Across the world, the burden of diabetes continues to grow year by year. Today, diabetes affects around 425 million adults, a number expected to rise to an estimated 629 million (1 in 10 adults) by 2045.
Asia bears a significant burden, with about 60% of the world’s diabetics living in this continent. Among diabetic patients, 90% of them have type 2 diabetes (T2D) – the preventable type of diabetes, with T2D rates having quadrupled worldwide since 1980. Nearer to home, T2D rates have been consistently on the rise among adults in Malaysia in the past 20 years – from 8.3% in 1996 to 14.9% in 2006, to 20.8% in 2011 and 22.5% in 2015.
In Malaysia, it was previously projected that 1 in 5 Malaysian adults would have diabetes by 2020. What is worrying is that this rate was already reached as early as 2014, underlining the seriousness of diabetes prevalence in Malaysia. Although 3.5 million Malaysian adults have diabetes, as many as 53% of diabetic adults are undiagnosed and do not know they have the disease. Meanwhile, the numbers continue to rise, with 4.5 million diabetics projected in Malaysia by 2020.
Even as poor diagnosis rates are causing concern, diabetic patients who are already diagnosed also show poor outcomes. Despite 99.5% of diagnosed diabetic patients being treated with medication, as many as 8 out of 10 patients still have uncontrolled diabetes. If we look at global standards like HbA1c levels, which are also used in Malaysia during the care of diabetics, the picture looks bleak. HbA1c levels (which offer a broader picture of blood glucose levels over 2 to 3 months) should be 6.5% or lower in a person with well-controlled diabetes. However, DISCOVER, a recent real world evidence study, has shown that the average HbA1c level in Malaysia is 9.0%, higher than the world average of 8.4% for unmanaged diabetes. DISCOVER – a global, prospective, observational study of patients with T2D who are starting second-line glucose-lowering therapy, saw the participation of 334 patients in Malaysia, who were mainly urban residents (92.9%) and mostly treated by primary care physicians (64.3%). The 9.0% HbA1c level observed surpasses the 8.1% recorded in 2012 by the National Diabetes Registry.
The DISCOVER study, which was initiated to plug knowledge gaps on diabetes treatments and outcomes globally, especially in terms of newer classes of glucose-lowering drugs, gathers real world evidence (RWE) on the management of diabetes. The study aims to improve understanding of T2D management and its efficacy, reduce the risk of complications from diabetes and improve quality of life for patients. RWE data, drawn from sources such as pragmatic trials, patient registries, claims databases, electronic medical records and surveys of healthcare professionals and patients, can complement existing data from controlled clinical trials.
“The contribution from a study like DISCOVER that collects real-world evidence is invaluable. In typical controlled clinical studies, the key aim is learning more about how a certain medication works in the human body, so we tend to control for variables in human biology. With a study that focuses on RWE, we can observe how people use a certain medication in an actual everyday clinical setting, which is often influenced by highly localised issues – anything from the medicine supply chain to local cultural attitudes and everything in between. From these insights, we can work more effectively to change patient behaviour,” said Dr Radhakrishna Sothiratnam, National Coordinating Investigator for Malaysia, DISCOVER study. “Through RWE studies, information such as disease burden and unmet medical needs, use of a treatment in representative patient populations and treatment pathways in everyday clinical practice, can be collected,” he said.
Significant lag in treatment of diabetics found
Another key finding of the DISCOVER study is that T2D patients in Malaysia on average experience a 3.3-year lag in treatment, whereby they continue taking first-line medication (medication prescribed when they were first diagnosed) for as long as 3.3 years despite the medication being ineffective in managing their diabetes, before commencing on second-line treatment (the next option if first-line does not work). Accessibility was found to be a key factor in prescribing treatment, with a sulphonylurea (a widely available type of drug accessible to 98.8% of patients) added to metformin (the commonly used first-line medication for diabetics) as a second-line treatment.
Often, diabetic patients, especially those on first-line treatment, do not regularly monitor their HbA1c levels, mistakenly believing that their glucose level is in control, as they are taking the prescribed medication. This lack of monitoring leads to uncontrolled diabetes and treatment lag, when the patient and doctor continue to rely on ineffective treatment. As diabetes is a progressive disease that is irreversible and gets more serious over time, treatment lag will allow the disease to worsen and for complications to develop, a situation that can be prevented with better monitoring. Indeed, the DISCOVER study recorded evidence that diabetic patients in Malaysia had a relatively high rate of potential complications. A quarter of patients had damage to small blood vessels (26.3%) and 1 in 10 had damage to larger blood vessels (9.9%), a relatively high rate, as they were only commencing second-line treatment, although the lag would likely have contributed to this rate.
