Diabetes in Pakistan: screen from 30, and there is no glucagon

A 34-year-old comes in about something unrelated. He is not overweight by the numbers you were taught, has no symptoms, and is a decade short of the screening age in the guideline you trained on.

In Pakistan you should be screening him — and if he turns out to be diabetic, there are three further things about his care that differ from what ADA says.

Why screening starts at 30 here

The Pakistani adolopment of the ADA guideline lowered the screening age from 45 to 30. That was a deliberate, documented change, and the reasoning is worth knowing rather than just the number:

• Pakistan has a type 2 diabetes prevalence of 26.7% — the highest national prevalence in the world.
• Over a quarter of Pakistanis with diabetes are aged under 40. Half are between 40 and 59.
• South Asian populations carry particularly high risk, attributed to poor maternal nutrition, high rates of childhood obesity, and dietary factors.
• Screening later means more people present through their complications — tertiary prevention rather than primary.
• Younger patients have more capacity for lifestyle change and tend to be more proactive.
• Most healthcare expenditure in Pakistan is out of pocket, so earlier detection can be cost-saving to the patient.

RAPID: the score built for this population

PROMPT — the national guideline from the Baqai Institute of Diabetology and the Diabetic Association of Pakistan — endorses the Risk Assessment of Pakistani Individuals for Diabetes score for population screening.

Four or more triggers biochemical testing.

Look at those waist cut-offs — 80 cm and 90 cm, not the European thresholds. South Asians develop metabolic risk at lower waist circumference and lower BMI. The same reasoning drives PROMPT's instruction that metformin be prescribed "irrespective of their baseline BMI": a lean patient is not a reason to withhold it.

The national guideline does not diagnose on HbA1c

This one surprises people, because ADA and WHO both accept it. PROMPT states plainly:

International bodies are now recommending HbA1c as diagnostic criteria but national and regional studies are required before it can be included in national guidelines.

That is a deliberate position, not an oversight. HbA1c performance varies with haemoglobinopathies, iron deficiency and anaemia — all common here — and the guideline held off pending national validation.

So diagnose on glucose:

• Fasting plasma glucose ≥ 126 mg/dL (7.0 mmol/L)
• Random plasma glucose ≥ 200 mg/dL (11.1 mmol/L)
• 2-hour post-glucose load ≥ 200 mg/dL (11.1 mmol/L)

Use HbA1c for monitoring, where it remains perfectly good.

Targets, including the row people forget

The second row is the one that gets forgotten. A patient with heart failure or advanced kidney disease chased to 6.5% is being exposed to hypoglycaemia for no benefit — and in Pakistan, without a rescue option. Which brings us to the most consequential difference of all.

There is no glucagon

Of the 243 recommendations in ADA's 2021 standards, the Pakistani adolopment adopted 219 unchanged, modified 5, adapted 1, and excluded 18. The categories:

Only one exclusion is named individually, and it is the one with teeth: the recommendation to prescribe glucagon for patients at risk of hypoglycaemia was excluded because glucagon is not available in Pakistan.

There is no rescue kit to give the family of a patient on insulin or a sulphonylurea. That should change three things — how heavily you weigh hypoglycaemia risk when choosing an agent, how hard you chase a tight target in a frail or comorbid patient, and how much time you spend teaching the family to treat a hypo orally and when to bring them in.

Continuous glucose monitoring is likewise described as unaffordable for most Pakistani patients, so recommendations assuming it are not actionable for the majority.

What to start

PROMPT: "Metformin should be prescribed to all patients along with lifestyle modifications, irrespective of their baseline BMI, if there are no contraindications."

One practical thing worth saying out loud to the patient: anorexia, nausea, diarrhoea and a metallic taste are minimised by taking it with meals. That single sentence prevents a lot of early discontinuation.

Where metformin cannot be used, PROMPT names sulphonylureas, DPP-4 inhibitors and insulin — and also lists alpha-glucosidase inhibitors, GLP-1 agonists, thiazolidinediones and repaglinide among available options.

Sulphonylureas are cheap and widely available, which in an out-of-pocket system is a genuine clinical advantage. The trade-off is hypoglycaemia risk, which — see above — matters more here than where you can hand out a glucagon pen.

How much to trust all this

The adolopment authors are unusually candid about their own work, and it is worth knowing. They state there are not enough original articles published based on the Pakistani population, and that the process relied on regional literature, judicious use of grey literature, and expert consensus informed by a suboptimal level of evidence. They also name their constraints: limited local guideline-development expertise, insufficient workforce and funding, no patient or general-practitioner perspectives, and institutional hierarchy inhibiting frank discussion among the panel.

That does not make the guideline wrong. It makes it the best available synthesis for a country where the research base is thin — and it tells you which parts to lean on. The screening age and the availability exclusions are solid facts. Fine-grained treatment sequencing is expert opinion adapted from ADA.

Two things to look up elsewhere

Ramadan. PROMPT defers to the IDF Diabetes and Ramadan Alliance guidelines. Pre-Ramadan risk stratification and dose adjustment are not covered by the national diabetes guideline itself.

Gestational diabetes. Separate national guidance was being developed following projects screening around 25,000 pregnant women. Use dedicated GDM guidance rather than extrapolating.

Bottom line

Screen from 30. Use RAPID and its South Asian waist cut-offs. Diagnose on glucose, not HbA1c. Give metformin regardless of BMI, and tell the patient to take it with food. Relax the target in heart failure and kidney disease. And remember there is no glucagon — which should make you more cautious about hypoglycaemia than any guideline written for a country that has it.

Our type 2 diabetes pathway includes a working RAPID calculator and sets out the full exclusion list. Also in the section: hypertension, urinary tract infection and community-acquired pneumonia.

ReviseFCPS1 is built by doctors in Pakistan, for doctors in Pakistan. All our clinical tools and pathways are free. If you are preparing for FCPS Part 1, try it free for 7 days — 10,176 doctor-verified MCQs and 8,236 real exam recalls.