Navigating the Complexities of Diabetes Management

Diabetes has always been of interest to me, and my interest has deepened after seeing the devastating impact it has on my patient who needed a toe amputation due to complications from his type 2 diabetes. The experience made me appreciate the consequences of poorly controlled diabetes and highlighted the urgent need for early intervention, consistent follow-up, and patient education about the disease. 

I recently came across the American College of Physicians (ACP) guideline for the use of newer pharmacologic agents for type 2 diabetes in Annals of Internal Medicine. These guidelines (1) led me to reflect on the growing demand these medications are likely to have in the region where I am from, the Middle East and North Africa (MENA). In 2019, the MENA region recorded the highest global prevalence of diabetes at 12.2% (2, 3). Unfortunately, the increasing prevalence is not only confined to MENA; it is a global concern. As a result, I am making more of an effort to keep up with advances in diabetes management. Optimization of blood sugar is important for many patients whom internal medicine physicians care for. The ACP guideline clearly describes the benefits of the newer pharmacologic agents for type 2 diabetes (1). In summary, ACP emphasizes the need to include sodium–glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) agonists in the treatment of type 2 diabetes with poor glycemic control on metformin. In addition, it recommends adding an SGLT-2 inhibitor or a GLP-1 agonist to metformin and lifestyle modifications in adults with inadequate glycemic control (1)—specifically, using an SGLT-2 inhibitor to reduce the risk for all-cause mortality, major adverse cardiovascular events, progression of chronic kidney disease, and hospitalization for congestive heart failure. A GLP-1 agonist is recommended to reduce the risk for all-cause mortality, major adverse cardiovascular events, and stroke. ACP advises against the addition of dipeptidyl peptidase-4 inhibitors to metformin because of their associated increased risk for congestive heart failure and major adverse cardiovascular events compared with the addition of SGLT-2 inhibitors or GLP-1 agonists. 

The economic implications of the newer medications are substantial. Ironically, insulin became available at a low cost immediately after its discovery in 1921 by Dr. Frederick Banting and Charles Best (a medical student at that time) (4). Banting said, “Insulin does not belong to me; it belongs to the world.” Yet today, newer diabetes agents enter the market at prices that are prohibitive. When discharging a patient after the management of a diabetic foot infection, I faced the issue of selecting which diabetes medications to prescribe. The ACP guideline helped me develop a management plan before referring the patient to an endocrinologist. I ensured that they understood the rationale behind this change in the medication list. This case reinforced how clinical guidelines can inform individualized care plans and support decision making, especially in resource-limited settings. In addition to medications, I recommend that patients regularly check their blood sugar levels before and after sugary meals. Many are surprised to see how their glucose levels rise after certain foods. This immediate feedback can be a powerful motivator for behavior change. 

References 

1. Qaseem A, Obley AJ, Shamliyan T, et al; Clinical Guidelines Committee of the American College of Physicians. Newer pharmacologic treatments in adults with type 2 diabetes: a clinical guideline from the American College of Physicians. Ann Intern Med. 2024;177:658-666. [PMID: 38639546] doi:10.7326/M23-2788
2. Moradinazar M, Babakhani M, Rostami R, et al. Epidemiological status of type 2 diabetes mellitus in the Middle East and North Africa, 1990-2019. East Mediterr Health J. 2022;28:478-488. [PMID: 35959663] doi:10.26719/emhj.22.050
3. El-Kebbi IM, Bidikian NH, Hneiny L, et al. Epidemiology of type 2 diabetes in the Middle East and North Africa: challenges and call for action. World J Diabetes. 2021;12:1401-1425. [PMID: 34630897] doi:10.4239/wjd.v12.i9.1401
4. Banting FG, Best CH. The internal secretion of the pancreas. J Lab Clin Med. 1922;7:251-266

Yasmine Elsherif, MD

Yasmine Elsherif, MD, is a dedicated medical professional who studied medicine at Tbilisi State Medical University in Georgia. She is currently an internal medicine resident in the United Arab Emirates, with a keen interest in oncology and a passion for integrating hospice care into the Middle Eastern health care system. Outside of her professional pursuits, Yasmine enjoys staying active through hiking and jogging during her free time. Her commitment to both her patients and personal growth reflects her drive to make a meaningful impact in medicine and beyond.