Use of sodium-glucose co-transporter-2 inhibitors in patients with type 2 diabetes mellitus and multiple cardiovascular risk factors: An Asian perspective and expert recommendations

Diabetes mellitus in Asia accounts for more than half of the global prevalence. There is a high prevalence of cardiovascular disease (CVD) in the region among people with type 2 diabetes mellitus (T2DM) and it is often associated with multiple risk factors including hypertension, renal disease and obesity. The early onset of T2DM and the eventual long disease duration portends an increasing proportion of the population to premature CVD. In addition to lowering blood glucose, sodium-glucose co-transporter-2 (SGLT-2) inhibitors exert favourable effects on multiple risk factors (including blood pressure, body weight and renal function) and provide an opportunity to reduce the risk of CVD in patients with T2DM. In this article, we consolidated the existing literature on SGLT-2 inhibitor use in Asian patients with T2DM and established contemporary guidance for clinicians. We extensively reviewed recommendations from international and regional guidelines, published data from clinical trials in the Asian population (dapagliflozin, canagliflozin, empagliflozin, ipragliflozin, luseogliflozin and tofogliflozin), CVD outcomes trials (EMPAREG-OUTCOME, CANVAS and DECLARE-TIMI 58) and real-world evidence studies (CVD-REAL, EASEL, CVD-REAL 2 and OBSERVE-4D). A series of clinical recommendations on the use of SGLT-2 inhibitors in Asian patients with T2DM was deliberated among experts with multiple rounds of review and voting. Based on the available evidence, we conclude that SGLT-2 inhibitors represent an evidence-based therapeutic option for the primary prevention of heart failure hospitalization and secondary prevention of CVD in patients with T2DM, and should be considered early on in the treatment algorithm for patients with multiple risk factors, or those with established CVD.

Continuation of Metformin Till Night Before Surgery and Lactate Levels in Patients Undergoing Coronary Artery Bypass Graft Surgery

BACKGROUND

Lactic acidosis is a rare but serious complication associated with metformin therapy in certain high-risk patients. NICE guidelines and the British National Formulary advise the discontinuation of metformin before surgery. The drug manufacturer's datasheet advises the withdrawal of metformin 48 h before surgery. However, the data regarding perioperative use of metformin is scarce.

AIMS

To evaluate the effect of continuation of metformin till night before surgery on lactate levels in patients undergoing coronary artery bypass graft (CABG) surgery.

MATERIALS AND METHODS

In this prospective cohort study, 1,800 consecutive patients who underwent CABG between 1^st November 2015 and 31^st October 2016 were enrolled. Following exclusion criteria, a total of 790 subjects were included for final analysis. Three-hundred and eight seven (48.9%) patients with diabetes received metformin till night before surgery (Met group), 239 (30.3%) patients with diabetes were non-metformin users (Non-Met group), and 164 (20.8%) patients were having no diabetes (Non-Diab group). Lactate levels and arterial pH were measured using arterial blood gas machine. Postoperative morbidity outcome data were obtained by collecting clinical data, routine biochemistry, and chest imaging.

RESULTS

The mean metformin dose was 1,124.6 mg/day (SD: 509.3; range: 500-2,500 mg/day). Mean postoperative lactate levels were 1.91 ± 0.7 in Met group, 2.04 ± 0.79 in Non-Met group, and 2.07 ± 0.78 in Non-Diab group. Lactic acidosis occurred in 41 patients and there was no difference among the groups [Met group = 18 (4.7%); Non-Met group = 14 (5.9%)]. Among secondary outcome measures, acute renal failure occurred more frequently in diabetic patients [Met group = 46 (11.9%) and Non-Met group = 32 (13.4%)] as compared with non-diabetic patients. There were no differences with regard to pneumonia, length of ICU stay, and duration of ventilatory support among the three groups.

CONCLUSIONS

Continuation of metformin till night before surgery is not associated with significant changes in lactate levels in patients undergoing CABG.

