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Dr R Suresh Prabu – An Experience Encyclopedia on Sulfonylurea

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Yeah sulfur durians i think uh prior to 10 years back they are one of the important second line drug after metformin and after 2010 we have several other groups of medications are available but still i think sulfonylureas are one of the important drugs we use to treat these patients so i can mention two groups of patients where it is very important uh for

Treating uh diabetes mellitus in first group i think uh patients there are a set of patients uh where we treat these patients as an inpatient uh when it comes to treatment of diabetes i i work in a trauma care center which caters a large number of people from south india so in that center we have a group of patients where these patients are treated with

Insulin but in spite of insulin they tend to have a higher blood sugar so in the subset of patients where we start sulfamel urea they tend to have a better glycemic control i think this is this subset of patients could be a a component of what we call it as maturity onset diabetes in young modi group of patients where these patients the control of blood

Sugar is better with sulphur and luria’s compared to other trees other medications during the initial years of diabetes during the first 15 years these patients are better controlled with sulfur urea than the other group of patients this is one group where absolutely sulfuric tend to be much more important another group of patients where when the patients when

We when when the first line and secondary drug has been uh used and still these patients have uncontrolled blood sugar value i feel that this is a group where sulfur urea tend to prevent the patients from progressing to insulin so that is a group where we use sulphural urea to prevent the patients from further deteriorating in glycemic control and helps to

Control the diabetes and prevent them these are the two group of patients i feel their sulfur ureas are important for treatment of diabetes mellitus yeah still i experienced uh those days before uh 2010 where i think we have only only a metformin sulfonylureas and i think uh the glitter zones have one of the drugs we we have so during those period i think

Uh the usage of sulfoneuria may be around sixty percentage of the page sixty to seventy percentage of our diaper diabetes melt dispersion will be unsulfaminuria and uh and the dosage what we use is much more higher i i still remember we use up to eight milligram of glimmie pride and we are studying in velour where to control because we don’t have other drugs

To prevent insulin or to start insulin to make the glycemic control better we use more number of patients and higher dosage compared nowhere now we have multiple drugs so that we can we can actually attack the multiple pathophysiology of diabetes with those types of medications but previously we have only few groups of medications we tend to use more and more

That group of medications with a higher dosage and larger number of patients so pre-dpp for era i think there’s a era where the sulphur usage is very high and the dosage is also very high in those type of patients the important thing is uh i think we had a debate some one year two years back where the debate is that whether the sulfonyl urea will be phased

Out so it will be phased out and it will be replaced by other newer group of medications but if you still see the scenario what uh nowadays because after 10 years before we still use sulfur urea in a considerable amount of patients and the important thing is all the new agents they have the hbo’s reduction is some 0.8 to 0.9 percentage which is actually

When the patient have an experience of 10.5 11. but they can bring down the hp 1c from 11 or 10 to around 8 or 7 9 or something so beyond that i think we need a gap in those patients who have uncontrolled diabetes mellitus but the hpos is beyond 9.5 these newer agents may not help in all the bishop i’m not saying that it will not help in a certain amount of

Patients where there is a gap between the dpp4 and the glycemic control in those situation i think sulfur ureas are very important to bring down the hbs we have seen patients on maximum dosage before metformin even we start in obese patients we start gel in beta in spite of that the sugars are uncontrolled i think there as these sulfur neurias help to bring

Down the blood sugar and keep the glycemic control for a longer duration the concern regarding sulfur urea is tend to use up more and more beta cells and the patient will be pushed to insulin within a short duration of time and that is actually uh that that as uh the theory actually it is not holding together because we are using multiple medications now so

We are we are actually attacking the diabetes with multiple pathophysiology so still i think sulfonylurea have a definite role uh in in controlling the blood sugar and keep the hpnc under control in patients who are already on the newer drugs including metformin my uh thing is uh uh two scenarios one when the hp once is high it does nine point five and hbo

Is less than a seven point five less than seven point five so in the less than seven point five group i sparingly use sulfonylurea we know that in those group of patients where metformin and the other secondary line drug which include adult inverters and dp4 emitters are very helpful when the baseline experience is more than 9.5 i think most of the recommendation

Also says that we can use a multiple combination in those group of patients i tend to use sulfinary as an initial drug means along with dpp4 and metformin so when the hp owns this baseline hp1 is more than 9.5 we know that the dpp4 and metformin tend to fail in those group of patients because apart from insulin resistance and mild insulin secreted effect these

Patients have absolutely have an insulin secretion defect as a primary problem rather than insulin resistance as a primary problem so in those group of patients i use as that’s a primary and secondary in second group and when the hp is less than 7.5 in that group i very rarely use sulfur urea because we have another group of medication we tend to control the

Blood sugar very well and we can we can postpone the sulfur luria at a later date once the sugars are getting uncontrolled i think carolina is one of the important uh i can say there’s a landmark trial not for linagliptin but for sulphur liuria glimmi pride because the drug which tend to prove its cardiovascular safety have actually cleared the cardiovascular

