Introduction: Considering the global burden of diabetes and lack of specialist in diabetology in our subsaharian area, general practitioners (GPs) play a major role as first referent for care of diabetic people. The aim of this work was to describe knowledge, attitudes and practices of GPs related to management of type 2 diabetes. Patients and Methods: It was about a transversal and descriptive survey held between July 14, 2015 and November 1st, 2015 in the medical districts and public corporations of health of Dakar in Senegal. Results: The population of study was made of 107 males and 40 females GPs. The majority (82.8%) was graduated since less than five years. Hygienic and dietetic measures (HDM) were known and commonly recommended by 77.60% of GPs in their daily practice. The caloric intakes were known by 21.1%. The 30 min of physical activity per day three times in the week was advised by 91.20%. Monotherapy with metformine associated with HDM was prescribed by 76.90%. Bitherapy with metformine and sulfonylureas associated to HDM w ere prescribed by 39.50%. Concerning insulin therapy, mixed insulin twice daily associated with rapid insulin before lunch was prescribed by 49.7%. Use of rapid acting insulin with three injections before each meal was prescribed by 36.10%. Treatment of the other cardiovascular risk factors was addressed by 97.30%. Smoking cessation was advised by 37.40%. Use of sweetened drink and intravenous glucose w ere most adopted in case of hypoglycemia, and use of glucagon was adopted by 23.10%. To improve the diabetic retinopathy 61.2% of GPs recommended tight control of other cardiovascular risk factors. Rigorous glycemic control and regular physical activity were recommended for painful neuropathy beside analgesics. Smoking cessation was also recommended by 61.90% for that. Against obstructive arterial disease of the lower extremities, tight control of blood pressure was recommended by 69.40% Conclusion: It comes out from these results the need for reinforcing post graduate trainings on diabetes for our GPs. Moreover, there’s an urgent need to elaborate and disseminate adapted guidelines and recommendations for improving efficient and standardized strategies for day to day management of type 2 diabetic people in our country.
The dramatic increase in diabetes has occurred in all countries, and in rural as well as urban areas. According to IDF projections [
The epidemiological studies conducted in Africa show that the diagnosis of diabetes is often ignored (2 to 3 cases not diagnosed for each known case). This situation had been pointed out since first publications on diabetes in Africa [
It was an observational survey, transversal and descriptive nearby GPs of the medical districts and public establishments of health of the area of Dakar. After having presented the aims of the study to the persons in charge of structures in order to obtain their authorization of investigation, a questionnaire was self- managed with each GP. The investigation was constituted by a questionnaire form including questions with multiple choices. The questionnaire consisted of 2 parts, a first part on the socio-professional characteristics of the GPs (sex, seniority, place of exercise, previous training on diabetes) and a second part related to knowledges, attitudes and practices in managing of hyperglycemia, degenerative complications as well as the associated cardiovascular risk factors.
The seizure and the data analysis were carried with the software EPI Info version 3.3.2. This software allowed to calculate the frequencies, the means and the standard deviations.
On 170 questionnaires delivered, 152 had been recovered. Only 147 questionnaires were exploitable. The population of study consisted of 107 men (72.80%) and 40 women (27.20%). According to their seniority of exercise, 82.8% were graduated since less than 5 years. Eighty GPs (54.4%) had received a continuous medical training on diabetes.
The main categories of antidiabetic medicines were known, however there were confusions between molecules, their side-effects and their counter-indications. Metformin was regarded as sulfonylurea by 28.60% of respondents. Respectively 20 (13.6%), 16 (10.8%) and 14 (9.5%) GPs considered Glibenclamide, Gliclazide and Glipizide like biguanides. Only 1 GP had recognized Glipizide as part of the sulfonylureas. Hypoglycemia was regarded as side-effect of the biguanides by 44.90% of GPs and for 35.5% of GPs, the sulfonylureas were providers of digestive disorders.
| Number | Percentage | |
|---|---|---|
| Classes of non insulinic drugs | ||
| Biguanides | 142 | 96.6% |
| Sulfonylureas | 146 | 99.3% |
| Incretin mimetics | 7 | 7.76% |
| Alpha-glucosidase Inhibitors | 96 | 65.3% |
| Glinides | 118 | 80.30% |
| Main side effect of biguanides | ||
| Metformin associated lactic acidosis | 66 | 44.9% |
| Main side effect of sulfonylureas | ||
| Hypoglycemia | 140 | 95.2% |
| Contraindications of sulfonylureas | ||
| Pregnancy | 91 | 61.90% |
| Liver failure | 81 | 55.1% |
| Contraindications of biguanides | ||
| Kidney failure | 89 | 60.5% |
knowledge of the non insulinic drugs.
One hundred fourteen GPs (77.6%) recommended the HDM during all treatment long. Seventy-five (51.0%) found that HDM could be enough to normalize glycaemia for a long time, and 58 GPs (39.5%) considered it as first line treatment.
For initial monotherapy prescription, 34.7% of GPs recommended to start metformin after failure of HDM and 76.9% considered the possibility to start Metformin at diagnosis at the same time with HDM. Use of sulphonylureas as possible monotherapy after failure of HDM was suggested by 11.6% of GPs and while for 19.0% of them, it was suggested as first line monotherapy at diagnosis at the same time with HDM. For 39.5% of GPs, the most recommended bitherapy was association of metformin plus suphonylureas.
Insulin was recommended when failure of non insulinic therapeutics was proven (87.80%) and in case of severe intercurrent infections (76.90%). Fifty-six doctors (38.10%) prescribed insulin when HbA1c was higher or equal to 9% and 55 among them (37.4%) prescribed it when the fasting blood glucose was higher than 3 g/L.