Supplemental calcium intake in the aging individual: implications on skeletal and cardiovascular health

Adequate calcium intake during childhood is necessary to achieve optimal peak bone mass and this has the potential by increasing bone reserves, to modulate the rate of age-associated bone loss. However, data regarding the efficacy of calcium obtained either through the diet or in the form of medicinal supplementation, for prevention of bone loss and osteoporotic fractures in the elderly is conflicting. Calcium alone is unlikely to be of benefit for this purpose though the co-administration of calcium and vitamin D may have modest fracture risk benefits. Supplemental calcium with or without vitamin D has recently come into the spotlight after the publication of the findings from a controversial randomized controlled trial that associated calcium supplementation with an increased risk of myocardial infarction. Since then, multiple studies have explored this potential link. The data remains conflicting and the potential mechanistic link if any exists, remains elusive. This review examines the relationship between supplemental calcium intake and skeletal and cardiovascular health in the aging individual through an appraisal of studies done on the subject in the last three decades. It also briefly details some of the studies evaluating fractional absorption of calcium in the elderly and the rationale behind the current recommended dietary allowances of calcium.

Reference range of random urinary calcium creatinine ratio in North Indian children and adolescents

PURPOSE

Urinary calcium creatinine ratio (UCaCrR) is a reliable indicator for monitoring hypercalciuria following vitamin D supplementation. However, the reference range varies from region to region. Previous studies did not take vitamin D and parathyroid hormone status into account while evaluating UCaCrR. Hence, we undertook this study to establish the 95th percentile of UCaCrR as an indicator of hypercalciuria in North Indian children and adolescents.

METHODS

Four hundred seventy-three participants (boys 62.2%, girls 37.8%) with adequate dietary calcium intake, normal serum levels of 25-hydroxy-vitamin D (>20 ng/mL), and without secondary hyperparathyroidism following supplementation were selected for evaluation of UCaCrR.

RESULTS

The mean age and body mass index of subjects were 11.2±2.6 years and 18.0±3.6 kg/m2, respectively. The 95th percentile of UCaCrR in the study population was 0.126. The mean, median, and 95th percentile of UCaCrR was significantly higher in prepubertal children (age ≤10 years) (0.0586±0.0374, median=0.0548, 95th percentile=0.136) compared to those >10 years old (0.0503±0.0363, median=0.0407, 95th percentile=0.123, P=0.02). No significant difference in UCaCrR was observed between genders and different weight categories.

CONCLUSION

UCaCrR of 0.13 defines the cutoff value for hypercalciuria in North Indian children and adolescents with adequate dietary intake of calcium and sufficient serum vitamin D levels.

Successful Management Of Tumor-Induced Osteomalacia with Radiofrequency Ablation: A Case Series

Tumor-induced osteomalacia (TIO) is a curable condition when the tumor is correctly located and completely removed. These tumors are, however, small and located in regions that make surgical removal difficult and sometimes risky in some patients. Experience of radiofrequency ablation (RFA) in the management of TIO is limited. We describe 3 patients with TIO who were treated in our hospital with RFA. They had suspected lesions in surgically difficult locations and were subjected to single sessions of RFA. The response was documented in terms of improvement in symptoms, normalization of hypophosphatemia and hyperphosphaturia, and disappearance of uptake on follow-up Ga⁶⁸ DOTANOC PET/CT imaging. All 3 patients had a clinical and biochemical profile consistent with TIO. The first patient (patient 1) had an intensely Ga⁶⁸ DOTANOC avid lesion involving the roof of right acetabulum. The second patient (patient 2) had a Ga⁶⁸ DOTANOC avid intramuscular lesion in left pectineus muscle and the third patient (patient 3) had a Ga⁶⁸ DOTANOC avid expansile osteolytic lesion involving the angle and ramus of right mandible. All 3 patients achieved complete biochemical as well as clinical remission with single sessions of RFA. Six months after the procedure, Ga⁶⁸ DOTANOC imaging revealed the absence of uptake at the previous sites, corroborating with the clinical improvement and normalization of hypophosphatemia and hyperphosphaturia. In conclusion, although surgical resection is the standard of care, RFA can be used successfully for treating patients with TIO. It can be an effective, less invasive, and safe modality of treatment in those patients where resection of the lesion is not possible because of inaccessible anatomical location or comorbidity that prohibits surgery. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Effect of Vitamin D Supplementation on Bone Turnover Markers in Children and Adolescents from North India

OBJECTIVES

Vitamin D is known to play an important role in bone mineral metabolism. Its deficiency may affect growth and status of bone markers in children. Hence, we undertook to study the status of bone markers in children with vitamin D deficiency (VDD) and impact of vitamin D3 supplementation on them.

