Croatian guidelines for the pharmacotherapy of type 2 diabetes

INTRODUCTION: The Croatian Association for Diabetes and Metabolic Disorders of the Croatian Medical Association has issued in 2011 the first national guidelines for the nutrition, education, self-control, and pharmacotherapy of diabetes type 2. According to the increased number of available medicines and new evidence related to the effectiveness and safety of medicines already involved in the therapy there was a need for update of the existing guidelines for the pharmacotherapy of type 2 diabetes in the Republic of Croatia. PARTICIPANTS: as co-authors of the Guidelines there are listed all members of the Croatian Association for Diabetes and Metabolic Diseases, as well as other representatives of professional societies within the Croatian Medical Association, who have contributed with comments and suggestions to the development of the Guidelines. EVIDENCE: These guidelines are evidence-based, according to the GRADE system (eng. Grading of Recommendations, Assessment, Development and Evaluation), which describes the level of evidence and strength of recommendations. CONCLUSIONS: An individual patient approach based on physiological principles in blood glucose control is essential for diabetes' patients management. Glycemic targets and selection of the pharmacological agents should be tailored to the patient, taking into account the age, duration of disease, life expectancy, risk of hypoglyce- mia, comorbidities, developed vascular and other complications as well as other factors. Because of all this, is of national interest to have a practical, rational and applicable guidelines for the pharmacotherapy of type 2 diabetes.

[The diabetic foot. The Croatian model--national consensus (clinical recommendations for diagnosis, prevention and therapy)]. / Dijabeticko stopalo. Hrvatski model--nacionalno usuglaseno misljenje (klinicke preporuke za dijagnostiku, prevenciju i lijecenje).

Diabetic foot occurs due to the loss of protective sense and circulation disorder and a marked proneness to infections. Mechanical stress of bone growths frequently leads to ulcerations. The prevention and timely treatment of diabetic foot requires the participation of both patients and all health care levels. This consensus is given for the purpose of procedure standardization. Education is the basis of prevention and should be carried out with every patient suffering from diabetes mellitus and those with a sensory defect in particular. Appropriate footwear significantly contributes to prevention and treatment of ulcers. As regards the treatment, the necessity of surgical approach with a long term and often manifold antibiotic therapy should be pointed out. Infections are usually mixed. The deeper the ulceration, the more likely the infection with anaerobes and Gram-negative bacteria occurs in addition to Gram-positive ones which are normally present in surface lesions. Strict metabolic control is a precondition for successful treatment. In conclusion, diabetic foot is a major health problem which requires multidisciplinary approach with permanent patient education as its essential part, and a specific cooperation of all levels and different health care specialties.

Emotional adjustment and metabolic control in newly diagnosed diabetic persons.

Emotional reactions to diagnosis were examined in a random sample of newly detected diabetic patients (n = 71) and compared with the indicators of glycemic control in a one-year-follow-up period. The social and emotional factors subscale of the diabetes care profile was used to determine the subjectively experienced burden, negative feelings and positive coping abilities. The initial struggle against the disease indicated three characteristic emotional patterns. Feelings of being able to cope with the disease predominated in group 1 (n = 36), negative emotional reactions, but with the ability to cope were observed in group 2 (n = 17) and negative feelings combined with weak coping abilities in group 3 (n = 18). The long-term indicators of glycemic control were shown to be worst in group 3 and best in group 1. Subjective perception of the disease was not associated with sociodemographic variables, with the exception of perceived coping abilities which were better in more educated persons and those with more familial support.

Incidence of IDDM during 1988-1992 in Zagreb, Croatia.

The objective of this study was to determine the incidence of insulin-dependent diabetes mellitus (IDDM) in the population of Zagreb, Croatia, during 1988-1992. A centralized diabetes registry was the primary source of data, while secondary sources were used to assess ascertainment. A total of 282 new cases of IDDM were diagnosed in the study period, the primary and secondary sources identifying annually 93-100% of the cases. The annual incidence rate ranged from 5.6 per 100,000 to 6.6 per 100,000. Early fatality in persons older than 50 years was the major cause of underascertainment. The incidence peaked in the 10-14 years age group (12.4 per 100,000), and remained stable after age 24 years. Males had a significantly higher incidence in the 5-9 and 24-44 years age groups. In the 45-54 years age group, females had a significantly higher incidence. No seasonality was observed. Despite the war conditions in Croatia, the low overall IDDM incidence rates did not change significantly during the study period.

War-induced prolonged stress and metabolic control in type 2 diabetic patients.

Sound evidence that psychological stress may significantly worsen metabolic control in diabetic patients in lacking. The stressful effects of war on glycaemia control have not been assessed as yet. A randomly selected sample of displaced Type 2 diabetic persons (N = 44) was compared to a matched group of diabetic persons who had not been forced to leave their homes. The self-reported stress, depression level, fasting and post-prandial blood glucose, glycosylated haemoglobin and serum lipids were compared. The two groups were found to be significantly different in scores for self-reported stress and depression levels (P < 0.001). The proportion of subjects belonging to the category of clinically significant depression was larger in the group of displaced persons (P < 0.001), as well as the proportion of extreme scores for self-reported stress (P < 0.001). No significant differences between the groups were found for variables measuring metabolic control (P > 0.05), except for the serum triglycerides which were found to be significantly higher in the group of displaced persons (P < 0.01). This is assumed to be the result of differences in nutrition. The results do not demonstrate an association between prolonged stress and glycaemic control in Type 2 diabetic patients. The variability of data measuring stress and depression level in two extreme groups with respect to HbA1c values suggests that individual factors which determine the response to stressors need to be explored.

Effect of war-induced prolonged stress on cortisol of persons with type II diabetes mellitus.

The study was designed to assess the impact of protracted, war-induced stress on cortisol levels and glycemic control in persons with Type II diabetes mellitus. A randomly selected sample of 44 displaced Type II diabetic persons was compared with a group of diabetic persons matched for sex, age, weight, duration of diabetes, and type of treatment who had not been forced to leave their homes. The self-reported stress, depression level, serum cortisol, fasting blood glucose, and glycosylated hemoglobin were compared. The two groups were found to be significantly different in scores for self-reported stress and depression level. Passive coping patterns prevailed in the displaced group. The serum cortisol levels correlated positively with self-reported stress, negatively with active coping patterns, and were significantly higher in the displaced persons group. No significant differences were found between the group on the variables measuring glycemic control. The results indicate that prolonged stress need not worsen glycemic control in Type II diabetic patients.