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ORIGINAL ARTICLE
Year : 2021  |  Volume : 19  |  Issue : 4  |  Page : 242-247

Effectiveness of management of type 2 diabetes mellitus through telephone consultation during COVID-19 lockdown in Lagos Nigeria


1 Department of Family Medicine, Lagos State University Teaching Hospital (LASUTH), Ikeja, Nigeria
2 Department of Internal Medicine, Lagos State University Teaching Hospital (LASUTH), Ikeja, Nigeria

Date of Submission12-May-2021
Date of Decision02-Jul-2021
Date of Acceptance26-Aug-2021
Date of Web Publication07-Dec-2021

Correspondence Address:
Dr. Oluwajimi Olanrewaju Sodipo
Department of Family Medicine, LASUTH, Ikeja
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_55_21

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  Abstract 


Aim: The aim of the study was to explore the impact of the coronavirus disease 19 (COVID-19) lockdown on the clinical outcome of patients with Type 2 diabetes mellitus (DM) attending a primary care Diabetes Clinic in Lagos State, Nigeria, in terms of their compliance with medication intake, blood pressure (BP), and glycemic control and ability to modify medication through telephone consultation. Methodology: A retrospective review of the clinical characteristics of patients was carried out. Telephone calls were made to patients with Type 2 DM who attended the chronic medical disorder clinic of the Family Medicine Department, Lagos State University Teaching Hospital, Lagos, Nigeria. The information obtained included questions on demographic data, type of medications used, and medication compliance, use of self-monitoring devices for BP, and blood glucose levels. Data analysis was performed using SPSS program version 26. Results: A total of 178 patients were eligible. Most (87%) reported using their medication as prescribed, 74% of patients had self-monitoring of blood glucose (SMBG) during lockdown, though only 29% checked glucose level regularly and 54% practiced home monitoring of BP (HMBP). Medication was modified in 34% of patients by the doctor who called in. Biguanides and Sulfonylureas were the most prescribed oral antidiabetic medications, while Renin Angiotensin Aldosterone System (RAAS) blockers were the most prescribed antihypertensive class. The HMBP was associated with lower systolic BP (t-test 3.49, P = 0.0008). Conclusions: Type 2 diabetic patients managed through telephone during the COVID-19 lockdown reported good level of drug compliance, while improved practice of SMBG, and HMBP resulted in better level of control. The findings of this review suggest that the use of e-consultation can play a role in patient management of Type 2 diabetes even beyond the COVID-19 era including reaching patients in distant locations who are unable to come to the hospital. There is a need for further studies on e-medicine role on various aspects of medical care.

Keywords: Coronavirus disease 19, Nigeria, Telephone, Type 2 Diabetes Mellitus


How to cite this article:
Sodipo OO, Ibrahim A, Oluwatuyi OE, Oduniyi OA, Odunaye-Badmus S, Adeleye O. Effectiveness of management of type 2 diabetes mellitus through telephone consultation during COVID-19 lockdown in Lagos Nigeria. Curr Med Issues 2021;19:242-7

How to cite this URL:
Sodipo OO, Ibrahim A, Oluwatuyi OE, Oduniyi OA, Odunaye-Badmus S, Adeleye O. Effectiveness of management of type 2 diabetes mellitus through telephone consultation during COVID-19 lockdown in Lagos Nigeria. Curr Med Issues [serial online] 2021 [cited 2022 Jan 27];19:242-7. Available from: https://www.cmijournal.org/text.asp?2021/19/4/242/331832




  Introduction Top


The detection of coronavirus disease 19 (COVID-19) occurred in December 2019, in Wuhan, China, with the causative pathogen being severe acute respiratory syndrome coronavirus 2 (SARS COV 2).[1],[2] It is described as a pneumonia where the clinical symptoms include fever, fatigue, dry cough, and dyspnea.[3] The COVID-19 is an ongoing pandemic and has been declared as a public health emergency of International concern.[4],[5]

Many countries implemented lockdown to contain COVID-19 and this affected the routine life and health of patients with chronic diseases such as diabetes, mental health, and hypertension. These patients who usually require regular follow-up for diagnostic tests and physicians visits for their routine checkup could not access them.[6],[7]

A lockdown was imposed in Nigeria in the month of March 2020, following an increase in the number of COVID-19 cases, which prevented patients from coming for regular clinic appointments, there was also concern from patients themselves about exposure to COVID-19 when they came to the hospital. Similarly, among health-care workers, the acute shortage of personal protective equipment and shortage of wide spread testing for COVID-19 patients also impacted their availability to provide care. It is well recognized that older age, diabetes mellitus (DM), severe obesity (body mass index >40 kg/m2), and hypertension increase the risk of complications and death in COVID-19 patients.[8],[9],[10] DM in particular has been identified as a risk factor for severe COVID-19 illness.[11],[12] The inability of high-risk patients such as those having DM to access care may have contributed to the high level of mortality among these vulnerable subgroups.