MATERIALS AND METHODS

Total 468 out of 615 children and adolescents with VDD, who were given either of the three doses (600, 1000, and 2000) of vitamin D supplementation, were included in the study. These 468 children with pre- and postsupplementation preserved samples with available anthropometry, serum biochemistry, 25-hydroxy-vitamin D, and parathormone were evaluated for bone formation (procollagen type 1 amino-terminal propeptide [P1NP]) and resorption (β-cross laps [CTx]) markers.

RESULTS

The mean age and body mass index of these children were 11.3 ± 2.3 years (boys: 11.5 ± 2.4; girls: 12.2 ± 1.2 years; P = 0.03) and 18.1 ± 3.8 kg/m² (boys: 18.2 ± 3.9; girls: 17.6 ± 3.2 kg/m²; P = 0.208), respectively. There were 8.8% subjects with severe, 42.7% with moderate, and 48.5% with mild VDD. There was a significant decline in serum P1NP (from 691 ± 233 ng/ml to 640 ± 259 ng/ml, P < 0.001) and CTx (from 1.67 ± 0.53 ng/ml to 1.39 ± 0.51 ng/ml, P < 0.001) following supplementation. Though decline in serum P1NP and CTx levels was observed in both boys and girls, among all three supplementation groups and VDD categories, the effect was more marked in serum CTx than P1NP levels.

CONCLUSIONS

Vitamin D supplementation in VDD children resulted in decrease in both bone formation (P1NP) and resorption (CTx). The impact, however, was more marked on bone resorption than bone formation.

Practice Guidelines for Enteral Nutrition Management in Dysglycemic Critically Ill Patients: A Relook for Indian Scenario

Background and aim

Intensive-care practices and settings differ for India in comparison to other countries. While guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to nutritional management of EN in dysglycemic patients, specific to patients in Indian critical care settings. Advisory board meetings were arranged to develop the practice guidelines specific to the Indian context, for the use of EN in dysglycemic critically ill patients and to overcome challenges in this field.

Materials and methods

Two advisory board meetings were organized to review various existing guidelines, meta-analyses, randomized controlled trials (RCTs), controlled trials and review articles, for their contextual relevance and strength. Three rounds of Delphi voting were done to arrive at consensus on certain recommendations. A systematic grading of practice guidelines by the advisory board was done based on strength of the consensus voting and reviewed supporting evidences.

Results

Based on the literature review, the recommendations for developing the practice guidelines were made as per the grading criteria agreed upon by the advisory board. The recommendations were to address challenges regarding prediction and assessment of dysglycemia (DG), acceptable glycemic targets in such settings, general nutritional aspects pertaining to DG nutrition, and nutrition in various superspecialty cases in critical care settings, where DG is commonly encountered.

Conclusion

This paper summarizes the optimum EN practices for managing DG in critically ill patients. The practical solutions to overcome the challenges in this field are presented as practice guidelines at the end of each section. These guidelines are expected to provide guidance for EN management in dysglycemic critically ill patients. These guidelines also outline the model glycemic control task force and its roles in nutrition care as well as an intensive care unit DG nutrition protocol.

How to cite this article

Mehta Y, Mithal A, Kulkarni A, Reddy BR, Sharma J, Dixit S, et al. Practice Guidelines for Enteral Nutrition Management in Dysglycemic Critically Ill Patients: A Relook for Indian Scenario. Indian J Crit Care Med 2019;23(12):594–603.

Adverse Effect Profile and Effectiveness of Sodium Glucose Co-transporter 2 Inhibitors (SGLT2i) - A Prospective Real-world Setting Study

BACKGROUND

Clinical trials have shown promising results in terms of glycemic control and weight reduction with the use of sodium glucose co-transporter 2 inhibitors (SGLT2i) in type 2 diabetes mellitus (T2DM). However, real-world evidence from standard clinical practice especially from Asia is still limited. The aim of this study was to evaluate the safety and effectiveness of SGLT2i in patients with T2DM in real-world setting.

METHODS

This was a prospective observational longitudinal study involving consecutive patients with T2DM, initiated on SGLT2i from 1 April 2015 to 31 March 2016. The adverse effects and metabolic parameters were evaluated at 3 monthly intervals up to 1 year.