Safety of uh the glimmie paradise what i can say previously we had a doubt that sulphur urea particularly the second generation or third generation sulfonylurea whether they are safe because prior to 2008 we don’t have any dedicated cardiovascular trial for cell phone urea because it is not mandatory by the fda so we don’t have any dedicated cardiovascular

Trial but when the carolina trial has come out and we know that this drug is similar to linagliptin we know that dpp4 are cardiovascular neutral and if you see the the curves between both the lenovoltin and glimmie pride is actually is hand in hand throughout the study period and indicates that glimmy pride is safer particularly i mean sulfonylureal the

The drug which is used in that one is glimmi pride is safer in uh glimmi pride along with linagliptin group over a period of long because the duration of the carolina trial is not a short one two years or three almost five to six years trial so it indicates that even after six years the cardiovascular safety of sulfonylurea is actually proved i mean it’s

What we can it can take into consideration so uh now i think uh previously when a patient have an existing cardiovascular disease we have some hesitation in using cell phone urease particularly the newer cell phone and the clinic but now i think we can with an evidence backing up us we can use this medication more uh with uh without having any fear of any

Cardiovascular outcome of those patients even though we have other group of drugs which tend to improve the cardiovascular measurement and other things but now we can use these drugs without any guilty or without any there’s a scientific evidence to backed treatment of our patients i think uh the three are four important uh risk factors with sulfoneuria one

Is hyperglycemic risk second one is weight gain which is also much more important third one is the cardiovascular safety and finally any other the underworld side effects of sulfur that is those the last two has been ruled out we know that even after long term usage we don’t have any underworld unknown side effects of sulfonylurea second one is the uh uh

The important one is the cardiovascular safety that has been proved the other two the weight gain and hypoglycemia is actually it is more of both physician and also the patient related so when i use a drug when i hp once is seven or eight i use three milligram of chlamy pride definitely this patient will go for hypoglycemia so that’s what so the selection

Of patient is much more important for and also inappropriately higher dosage of sulfur urea tend to cause weight gain so when i use a patient who is already obese and needs a and needs a drug which to control the insulin resistance i use this drug this will definitely cause weight gain so the important thing is the selection of patients the dosage what we

Use and also how we follow up these patients are very important so this drugs i think in that clinical trial the carolina trial and we know that the weight gain in those patients is not more than one or two kgs it is actually maybe in our clinical practice may not be a significant one where the patient tends to gain one plus or minus one kg during the course

Of the treatment so selection of patients means use with the lowest dosage use with a single daily dosage and then titrate the tablets so that the patient will have lesser chances of hyperglycemia and never use it two times per day unless you have a very high fasting hyperglycemia second one is weight gain weight gain if you use as a traditional uh correct

Dosage we may not have much weight gain compared to the other medication other thing combining with other group of medication if you combine with agility emitters probably we can have elevate the weight gain symptoms of uh glimming pride so that judiciously we can use without causing much side effects with chlamy pride and or other newer sulfalures yeah i

Think two group of patients one with copic patients without covet patients with coin patient as you already mentioned these patients will be on steroid but the problem is a good thing with this is not be a long duration so maximum this patient will be on 10 days of uh in steroids and during those stage this patient will be on insulin anyhow this patient will

Be sick and patient will get admitted and this patient will be on insulin and post cobit after they recover from kobit there’s a situation where the first three men’s are very vulnerable when those type of patients if their sugars are very much uncontrolled to prevent further complication they may tend to continue insulin and the sulfoneura will be add on

If there is no contraindication the second group of patients where they don’t have a covenant they restrict the movements has been restricted by the logged on and other physical activities not there and the diet pattern has been changed excessive so those type of patients where the sugar tend to get uncontrolled probably we have to emphasis most more on your

Lifestyle changes and exercise and if needed we have to increase the uh the medications uh sulfur urea the the dosage increase will be there only after reaching the maximum dose of metformin and the other group of because we tend to further increase the weight gain to prevent that we think we have to use judiciously in those group of patients so uncontrolled

Sugars are common both in with postponed and the non-covet patients but lifestyle changes is the one predominant one to prevent the complications and hyperglycemia in those group of patients yeah i think other thing is availability no i i write a drug and a patient who comes from a remote village that could be available that i’ve recent drugs if i write i

Think it may not be available so i am confident that this drug will be available everywhere that is the one thing and uh cost as he already mentioned cost is the one because when a patient earns only two thousand rupees or a thousand rupees per uh per day or per two days or three days and those group of patients i i’ll be more confident that this patient will

Be continuing the medicine if it is affordable to the patients so those two things are much more that’s why the ada have kept these products under a group where when the patient is unaffordable or cost is an issue these are the drugs to be proposed i think southern area fits there in those group of patients

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Dr R Suresh Prabu – An Experience Encyclopedia on Sulfonylurea By Metabolic Milestone Initiative