Glycaemic control and microvascular complication among patients with youth onset diabetes in India using differing types of insulin and methods of glucose monitoring.

Diabetes Research and Clinical Practice, 2004 (Article in Press)

Abstract

We assessed Whether insulin types and monitoring methods were relevant to glycaemic control, microvascular complications as well as costs of management in 208 patients with youth onset diabetes in India. The type of insulin and monitoring method used made no difference to the glycaemic and complication status. Cost considerations support bovine insulin use along with urine glucose monitoring as an appropriate approach to diabetes self care in developing couniries.
2004 published by Elsevier Ireland 1.1d.

Keywords: Glucose monitoring; Types of insulin; Glycaernic control

Insulin requiring youth onset diabetes mellitus' in India includes patients with type I diabetes (38%), ketosis resistant type (32%) and fibrocalculous pancreatopathy (10%) [1,2]. The majority (60%) of them are poor and prefer urine glucose monitoring and bovine insulin. DCCT has shown the advantages of tight glycaenlic control (3], although the ellicacy of SHBG in reducing glycosylated Hb has been questioned [4].

We assessed die relative efficacy of different methods of management in 208 insulin requiring patients attending 'diabetes clinic of young' at AllMS, Delhi, during 1990-2002 (M:F, 87:121; mean age ± S.D., 27.3 ± 9.1 years; duration of follow up, 6.4 ± 2.9 years). Patients aged less than 8 years, or with recent infections or pregnancy were excluded. Thcre were four study groups as followed: group 1, patients on hurnan insulin and using SHBG; group 2, bovine insulin and SHBG; group 3, bovine insulin and urine glucose monitoring; group 4, any type of insulin with no monitoring.

The type Of insulin therapy and glucose monitoring method adoptcd were based on choice and ' affordability. Patients were followed up at two months intervals for insulin suppily and care. Benedict's method or commercially available strips were used to monitor urine glucose at least once a day. The knowledge on insulin injection, hypoglycaemia awareness and dietary precautions were assessed in a subset of 52 patients using a questionnaire [5]. The mean of the last three HbA I values (normal range, 6.5-8%) was used to assess glycaemic control status. A 24th urinary protein between 51 and 499mg indicated microproteinuria and the values >500 mg was regarded as macroproteinuria [6].

Data is shown as mean ± S.D. (Table 1). The mean duration of diabetes, BMI., HbA I values at the tirne of first presentation, their follow up period in the clinic, daily insulin dose requireiment and mean diabetes education score were not significantly different(ANOVA) among the Four groups. All the four groups showed improvement in the mean BMI and HbAl values after a mean follow up period of 6 years. However, the mean delta HbAI and frequency or microproteinuria or macroproteinuria were not different between groups. Number of subjects with HbAI>9.0% was not significantly different in groups 1, 2 and 3. there was an inverse relation between final HbAI values and the diabetes knowledge score (r=-0.146, p=0.21) The monthly expenditure on the management of diabetes by each patient was Rs.1440($ 30.6), 990 ($21), 360($7.6) in groups 1,2 and 3 respectively. the cost of SHBG was 32 fold higher than urine glucose monitoring.

There is paucity of information from developing countries regarding the efficacy of different types of insulin and monitoring methods based on long term glycamic control and complications like nephropathy. Despite the prohibitive cost of the therapy, poor patient education and poor preservation of glucose monitoring strips the mean HbAI levels observed in the present study were comparable to that reported from diabetic clinics of developed countries [7-9]. In consideration of the relative cost of the different methods of management used, it can be concluded that urine glucose monitoring and bovine insulin therapy may be appropriate for many patients with type I diabetes mellitus in India.

Table 1
Clinical characteristics of the study groups using different methods of treatment and monitoring

Parameters	Human insulin and blood glucose monitoring	Bovine insulin and blood glucose monitoring	Bovine insulin and urine glucose monitoring	No self monitoring	P-value
	(group 1)	(group 2)	(group 3)	(group 4)
N	46	65	60	37
Age (year)	23.3± 9.7	29.7 ± 9,4	28.9 ± SA	25.6 ± 7.8	group 1< group 2 and group 3
Duration of diabetes (year)	10.6 ± 74 (46)	12.9 ± 6.6 (65)	11.7 ± 5.6 (60)	9.9 ± 5.8	N S
Duration of follow-up (year)	6.6 ± 2.8 (37)	5.5 ± 2.8 (46)	6.7 ± 29 (65)	6.5 ± 2.9 (60)	NS
Diabetes education score	31.8± 2.6 (11)	31.2 ± 2.9 (31)	29.1± 3.8 (3.1)	32.7 ± 3.2(4)	NS
BMI, basal (kg/m2)	I9.3 ± 3.8 (44)	19.0 ± 4.2 (64)	18.7 ± 1.6 (55)	18.9 ± 4.6	NS
BMI, post follow-up (kg/m2)	20.6± 4.7 (41)	20.6 ± 3.9 (60)	20.0 ± 3.4 (50)	20.9 ± 4.0(34)	NS
Daily insulin dose used (IU)	33.8 ± 12.8 (36)	36.9 ± 13.4 (53)	39.8 ± 13.6 (46)	31.8 ± 13.4(34)	NS
HbAl basal (%)	12.1±12.8 (45)	12.5±3.0 (64)	12.8±3.2 (58)	13.8 ± 3.2	NS
HbAl post follow-up	10.6 2.3 (45)	11.2 ± 2.1 (63)	12.0 ± 2.9 (55)	12.04 ± 2.8(37)	group I vs group 3 and group 4
Delta HbA I	1.5±3.1 (47)	1.31±3(62)	0. 84±4(54)	1.7 ± 2.9 (37)	NS
Subjects with HbAl <9%	9/45 (20%)	11/63 (17.5%)	9/55 (16.5%)	5/37(13.5%)	NS
Microproteinuria	22.31 (71.0%)	34/54(63.0%)	21/38 (55.3%)	22/30(73.3%)	NS
Macroproteinuria	9.7(31)	13.0 (54)	23.7 (38)	(30)
Insulin cost per month in Rs.	630(A)	180(3.8)	ISO(3.8)
(USS)
Monitoring cost per month m	660(14.0)	660(14.0)	30 (0~6)
Rs. (USS)
Net cost per month in diabetes	1440 (3 0. 6)	990 (21.0)	360 (7.6)
management in Rs- (USS)
Data is shown as mean ± S.D.

© 2000 Elsevier Science Ireland Ltd. All rights reserved. With permission from Elsevier Science Ireland Ltd.