RESULTS

Total 486 patients were initiated on SGLT2i. At baseline, mean age, glycosylated haemoglobin (HbA1c), and weight was 51.03 ± 9.82 years, 8.76 ± 1.59%, and 89.32 ± 16.04 kg, respectively. Data of 388 patients were available at 6 months of follow-up for analysis of adverse effects profile. About 38.6% patients experienced adverse effects. Genitourinary tract infection was the most common adverse effect (20.6%) followed by generalized weakness (10.5%). Significant reduction in mean weight and HbA1c reduction seen at 6 months (n = 202): 3.2 kg and 1.26%, respectively, and at 12 months (n = 104): 3.9 kg and 1.27%, respectively.

CONCLUSION

In this real-world study of patients with T2DM living in hot climate, use of SGLT2i was associated with adverse effects in higher proportion of patients than those reported in clinical trials, but effectiveness was comparable. Patient guidance regarding adequate hydration and hygiene can maximize the benefits of this promising class of drugs.

Supplementation with Three Different Daily Doses of Vitamin D3 in Healthy Pre-pubertal School Girls: A Cluster Randomized Trial

OBJECTIVE

To compare the adequacy and efficacy of different doses of vitamin D3 in pre-pubertal girls.

DESIGN

Cluster Randomized controlled trial.

SETTING

Public school in Delhi, India, between August 2015 and February 2016.

PARTICIPANTS

216 healthy pre-pubertal girls, aged 6.1-11.8 years.

INTERVENTION

Daily supplementation with 600 IU (n=74), 1000 IU (n=67) or 2000 IU (n=75) of vitamin D3 under supervision for 6 months.

OUTCOME MEASURES

Primary: Rise in serum 25 hydroxy Vitamin D (25(OH)D); Secondary: Change in bone formation and resorption markers.

RESULTS

Following 6 months of supplementation, the mean (SD) rise in serum 25(OH)D was maximum with 2000 IU (24.09 (8.28) ng/mL), followed by with 1000 IU (17.96 (6.55) ng/mL) and 600 IU (15.48 (7.00) ng/mL). Serum 25(OH)D levels of ≥20 ng/mL were seen in 91% in 600 IU group , 97% in 1000 IU group and 100% in 2000 IU group. The overall mean (SD) rise in urinary calcium creatinine ratio (0.05 (0.28) to 0.13 (0.12) mg/mg), and serum procollagen type I N-terminal propeptide (538.9 (199.78) to 655.5 (218.24) ng/mL), and reduction in serum carboxy-terminal telopeptide (0.745 (0.23) to 0.382 (0.23) ng/mL) was significant (P<0.01). The change in the above parameters was comparable among the three groups after adjustment for age.

CONCLUSIONS

Daily vitamin D supplementation with 600 IU to 2000 IU for 6 months results in Vitamin D sufficiency in >90% of pre-pubertal girls.

Once Weekly Dulaglutide Therapy in Type 2 Diabetic Subjects, Real-world Evidence from a Tertiary Care Diabetes Center in India

AIMS

To evaluate the real-world efficacy, durability, and side-effect profile of once weekly GLP1RA: dulaglutide in Indian type 2 diabetes mellitus (T2DM) patients.

MATERIALS AND METHODS

A retrospective observational study. Data for efficacy (HbA1c and weight), adherence/discontinuation and patient reported side-effects, of 117 patients who were prescribed dulaglutide were analyzed.

RESULTS

Final analysis was done on complete data of 74 patients (6 months follow-up), this indicated that dulaglutide is effective (mean-reduction at 6 months of: HbA1c; 0.87% and weight; 3.8 kg). Subjects with a poorer glycemic control (greater HbA1c) or greater weight at initiation had a better fall in HbA1c and weight reduction at the end of the study. The most common side-effects were gastrointestinal (15% nausea and 6% loose motions). Also, 25% (n = 19) of our study subjects discontinued dulaglutide because of gastrointestinal side-effects.

CONCLUSION

Our real-world experience is well aligned to systematic data of the randomized controlled trials (RCTs) regarding the efficacy of dulaglutide in the treatment of T2DM (our study vs. RCTs; HbA1c reduction: 0.87% vs. 0.78% to 1.64%, weight reduction: 3.8 vs. 0.3 to 3 kg). The most common side-effects and reason for discontinuation were gastrointestinal side-effects. Finally, by virtue of their observed benefit, we expect a superior cardiovascular risk-reduction with dulaglutide use in our population.