After failure of oral hypoglycemic agent, premixed insulin with 2/3 of total dose administrated in the morning and 1/3 in the evening associated with a fast acting insulin before lunch, was adopted by 49.7% of GPs.
For 53 GPs (36.10%), the regimen of insulin therapy suggested was rapid acting insulin three time per day, one injection before each meal then.
- Diabetic retinopathy
One hundred thirty (88.40%) and 98 (66.70%) GPs had respectively recognized the maintenance of optimal glycemic balance and the maintenance of a stable blood pressure balance as factors to prevent diabetic retinopathy. Thirty- six doctors (24.50%) were aware of possibility of photocoagulation with laser. One hundred thirty-five (91.80%) had recognized that fundus examination of eye as soon as type 2 diabetes is diagnosed and then each year, as well the most optimal balance of glycaemia could allow an early tracking and the prevention of the diabetic retinopathy. Ninety GPs (61.20%) had considered that good control of cardiovascular risk factors could also allow a prevention of diabetic retinopathy retinopathy.
- Diabetic neuropathy
One hundred eight GPs (73.50%) had adopted the antalgic treatment in case of painful neuropathy. Only 47 (32.00%) and 27 (18.40%) GPs respectively adopted the treatment by nerve sedatives and insulin therapy in case of painful peripheral neuropathy. For the prevention of neuropathy, 138 (93.90%) and 113 (76.90%) had recognized respectively that rigorous glycemic control and regular physical activity could allow a prevention of diabetic neuropathy. Smoking cessation also was recommended by 91 (61.90%) GPs for this last objective.
- Diabetic kidney disease
Concerning the measures adopted in the event of nephropathy, the maintenance of an optimal glycemic balance and the maintenance of a perfect blood pressure balance were recognized respectively by 135 (91.80%) and 102 (69.40%) GPs. For the maintenance of an optimal blood pressure control, the use of Angiotensine converting enzyme inhibitors (ACE inhibitors) was more frequently adopted (49.00% of GPs) than angiotensin receptor blockers (ARBs) (34.70% of GPs).
One hundred thirty-three GPs (90.50%) and 123 (83.70%) recognized respectively that the strict control of glycaemia and blood pressure could help to prevent diabetic nephropathy. The reduction of food protein intake ration as a way to prevent diabetic nephropathy, was recommended by 44 (13.60%) GPs.
-Peripheral artery disease
For the drugs used in case of obliterating arteriopathy of the lower limb, antiplatelet agents were mostly prescribed (81.60% of GPs) followed by arterial vasodilators (52.40% of GPs) and statins (46.90% of GPs). Obtaining a good glycemic control and the correction of a dyslipidemia were recommended by respectively 92.50%, and 81.60% of GPs for better management of peripheral artery disease. Tight control of glycaemia and blood pressure was also recommended by 69.40% of GPs.
- The diabetic foot
One hundred twenty-nine (87.80%) GPs and 122 (83.00%) respectively adopted optimized insulin therapy and antibiotic therapy by general route. Prevention with tetanus vaccine was recommended by 80.30% of GPs. For the prevention of the diabetic foot, the daily hygiene of feet and the adequate foot wearing were applied by respectively 140 (95.20%) and 139 (94.60%) of GPs. The control of glycemic balance was also recognized by 136 (92.50%) GPs.
Other preventive measures had been recommended by 2.7% of GPs (self-inspection of feet, avoiding the exposure to sources of heat, never tearing off a scale, avoiding foot lesions).
- Hypertension
In first intention, 98 GPs (66.70%) adopted the treatment by ACE inhibitors of the and 18 GPs (12.20%) proposed associations of antihypertensive drugs. In second intention, 49 GPs (33.30%) proposed the use of ARBs.
- Dyslipidemia
The majority of GPs (86.40%) recommended statins and 85.70% of them indicated diet against dyslipidemia. The maintenance of good glycemic balance was advocated by 69 GPs (46.9%).
- Obesity
One hundred thirty-six GPs (92.50%) and 101 (68.70%) respectively advised regular physical-activity and hypocaloric diet for their obese diabetic patients. Use of hypolipidemic drugs was advised that by 44 GPs (29.90%) for this situation of obesity
- Smoking
One Hundred thirty GPs (89.10%) advised immediate smoking cessation and dedicated tobaccologic consultation was advised by 55 (37.40%) GPs.
Epidemiological studies made in our African areas emphasize on the significant role of the GPs in the global strategy of managing type 2 diabetic patients because of lake of medical doctors in general, and diabetologist in particular [
The place of HDM in type 2 diabetes management is overall well-known by our GPs as in previous similar study in Senegal [
The majority of GPs prescribed insulin in the event of proven failure of oral therapeutic (87.80%) and severe intercurrent infections (76.90%).
For all type 2 diabetic people, a comprehensive approach with multiple facets must be adopted to reduce the cardiovascular risk. Methods for vascular protection include lifestyle modification (food mode, weight loss, rise of the physical activity, weaning of the tobacco) and pharmacological treatments (antiplatelet agents, statins, ACE inhibitors, ARBs, control of glycaemia and blood pressure) [
The broad outlines for management of degenerative complications were known. However, there was some mix-up like recommendation by 23.10% of GPs for the use of glucagon in the event of hypoglycemia occurring in type 2 diabetes without consideration of the etiology. This fact, as example of misunderstanding among others underline the urgent need for implementation of continuous medical education programs whose benefit has been demonstrated before elsewhere [
Leye, A., Ndiaye, N., Diack, N.D., Ndour, M.A., Fall, B.C., Leye, Y.M. and Mane, P.O. (2017) Knowledge, Attitudes and Practices Survey in Management of Type 2 Diabetes by General Practitioners in Dakar. Journal of Diabetes Mellitus, 7, 294-301. https://doi.org/10.4236/jdm.2017.74024