Muhammad Umar Wahab ( Department of Diabetes and Obesity, Umar Diabetes Foundation and Umar Diabetes and Foot Care Centre, Islamabad, Pakistan. )
Umar Yousaf Raja ( Department of Endocrinology, Shifa International Hospital, Islamabad, Pakistan. )
Sanjay Kalra ( Department of Endocrinology, Bharti Hospital, Karnal, India. )
Medication is essential for diabetes care, and this is reflected in the Essential Medicines lists prepared by the World Health Organization and various countries. The need for essential diagnostics, and essential devices, however, has not been addressed adequately. In this communication, we call for creating a list of the essential diagnostics and devices that are required in primary and secondary/ tertiary diabetes care. We hope that this will encourage policymakers and clinicians to work together, to ensure that these are made available, accessible, and affordable for all patients.
Keywords: Diabetes, Diagnostics, Essential medicines, Glucometers, Insulin, Ketone strips, Medical devices, World Health Organization.
Essential Medicines in Diabetes Care
The World Health Organization (WHO) maintains an Essential Medicines list (EML), which serves as a template for various countries to prepare their National Essential Medicines list (NEML).1 Pakistan's NEML currently in its fourth revision, dates to 2007.2 WHO also lists essential medicines for children separately.3 There is a move to list essential diagnostics by the WHO,4 and essential devices, by countries such as India,5 as well. Essential medicines are those that satisfy the health care needs of a given population. In the diabetes care context, essential medicines are those that must be available to ensure safe and effective glycaemic and metabolic control, in a well-tolerated manner.
Essential Medicines in Pakistan
The Pakistani NEML lists various "insulins and other antidiabetic agents" as essential drugs. These are glibenclamide and metformin tablets, and soluble, compound insulin zinc suspension and isophane insulin. While soluble insulin injection is mentioned as a 100 IU/ml preparation, intermediate acting insulins include two concentrations: 40 IU/ml and 100 IU/ml.
Essential Diagnostics and Devices
Diabetes management today needs much more than just drugs. Behavioural and lifestyle modification therapy are essential components of diabetes care. At the same time, modern devices are needed to screen, diagnose and monitor glycaemia, and to deliver insulins and other injectables. There is no mention of these devices, including diagnostics, in NLEM. In this communication, we list the various diagnostics and devices that are required in primary and secondary/ tertiary care set ups (Table).
The Table is a basic classification and list of various devices and diagnostics. It purposely limits itself to glycaemic monitoring and to complication screening. Various insulin and injectable delivery devices are listed, all of which may not be available in Pakistan. However, 40 IU/ml syringes are used in Afghanistan and India, while 500 IU/ml syringes are used for U500 regular insulin in USA.
We hope that this paper will encourage discussion and debate regarding the 'essentiality' of these products. This communication should encourage policymakers to prepare comprehensive lists of essential drugs, devices and diagnostics for use in diabetes care, as well as in overall medical/ surgical care. It should also spur diabetes care providers to ensure provision of essential equipment in their setups.
1. WHO model list of essential medicines - 21st list, 2019. Available from URL: https://www.who.int/publications/i/item/WHOMVPEMPIAU2019.06. Last accessed on 03 April 2021.
2. National Essential Medicines List of Pakistan. Available at: https://www.who.int/selection_medicines/country_lists/pak_EML_2007.pdf?ua=1. Last accessed on 03 April 2021.
3. WHO Model List of Essential Medicines for Children - 7th list, 2019. Available from URL: https://www.who.int/publications/i/item/WHOMVPEMPIAU201907. Last accessed on 03 April 2021.
4. Second WHO Model List of Essential In Vitro Diagnostics. Available from URL: https://www.who.int/medical_devices/publications/EDL_2_0_Standalne_11_2019_v2.pdf. Last accessed on 03 April 2021
5. Medical Device & Diagnostics. Available at: https://cdsco.gov.in/opencms/opencms/en/Medical-Device-Diagnostics/Medical-Device-Diagnostics/. Last accessed on 03 April 2021.