Judicious use of DXA-BMD in assessing fracture risk by using clinical risk factors in the Indian population

FRAX scores were significantly higher in patients admitted with fragility fractures than controls and can be useful in choosing the right patients for bone density testing, thus using of an expensive test judiciously.

PURPOSE

This study was planned to compare the FRAX scores for the risk for major osteoporotic fracture (FRAX-MOF) and hip fracture (FRAX-HF) in patients with fragility fractures (cases) and those admitted for other indications (controls) in the orthopedic ward in our institute.

METHODS

Historical and anthropometric data were prospectively recorded from 500 consecutive patients admitted in the orthopedic ward in in Medanta, the Medicity, Gurgaon, India. The receiver operating characteristic (ROC) curves were constructed for FRAX-MOF and FRAX-HF and the area under the curve (AUC) was calculated between cases and controls.

RESULTS

The FRAX-MOF was significantly high in cases as compared to controls (7.34 ± 4.41 versus 5.64 ± 4.3; p = 0.001). The FRAX-HF was also significantly high in cases as compared to controls (2.95 ± 3.13 versus 1.67 ± 2.21; p < 0.001). The areas under the curves were 0.627 for FRAX-MOF and 0.654 for FRAX-HF. For FRAX-MOF, a cutoff of 2 has a 90% sensitivity, but only 15% specificity; whereas a cutoff of 10.5 had a specificity of 90% to differentiate those with and without fractures, but only 23% sensitivity. For FRAX-HF, a cutoff 0.3 had about 90% sensitivity and 20% specificity, whereas a cutoff of 3.5 had 90% specificity and 25% specificity to differentiate cases and controls.

CONCLUSIONS

This study compared the FRAX-MOF and FRAX-HF in patients with and without fragility fractures and derived cutoffs for practical clinical use of FRAX-MOF and FRAX-HF to optimize the use of DXA-BMD.

Effect of Empagliflozin on Liver Fat in Patients With Type 2 Diabetes and Nonalcoholic Fatty Liver Disease: A Randomized Controlled Trial (E-LIFT Trial)

OBJECTIVE

Sodium-glucose cotransporter 2 (SGLT-2) inhibitors have been shown to reduce liver fat in rodent models. Data regarding the effect of SGLT-2 inhibitors on human liver fat are scarce. This study examined the effect of empagliflozin (an SGLT-2 inhibitor) on liver fat in patients with type 2 diabetes and nonalcoholic fatty liver disease (NAFLD) by using MRI-derived proton density fat fraction (MRI-PDFF).

RESEARCH DESIGN AND METHODS

Fifty patients with type 2 diabetes and NAFLD were randomly assigned to either the empagliflozin group (standard treatment for type 2 diabetes plus empagliflozin 10 mg daily) or the control group (standard treatment without empagliflozin) for 20 weeks. Change in liver fat was measured by MRI-PDFF. Secondary outcome measures were change in alanine transaminase (ALT), aspartate transaminase (AST), and γ-glutamyl transferase (GGT) levels.

RESULTS

When included in the standard treatment for type 2 diabetes, empagliflozin was significantly better at reducing liver fat (mean MRI-PDFF difference between the empagliflozin and control groups -4.0%; P < 0.0001). Compared with baseline, significant reduction was found in the end-of-treatment MRI-PDFF for the empagliflozin group (16.2% to 11.3%; P < 0.0001) and a nonsignificant change was found in the control group (16.4% to 15.5%; P = 0.057). The two groups showed a significant difference for change in serum ALT level (P = 0.005) and nonsignificant differences for AST (P = 0.212) and GGT (P = 0.057) levels.

CONCLUSIONS

When included in the standard treatment for type 2 diabetes, empagliflozin reduces liver fat and improves ALT levels in patients with type 2 diabetes and NAFLD.

Cutaneous mucormycosis as a presenting feature of type 1 diabetes in a boy - case report and review of the literature

BACKGROUND

Mucormycosis is a potentially fatal complication of diabetes. The rhino-orbito-cerebral form is the most common presentation, however, rarely other types can also be seen.