Significant lag in treatment of diabetics found
Another key finding of the DISCOVER study is that T2D patients in Malaysia on average experience a 3.3-year lag in treatment, whereby they continue taking first-line medication (medication prescribed when they were first diagnosed) for as long as 3.3 years despite the medication being ineffective in managing their diabetes, before commencing on second-line treatment (the next option if first-line does not work). Accessibility was found to be a key factor in prescribing treatment, with a sulphonylurea (a widely available type of drug accessible to 98.8% of patients) added to metformin (the commonly used first-line medication for diabetics) as a second-line treatment.
At the same time, with cardiovascular diseases being a health concern among so many Malaysians – for example, ischaemic heart disease was the principal cause of death in 2016, at 13.2% of all deaths, findings from studies that show how specific treatments for diabetes can reduce cardiovascular risks are of importance to Malaysian patients.
The impact of innovative new treatments for diabetes
“Diabetes is a serious risk factor, leading to deaths and hospitalisation. As many as 60% of diabetics are found to be dying from cardiovascular diseases. They have up to a four-time higher risk of suffering from heart diseases such as heart failure, heart attack or peripheral vascular disease, while the risk of suffering a stroke is twice as high. Diabetics also tend to develop coronary artery disease at a younger age and are more prone to suffering repeated heart attacks. Many patients also may not realise that heart failure has been found to manifest earlier than other types of diabetes-related heart disease such as heart attacks and stroke,” said Dato’ Dr Tamil Selvan Muthusamy, Consultant Cardiologist at Cardiac Vascular Sentral Kuala Lumpur (CVSKL).
With diabetes being a risk factor in so many diseases, it is important to manage these risks effectively, such as by choosing the right diabetes medication. One key recent study that looks at how treatment for diabetes can reduce the risk of other diseases where diabetes is a risk factor is CVD-REAL 2, which investigated the positive cardiovascular effects associated with certain drugs for diabetics. CVD-REAL 2, which is also a RWE study, was conducted among more than 400,000 T2D patients in 6 countries across 3 regions (Singapore, Japan, South Korea, Australia, Canada and Israel) 14.
The study examined the impact of newer classes of glucose-lowering medicines, in particular, the effect of sodium-glucose co-transporter-2 inhibitors (SGLT2i) on patients who are newly being prescribed second-line diabetes treatment. SGLT2 inhibitors, which work by preventing the kidneys from reabsorbing glucose back into the blood helps lower blood glucose levels, by causing excess glucose to be removed from the body via urine.
In this study, a majority of participants (74%) did not have a history of cardiovascular disease.
From the study, it was observed that there was a significant risk reduction in the group taking SGLT2i medication compared to other oral glucose-lowering medicines, with 36% lower risk of hospitalisation due to heart failure, 32% lower risk of stroke, 19% lower risk of heart attack and 49% lower risk of death from cardiovascular causes overall. The results suggested that starting diabetics on SGLT2i medication as soon as their first-line treatment requires supplementation or replacement can potentially prevent cardiovascular complications from diabetes.
“With the latest research suggesting positive effects of new diabetes drugs on diseases whereby diabetes is a strong risk factor, it is important to consider these benefits and match them with the patient’s individual risks when choosing a drug to treat their diabetes. It is good to see the research findings that SGLT2i drugs are beneficial across ethnic and racial groups, geographic regions, and even across existing levels of cardiovascular risk. This is especially good for patients starting on second-line treatment already having relatively high levels of complications, due to treatment lag and poor disease control. Also, other demographic factors like higher incidences of stroke among Asian patients mean SGLT2i is a welcome option for Asian diabetics. However, more needs to be done to increase awareness on the benefits of SGLT2i drugs for treating T2D patients, and to improve access to SGLT2i for T2D patients in Malaysia,” said Dr Hew Fen Lee, Consultant Endocrinologist, Ramsay Sime Darby Medical Centre and Puchong Medical Centre.
A call for early awareness
Patient X is among the millions of diabetics in Malaysia. Like many Malaysians, he had no idea that he was diabetic until he went for a medical check-up.
“My condition could perhaps be attributed my lifestyle and my being overweight. I do feel lucky that my condition was detected early and managed well by my doctor. Imagine my shock when I was diagnosed with diabetes, with my blood sugar (HbA1c level) at a score of 11! Today, I want to encourage all Malaysians to take charge of their health and have better awareness of health problems they might have and their overall health risks. Having a disease like diabetes can really impact your quality of life,” said Patient X.
“When you’re at an early stage of diabetes, make sure to keep track of your blood glucose and HbA1c levels, besides taking your medicines as prescribed by the doctor, and manage your lifestyle as advised. It is commonly said that prevention is better than cure, but if it is too late to prevent diabetes, make sure to prevent complications by being the best patient you can, with the best disease control methods and the right medicines,” Patient X concluded.
This article was contributed by AstraZeneca Sdn Bhd.
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