This is a 5 Part lecture where Dr. Rakesh Sahay (Professor and Head of Department, Osmania medical college and Hospital, Hyderabad) explains New Onset Diabetes Management.
Now if you look at what the ada says first line therapy earlier it was always first line therapy with with metformin now they also added the fact that we need to look at the presence of atheroscleroid cardiovascular disease or renal disease and consider using sgld2 inhibitors or glp1 analogues as the first line therapy in the presence of either atherosclerotic
Cardiovascular disease or renal disease or presence of heart failure in the presence of any of these three conditions we could think of using either hdl2 inhibitors when there is presence of heart failure or ckd and glp1 analogues being the preferred choice in the presence of atherosclerotic cardiovascular disease in the absence of these the first line would
Be metformin then you would go on to the addition of other therapies depending on whether you would like to minimize hypoglycemia when you would consider dpp for inhibitors or the gld2 inhibitors or the glp1 analogues whereas if your concern is to minimize the weight gain or cause weight reduction then the the choice would be between dpp for inhibitors glp1
Analogues and sgld2 any meters now and then the the final other consideration that is always there is if you are considering the cost as a hindrance factor for the management of diabetes the consideration is towards the use of low-cost therapies like issues or tzds the su’s still have a very important place they are important even in patients who are started
On hcl2 inhibitors who are on metformin who still are not under control now the other important factor that has come in in this algorithm is that the fact that we could start with a dual therapy if the hbmc is more than 1.5 percent higher than the target that we’re aiming at so if you’re looking for a target of seven percent and if you have some an individual
Who has got a hbmc of eight point five percent then the suggestion is to use dual therapy rather than monotherapy at that point of time then looking at the rssdi esi clinical practice recommendation for the management of type 2 diabetes again this was published in 2020 and it’s going to be revised soon and in this also we have a consideration to look at the
Age the bmi the abcd rather so where a stands for age advancing age you look at prefer certain medications over the others bmi increasing bmi you look at certain medications with the presence of ckd you look at certain medications with duration of diabetes d is the duration of diabetes is established cbd f is the finance and g is the glycemic status and h is
The hypoglycemia concern so all these a b c d to h are incorporated in this wheel where you can see clearly this makes it very easy for people who are trying to decide which form of therapy is more suitable for their patients they could do it very easily by looking at the wheel as you can see in the a portion you’re looking at advancing edge you’re looking at db
Before any beaters is the first choice agis sglt2 any beaters then so on and so forth you have the other agent whereas with the increasing bmi you’re looking at the first choice being hdlt to any meters or the glp one analogues with the presence of uh ckd the first choice is hdl t20 meters with the presence of longer duration of diabetes you have hdl2 inhibitors
The dp4 inhibitors and then the other is coming in and then again looking at the established cardiovascular disease again the two major clusters of drugs like sgl 20 meters and glp1 analogs fit in there now when you’re looking at finances the s2 comes in first followed by insulin followed by bio glutathione followed by agis so that is how we would look at it so
If you look at the hcl20 meters we know that they work through the sglt2 receptor present in the proximal convoluted tubule which accounts for 90 percent of the absorption of glucose in the proximal tubule so they need to increase glucose excretion in the urine leading to a glycemic reduction of 0.8 to 1 percent and this can be combined with different classes
Of drugs now if you look at the glycemic benefits i’ve just enumerated they have several extra glycemic benefits like reduction in body weight reduction in blood pressure 2.9 kg reduction in body weight and almost 5 millimeter reduction in blood pressure with 10 milligram dose of agent like the upper glycemic they also have the benefit of causing less glycemic
Variability providing a better glycemic legacy to our patients who are started on these agents early and because of the glycemic durability that they have and less specific variability that occurs with the use of these drugs they provide a good legacy for reducing the risk of complications and they combine very well with the metformin and they have a synergistic
Action which meant forming with a combination causing a glycemic reduction of almost greater than one percent or close to one and a half or two percent also with the combination of metformin with any of the sgt20 meters here we are seeing the combination of metformin with the bucket process and what we see is that this initial combination works very well in terms
Of providing all these benefits and also providing a good cardiovascular outcome now if you come to the dpp 4 animators as we can see here the dpp four animators are probably the most versatile agents because what we see is that they act on many of the mechanisms as you can see the table shows a listing of all the mechanisms which are contributing towards the
Development of hyperglycemia and dpp for animators are influencing most of them or influencing more than 50 of them and uh while we see that some of them are addressing single defects like the sgld20 meters affecting only the kidney glucose loss the agi is working only on the gi tract while some of the agents like metformin have a multiple actions and the dpb
Before inhibitors are also very versatile having multiple actions we have a vast amount of experience with the use of these lymphedemas and neuroleptins are also coming in and this is a growing family of molecules which which have a good glycemic reduction they have a reduction in the hb1c fpg postplanning glucose levels and they also provide less variability
With lower risk of hypoglycemia and low weight gain if you look at all the cardiovascular outcome trials with the glyptons we see that with cetagene there was a very good cardiovascular outcome trial called the decos trial which was a large number of patients and it showed that the cetagleptin is a very safe molecule and the same outcome was seen even with the
Outcome trial of lena lipton the carbonyl and the carolina trial now coming to this very important class of drugs called the su’s looking towards the newer agents the newer class of drugs they are probably more safer glimparade is one of those and glycoside extended releases probably one of those in the neuron or the modern sulphur nucleus which are associated with
Very low cardiovascular risk as it’s been shown from various observation studies this is one of them observational studies real world observation studies or whether you look at a meta-analysis of all the other studies which have looked at the cardiovascular effect of sus and all these studies have shown that these molecules along with metformin work very well
In terms of glycemic efficiency which has a good durability of glycemic efficacy and they do not cause any ischemic preconditioning as was seen with some of the molecules like living formidable molecules like glutamine or glycoside do not cause this problem and we could see this from the advanced trial with likelihood or even the carolina trial which was a cbot
Trial with the carolina comparison of glimmi pyrite with linagliptin and the tosca iit trial was a comparison of issues with privileges five liters on it showed that lima polite was non-inferior to bioglycogen in terms of the cardiovascular effects and the carolina trial actually went on to show that uh this was a well-designed cardiovascular outcome trial which
Had an active comparator arm with linagliptin versus libya pride and what we could see is that there was a very clear non-inferiority of both the molecules that is gleaming pride uh worked as good as neenah gripping organoglyphin was as good as in terms of the cardiovascular safety from the cardiovascular safety point of view these two molecules fade exactly
Similarly and even when you put looked at the four point means you had similar effects but there was small differences in terms of the risk for heart failure which was more with lenovo hypoglycemia was slightly more with the democrat but did not lead to any increased adverse cardiovascular outcomes time below range of less than 54 being less than one percent
And when you’re looking at the pre-pandel and postpartum targets type 2 diabetes target is more than 70 being in time in range and for pregnancy we will would like to you
Transcribed from video
Treatment Guidelines and treatment options for Diabetics (Part 3) By Sunpharma Sunkalp