CASE PRESENTATION

We describe the case of a 4½ -year-old boy not previously known to be a diabetic who presented to the plastic surgery department for gangrene of the left middle finger with surrounding erythema and induration. After the diagnosis of diabetes and initial treatment, pus from the wound showed broad aseptate hyphae suggestive of mucormycosis which was further confirmed on culture. Aggressive surgical debridement including amputation, antifungal treatment and glycemic control achieved a complete cure.

CONCLUSIONS

Cutaneous mucormycosis is a rare complication of type 1 diabetes mellitus and can even be seen at the onset of diabetes. High index of suspicion, timely antifungal treatment and aggressive surgical debridement usually lead to recovery in the localized form of the disease.

Correction to: Global dietary calcium intake among adults: a systematic review

The original Electronic Supplementary Material file 3 contained an erroneous reference for Mali. A link to the corrected file is provided here.

Association of insulin-like growth factor-1 and IGF binding protein-3 with 25-hydroxy vitamin D in pre-pubertal and adolescent Indian girls

BACKGROUND

There is a high prevalence of vitamin D deficiency (VDD) in India. Molecular mechanisms suggest a strong relationship between vitamin D and growth factors. However, there is a paucity of literature with regard to a relationship between insulin-like growth factor-1 (IGF-1), insulin-like growth factor binding protein-3 (IGFBP-3) and vitamin D particularly in subjects with VDD. The objective of the study was to assess the relationship between growth factors and serum vitamin D-parathormone (PTH) status in school girls and study the impact of vitamin D supplementation on growth factors in pre-pubertal girls with VDD.

METHODS

Our study subjects were apparently healthy school girls aged 6-18 years. The baseline height, weight, body mass index (BMI), pubertal status, serum 25-hydroxy vitamin D (25OHD), PTH, IGF-1 and IGFBP-3 were assessed in 847 girls aged 6-18 years and in 190 pre-pubertal girls with VDD following supplementation.

RESULTS

The mean age, BMI and serum 25OHD of girls were 11.5±3.2 years, 18.7±4.8 kg/m2 and 9.9±5.6 ng/mL, respectively. VDD was observed in 94.6% of girls. Unadjusted serum IGF-1 levels and IGF-1/IGFBP-3 molar ratio were significantly higher in girls with severe VDD as compared to girls with mild-to-moderate VDD. However, these differences disappeared when adjusted for age, height or sexual maturation. The serum IGF-1 and IGFBP-3 levels increased significantly post supplementation with vitamin D.

CONCLUSIONS

There were no differences in serum IGF-1 levels and the IGF-1/IGFBP-3 molar ratio among VDD categories when adjusted for age, height and sexual maturation in girls. Vitamin D supplementation resulted in a significant increase in serum IGF-1 levels in VDD pre-pubertal girls.

Pitfalls in interpreting interventional studies for osteoporosis

After adulthood, changes in the skeleton are slow and takes years for accruing or losing any appreciable amount of bone mass. Proper interpretation of studies that evaluate the effect of nutrients (like calcium, vitamin D) and anti-resorptive agents (like bisphosphonates) on bone mass is important so that the true effect of the agent is measured correctly. In this report, we are highlighting two issues of utmost importance for correctly interpreting interventional studies for osteoporosis. One issue is the bone remodelling transient (BRT). It refers to a transient change in bone mineral density (BMD) by any agent that reduces remodeling space temporarily. This change is, however, not sustained for a long period and can be misinterpreted as a true gain in bone mass. The second issue is difference between calcium balance and bone balance. Calcium balance is the difference between the amount of calcium ingested in a day and the amount of calcium lost in that day. Recommendations for dietary calcium intake are based on calcium balance studies that presume calcium balance as an equivalent for bone balance. However, these are two different entities and need to be distinguished. Dietary calcium requirements should be established by bone balance studies using bone densitometry, not by calcium balance studies.

Glucocorticoid sparing effect of zoledronic acid in sarcoid hypercalcemia

INTRODUCTION

Glucocorticoids are regarded as first-line therapy in the management of hypercalcemia associated with sarcoidosis. However, prolonged glucocorticoid therapy leads to metabolic abnormalities, Cushingoid habitus, and impairment of bone health. This study demonstrates the efficacy and glucocorticoid-sparing effect of zoledronic acid in sarcoid hypercalcemia.