There is increasing debate and clamor about the use of telemedicine options including e-health and telephone consultations to assess and review patients who are unable to visit the hospital during the lockdown period. Unfortunately, most government hospitals in Nigeria do not have a robust and fully integrated e-health network.[13],[14] A majority of Nigerians however have mobile telephones and are required to provide their phone numbers while registering at various hospitals. There is therefore a need to assess the possibility of practicing telephone consultation as a form of e-medicine using the results of this retrospective review of calls made to diabetic patients during the lockdown period in Lagos State, Nigeria.

Aim

The aim was to impact the COVID-19 lockdown on the clinical outcome of patients with type 2 DM.

Objectives

  1. Assess the sociodemographic and clinical characteristics of the patients
  2. Assess the impact of e-consultation during the COVID-19 lockdown
  3. Assess the glycemic and blood pressure (BP) control pattern of patients and relationship with practice of self-monitoring of blood glucose (SMBG) and home monitoring of BP (HMBP), respectively.



  Methodology Top


Study area

This study was carried out in the chronic medical disorder (CMD) clinic of the Family Medicine Department, Lagos State University Teaching Hospital, (LASUTH) Ikeja, Lagos. The hospital is situated in Southwestern part of Nigeria in Lagos State. It serves as a training, research, and referral center in the state. The CMD clinic enrolls uncomplicated Type 2 DM patients. The weekly attendance of the CMD clinic is about 30–40 type 2 DM patients. Due to the COVID-19 pandemic and subsequent lockdown, regular clinic was unable to provide face-to-face physical consultations. Hence, patients who were due for clinical reviews were contacted through their telephone numbers.

Study design

The study was a retrospective review of the clinical records of Type 2 DM patients who were called for phone consultation to assess their clinical status and to offer routine follow-up care during the lockdown period of April- June 2020.

Study population

It consisted of adult patients with Type 2 DM who were on medications and had registered for medical care at the CMD clinic of the LASUTH, Ikeja, Lagos State.

Inclusion criteria

Adult patients with Type 2 DM who were on treatment and had valid phone numbers with clinic appointments within the study period.

Exclusion criteria

Patients who were unable to be contacted through telephone were excluded from the study.

Data collection

A total of 200 patients with Type 2 DM were eligible for the consideration, of which 178 could be contacted on phone. One phone call was made, with subsequent calls also made based on assessment by doctors in the department, to patients who were due for clinic appointments, to inquire about their clinical status, medication use, SMBG, and HMBP among others. They had their medications reviewed as appropriate and were counseled on clinical parameters. Phone numbers were also given to the patients to contact the clinic in the event of making clinical enquiries and consultation. The sociodemographic and clinical characteristics were obtained from the patient database folder while blood glucose values and BP readings were obtained through the telephonic consultation and analyzed.

Definition of outcome variables

  1. Glycemic control was assessed as good (fasting blood glucose <110 mg/dl) or random blood glucose (>70 mg/dl–140 mg/dl) and poor (fasting blood glucose >110 mg/dl) or (random blood glucose >140 mg/dl)
  2. Hypoglycemia was defined as fasting or random blood glucose as <70 mg/dl
  3. SMBG was assessed as <3 times per week and >3 three times a week.


Ethical considerations

Due to the COVID-19 pandemic, ethical approval was obtained from the Lagos State Teaching Hospital, Ikeja review board with reference number LREC/6/10/1490. The patient confidentiality was protected with no risk of individual patient identification.


  Results Top


More than half (51%) of the respondents were elderly (≥60 years old) with about 54% using HMBP during lockdown as shown in [Table 1]. A majority of respondents reported using their medication as prescribed, with about three quarter (74%) having checked their blood glucose during lockdown, though only 29% checked more than three times a week as shown in [Table 1]. About one-fifth had adjustment to their medications by the doctor as shown in [Table 1].
Table 1: Clinical characteristics and pattern of medication use of the respondents

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Majority of the respondents were using biguanide (96.7%) and sulphonylurea (60.7%) as oral antidiabetic medications, with the use of dipeptidyl peptidase-4 inhibitors (22.5%) and insulin (15.7%) also common. The most common antihypertensive medication classes used were Renin Angiotension Aldosterone System (RAAS) inhibitors (64%) and calcium channel blockers (51%). Other commonly prescribed medications were anticholesterol (76.4%), antiplatelet (56.2%), and antineuropathy drugs (32.6%) as shown in [Table 2].
Table 2: Type of medication used by the respondents

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More than half (54%) of the respondents had suboptimal glucose control, while about 2% had hypoglycemia. A majority of the respondents, however, had good BP control as shown in [Table 3].
Table 3: Glycaemic and hypertension control pattern of the respondents

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Home Monitoring of Blood Pressure was associated with lower systolic BP (t-test 3.49, P = 0.0008) as shown in [Table 4].
Table 4: Relationship between use of medication, monitoring of glucose, and blood pressure with clinical parameters

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  Discussion Top


The findings from this study showed about three-quarter of the respondents had checked their blood glucose during the period under review; however, a majority had not checked their glucose regularly. A similar study during the lockdown in India reported that only 28% of diabetics were testing their glucose sugar levels regularly.[1]

