulin dose
downward to avoid this risk, he adds.
“Getting patients to adhere to the prescribed treatment reg-
imen can be a challenge, especially if the patient has to take
a lot of injections,” says endocrinologist and internist Omar
Abdulaal, MD, chairman of the Diabetes Care Community
and director of the Internal Medicine Program, King Fahd
Military Medical Complex, Dhahran, Saudi Arabia.“We try
to overcome this by telling patients it is what we have to do
and through education.”
“Patients like NovoRapid because it’s available at our clinic
and it’s a very effective medication,” says Dr.Abdulaal.“Pa-
tients also like the pens because they are convenient and easy
to use.They can carry a pen with them and even use it in a
restaurant.” Dr.Abdulaal says that, often, patients who might
otherwise resist taking injections will agree to self-inject
multiple times daily because the pens are so much easier to
use and less painful than the older insulin syringes.
One key to improving patient adherence is making sure
patients agree upfront to what they are willing to do, Dr.
Abdulaal says. Getting the patient involved in discussing the
treatment plan early on is critical. “Sometimes we will tell
a patient,‘If you don’t like this regimen, tell us which one
works for you,’” he says. For example, some patients may
agree to self-administer injections at mealtimes, even if they
don’t agree to injections at other times.
Challenges in Managing
Diabetes in Pediatric Patients
Managing diabetes in children is a challenge for physicians
and parents worldwide.“It’s particularly hard in our culture,
where the average family has 6 to 8 children and everyone
eats from the same food tray.This makes it harder to count
food portions and carbohydrates the child is eating at each
meal,” says Bassam Bin-Abbas, MD, consultant of Endocri-
nology and Diabetes, King Faisal Specialist Hospital and Re-
search Center, Riyedh, Saudi Arabia.“It can be a challenge to
calculate the correct dosage when using fast-acting insulins.”
In managing the care of children with diabetes,“You are
changing the lifestyle of the whole family.You don’t want to
isolate the child by giving him a different dish separate from the
rest of the family,”Dr.Bin-Abbas explains,who advises families
to use a big serving tray on which each member has his or her
own individual dish.This avoids isolating the child while allow-
ing parents to more accurately count the child’s carbohydrates
and portions to determine the correct dosage of insulin.
The International Diabetes Federation estimates that there
are approximately 64,000 children (0 to 14 years) with type
1 diabetes in the Middle East and North Africa.“We are see-
ing a lot more onset of type 1 diabetes among children,” says
Dr. Bin-Abbas, who treats children up to age 14 in his clinic.
Dr. Bin-Abbas, who also serves as associate professor of Pe-
diatric Endocrinology at the College of Medicine,Al-Faisal
University, says he is also seeing an increase in the number
of neonatal diabetes cases occurring in infants as young as 6
months old.To reduce the risk of hypoglycemia, Dr. Bin-Ab-
bas waits until these children reach at least the age of 2 years
before starting a rapid-acting analog insulin therapy, such as
NovoRapid, at mealtimes. NovoRapid is approved for use
in children 2 years and older.“The insulin pens are very
convenient to use,” says Dr. Bin-Abbas, who adds that many
local hospitals prefer NovoRapid for the pediatric population
because the pens are smaller and easier for children to handle.
Extra Care Needed for Diabetes Patients
Who Fast During Ramadan
Type 1 diabetes patients who choose to fast during the holy
season of Ramadan are at higher risk of hypoglycemia; they
and their treating physicians need to be especially vigilant.
“Usually, patients
should not fast,” says
Saher Safarini, MD,
consultant endocrinol-
ogist and head of Di-
abetes and Endocrine
Center, Dallah Hospital,
Riyadh, Saudi Arabia.
“But for those who do,
we try to help them.
We tell them to take
the long-acting (analog
basal) insulin at sun-
set, plus one injection
of fast-acting insulin
before the first and
second meal.” Fasting
patients are also advised
to check their blood
glucose level at around
3 to 4 p.m., when they
are most at risk for hy-
poglycemia. Dr. Safari-
ni’s diabetes center has
a hotline patients can
call, and clinic staff per-
form special outreach
to patients during the
season to guide them.
Lower HbA1c Targets
Recommended for Children
with Type 1 Diabetes
The American Diabetes Associa-
tion (ADA) has lowered its target
recommendation for glycosylated
hemoglobin (HbA1c) levels for
children (patients younger than
19 years) with type 1 diabetes to
less than 7.5%.5
Previous targets
were as high as 8.5% for children
under 6; 8% for children 6 to 12;
and 7.5% for adolescents 13 to 18.
The ADA revised its guidelines
based on the latest scientific
evidence showing that prolonged
hyperglycemia can lead to early
development of serious com-
plications in children, including
cardiovascular and kidney disease.
The revised guidelines, issued in
June 2014, are also in accord with
those of the International Soci-
ety for Pediatric and Adolescent
Diabetes (ISPAD).