METHODS

We present three patients with sarcoid hypercalcemia. They were successfully managed with oral glucocorticoids for many months. However, all patients developed adverse effects of glucocorticoids. When tapering of glucocorticoids was attempted, hypercalcemia recurred. Zoledronic acid was administered in order to control hypercalcemia and to allow tapering of glucocorticoids.

RESULTS

Following zoledronic acid administration, serum calcium level normalised and glucocorticoids could be discontinued in all the three patients. Normocalcemia was maintained for an average of 18 months after a single infusion. Sarcoidosis remained in remission in all the three patients.

CONCLUSION

Zoledronic acid should be studied as a potential first-line agent for sarcoid hypercalcemia. Furthermore, disease-modifying effects of zoledronic acid in sarcoidosis should be investigated.

Global dietary calcium intake among adults: a systematic review

Low calcium intake may adversely affect bone health in adults. Recognizing the presence of low calcium intake is necessary to develop national strategies to optimize intake. To highlight regions where calcium intake should be improved, we systematically searched for the most representative national dietary calcium intake data in adults from the general population in all countries. We searched 13 electronic databases and requested data from domain experts. Studies were double-screened for eligibility. Data were extracted into a standard form. We developed an interactive global map, categorizing countries based on average calcium intake and summarized differences in intake based on sex, age, and socioeconomic status. Searches yielded 9780 abstracts. Across the 74 countries with data, average national dietary calcium intake ranges from 175 to 1233 mg/day. Many countries in Asia have average dietary calcium intake less than 500 mg/day. Countries in Africa and South America mostly have low calcium intake between about 400 and 700 mg/day. Only Northern European countries have national calcium intake greater than 1000 mg/day. Survey data for three quarters of available countries were not nationally representative. Average calcium intake is generally lower in women than men, but there are no clear patterns across countries regarding relative calcium intake by age, sex, or socioeconomic status. The global calcium map reveals that many countries have low average calcium intake. But recent, nationally representative data are mostly lacking. This review draws attention to regions where measures to increase calcium intake are likely to have skeletal benefits.

Influence of gastrointestinal events on treatment of osteoporosis in Asia-Pacific women: Perspectives from physicians in the MUSIC OS-AP study

BACKGROUND

The objectives of the physician survey component of the MUSIC OS-AP study were to describe physicians' approaches to treatment of women with postmenopausal osteoporosis and to understand the influence of gastrointestinal (GI) events on treatment in clinical practice.

METHODS

Physicians were recruited from 5 Asia-Pacific countries. Questionnaires collected information about physicians' standard practices for treatment of patients with osteoporosis, as well as their perspectives on the influence of GI events on osteoporosis treatment approaches.

RESULTS

A total of 59 physicians participated in the study. The most frequently prescribed or recommended treatments were vitamin D (84% of patients), calcium (82%), and oral bisphosphonates (59%). When choosing a medication for treatment-naïve patients, GI sensitivity was often or always a factor for 79% of physicians. Among physicians not prescribing pharmacologic treatment, a mean of 18% of non-prescriptions were due to GI sensitivity. For patients with pre-existing GI conditions, physicians most frequently ranked use of non-oral osteoporosis medication as the first treatment strategy (47%), followed by co-prescription with a proton pump inhibitor or other gastro-protective agent (31%). For patients developing GI symptoms after starting pharmacologic treatment, the most frequently first-ranked management strategy was to check if patients were taking their osteoporosis medication correctly as prescribed (64%), followed by temporary discontinuation of the medication (i.e., a drug holiday) until GI events have resolved (31%) and co-prescription with a proton pump inhibitor or other gastroprotective agent (24%).

CONCLUSIONS

These results suggest that GI events influence the prescribing practices of physicians in the Asia-Pacific region and sometimes result in non-treatment of women with osteoporosis.