It was postulated that this is probably due to the unavailability of SMBG machines/strips or due to the fact that SMBG is not practiced widely in India, as in in Nigeria for a myriad of reasons.[15],[16]

In Nigeria, the landmark diabetes care study showed that 72.8% of patients did not practice SMBG.[17] Another review in Nigeria reported that the practice of SMBG ranges from 3.4% in rural areas to 73% in urban areas.[18] Some of the reasons for the low practice of SMBG includes cost, denial as patients do not want to know their glucose levels, doctors do not recommend or promote SMBG, results not being acted upon, inconvenience and pain.[19]

Education of patients about the use of SMBG and its importance should be done at every clinic visit. There is a need for regular SMBG, especially among patients with diabetes on insulin therapy. The education on glycemic targets including values and signs of hypoglycemia is also important.[15],[16]

Majority of the patients in this study were using sulphonylureas, biguanides, DPP-4 inhibitors, and insulin. A minority were using sodium glucose transporter-2 (SGLT-2) inhibitors, alpha-glucosidase inhibitors, and thiazolidinediones. It has been advised that SGLT-2 inhibitors should be stopped in patients who are very ill, to reduce the risk of acute metabolic decompensation but should not be done prophylactically.[20],[21] Several theories have also been postulated about the predisposition of using oral diabetic drugs such as pioglitazone, glucagon-like peptide-1 agonists, and DPP-4 inhibitors to infection with SARS-COV-2, but it is largely unproven.[21],[22] Most patients will require insulin if they develop sepsis or diarrhea while at home.[21],[23]

Among the antihypertensive medications, angiotensin 2 receptor blockers (ARB) and angiotensin-converting enzyme (ACE) inhibitors were the most prescribed, while more than three-quarter of the respondents were also using anticholesterol medications. This is not Suprising as most DM patients have other components of the metabolic syndrome including hypertension and dyslipidemia.[21]

There has been concern about the use of ARB/ACEs inhibitors as it was presumed to predispose to SARS-COV 2 infection by increasing the expression of ACE2, which could accelerate the entry of the virus into the cells.[24] However, an alternative theory is that SARS-CoV-2 might impair the protective ACE 2 receptor pathway and increase deleterious angiotensin-2 activity, thereby use of ACE inhibitors and ARB could protect against severe lung injury following infection.[21] On the basis of currently available evidence, most guidelines advocate that patients should continue with their antihypertensive regimens including ACE inhibitors and angiotensin 2 receptors.[21],[25] The anti-inflammatory effect of statins has been attributed to the upregulation of ACE2.[26] However, despite the belief that modulation of ACE2 expression is associated with infection rates in COVID-19, statins should not be discontinued because of the long-term benefits and the potential for tipping the balance toward a cytokine storm by rebound rises in interleukin (IL)-6 and IL-1β if they were to be discontinued.[21] Considering the close relationship between diabetes and cardiovascular disease, it is recommended that control of lipid concentrations in all patients continues, even if they develop COVID-19.[21]

The glycemic control of diabetic patients has been affected in different ways during the lockdown period, especially with affectation of drug usage, exercise, regular follow-up tests, and physicians visit for their routine checkup.[27],[28] A study among diabetic Saudis during the lockdown reported lower drug compliance levels, though the levels of hypoglycemia and hyperglycemia did not differ pre- and post-lockdown.[29] This was different from results by Bonora which reported improved glycemic control among Type 1 DM as the lockdown allowed them to stop working and be able to comply with healthy lifestyle habits.[30] Our review findings showed high self-reported levels of drug compliance, though it was not designed to asses pre- and post-lockdown glycemic control. The importance of self-monitoring with glucometers and sphygmomanometer was demonstrated by the lower systolic BP, diastolic BP, and glucose levels among respondents in this review, which is in keeping with guidelines which emphasize its use.[31],[32] The use of telemedicine allowed for modification of patients medications, though pitfalls such as prescribing medications without diagnosis or from restricted lists should be avoided.[33] There is a need for proper legal framework in Nigeria, especially as it concerns privacy and legal liability, as e-consultation can help in reducing long waiting times in the hospital and increase access in difficult to reach areas.

Limitations

The present study has limitations as it depended predominantly on the patients' honesty and there was difficulty in comparing variables pre- and post-COVID-19 era.


  Conclusions Top


Type 2 diabetic patients being managed at a family medicine center reported good level of drug compliance with those practicing SMBG and HMBP, reporting better levels of control during the COVID-19 lockdown. The findings of this review suggest that the use of e-consultation can play a role in patient management of diabetes even beyond the COVID-19 era including reaching patients in distant locations who are unable to come to the hospital. There is a need for further studies on the role of e-medicine role on various aspects of medical care.

Research quality and ethics statement

All authors of this manuscript declare that this scientific study is in compliance with standard reporting guidelines set forth by the EQUATOR Network. The authors ratify that this study required Institutional Review Board/Ethics Committee review, and hence prior approval was obtained from the Lagos State Teaching Hospital, Ikeja review board with reference number LREC/6/10/1490. We also declare that we did not plagiarize the contents of this manuscript and have performed a Plagiarism Check.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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