The changing profile of hypercalcemia in a tertiary care setting in North India: an 18-month retrospective study

This retrospective study was undertaken to determine the profile of hypercalcemia in all patients who presented to Medanta-The Medicity, a tertiary care hospital in North India. A total of 255,830 patients presented to the hospital during 1^st January 2014 till 30^th June 2015 (18 months). Among them calcium measurement was done in 26,297 (10.2%) patients. A total of 552 patients was found to have hypercalcemia. Among them, 15 (2.7%) patients had transient hypercalcemia and 537 (97.3%) had sustained hypercalcemia. The incidence of hypercalcemia was 2.09%, being transient in 0.05% and sustained in 2.04%. The most common causes in the sustained group were malignancy (23.1%) followed by primary hyperparathyroidism (PHPT, 21.9%). Most cases of PHPT were asymptomatic. Interestingly, we found emergence of two unusual groups of hypercalcemia, namely hypercalcemia of advanced chronic liver disease (n = 34) and vitamin D toxicosis (n = 21) in the non-parathyroid group of hypercalcemia. This changing pattern of hypercalcemia should be kept in mind while evaluating a patient of hypercalcemia in a hospital setting.

Forum for Injection Technique and Therapy Expert Recommendations, India: The Indian Recommendations for Best Practice in Insulin Injection Technique, 2017

Health-care professionals in India frequently manage injection or infusion therapies in persons with diabetes (PWD). Patients taking insulin should know the importance of proper needle size, correct injection process, complication avoidance, and all other aspects of injection technique from the first visit onward. To assist health-care practitioners in their clinical practice, Forum for Injection Technique and Therapy Expert Recommendations, India, has updated the practical advice and made it more comprehensive evidence-based best practice information. Adherence to these updated recommendations, learning, and translating them into clinical practice should lead to effective therapies, improved outcomes, and lower costs for PWD.

Indian Injection Technique Study: Injecting Complications, Education, and the Health Care Professional

INTRODUCTION

Using the Indian and rest of world (ROW) injection technique questionnaire (ITQ) data, we address key insulin injection complications.

METHODS

In 2015 we conducted an ITQ survey throughout India involving 1011 patients. Indian values were compared with those from 41 other countries participating in the ITQ, known here as ROW.

RESULTS

More than a quarter of Indian insulin users described lesions consistent with lipohypertrophy (LH) at their injection sites and approximately 1 in 5 were found to have LH by the examining nurse (using visual inspection and palpation). Just over half of Indian injectors report having pain on injection. Of these, 4 out of 5 report having painful injections only several times a month or year (i.e., not with every injection). Doctors and diabetes educators in India (as opposed to nurses) have a larger role in teaching patients how to inject than they do in ROW. Despite this specialized approach, a very high percentage of patients report that they have not been trained (at least cannot remember being trained) in a wide range of essential injection topics. Only about 30% of Indian injectors get their sites checked at least annually, with nearly a third only having sites checked when they specifically complained and nearly 4 out of 10 never having had their sites checked.

CONCLUSION

Indian HCPs can clearly do a better job covering all the vital topics essential to proper injection habits.

Indian Injection Technique Study: Population Characteristics and Injection Practices

INTRODUCTION

It was estimated that 3.2 million Indians with diabetes injected insulin in 2010, but little is known about the techniques used.

METHODS

In 2015 we conducted an injection technique questionnaire (ITQ) survey throughout India involving 1011 patients. Indian values were compared with those from 41 other countries participating in the ITQ, known here as rest of world (ROW).

RESULTS

Mean HbA1c was 8.6. BMI values in India were 1.5-3 units lower than in ROW depending on patient group, meaning the risk of intramuscular (IM) injections is high in India. The mean total daily dose (TDD) of insulin was lower in every category of Indian patient than in ROW, perhaps reflecting the lower BMI. Needle reuse, whether with pens or syringes, is much higher in India than ROW and so is the number of times the needle is used. The majority (56.8%) of Indian insulin users performed only 2 injections/day as opposed to ROW where 45% of patients performed at least 4 injections/day. Indian patients inject insulin in the thighs more often than patients in ROW, a site where IM injections are more risky. Many patients do not have proper access to sharps containers or have other risk factors that could lead to blood-borne pathogen spread. More than 60% of used sharps in India go into the rubbish, with nearly 12% not even having the minimum protection of a cap.

DISCUSSION

The shortest needles are very common in India; however, the level of needle reuse is high. Multiple daily injections therapy is not as common in India as ROW. More focus needs to be given to dwell times under the skin, reconstitution of cloudy insulins, skinfolds, and safe sharps disposal.