RSSDI-ESI Clinical Practice Recommendations for the Management of Type 2 Diabetes Mellitus 2020

A Review on Affordable Combinations in Type 2 Diabetes Care: Exploring the Cost-Effective Potential of Glipizide + Metformin and Glimepiride + Metformin + Pioglitazone

Management of type 2 diabetes mellitus (T2DM) largely relies on medication adherence of individuals with diabetes to achieve optimal glycemic control. The economic burden of diabetes could impede adherence, leading to a reduction in treatment efficacy and increased risk of complications. Furthermore, monotherapy in diabetes is losing traction due to its ineffectiveness in achieving early and sustained optimal glycemic control in a significant proportion of the population. Hence, clinicians prefer combination treatment due to their improved efficacy and safety. Considering these factors, the current review highlights the safety and efficacy of the affordable combination therapies, a dual therapy, glipizide + metformin, and a triple-drug combination of glimepiride + metformin + pioglitazone and its applicability in the management of T2DM among individuals with diabetes in India.

Dietary total antioxidant capacity of Moroccan Type 2 Diabetes Mellitus patients

AIMS

A new approach to a healthy diet is the assessment of dietary Total Antioxidant Capacity (TAC). The aim of this study was to assess the dietary TAC among Moroccan Type 2 Diabetes Mellitus (T2DM) patients and identify the main food sources contributing to the total antioxidant capacity intake.

METHODS

A total of 254 patients with T2DM was included in the study. The usual dietary intakes were assessed by means of a validated food frequency questionnaire. The dietary TAC was estimated using published databases of the antioxidant content of foods measured by the FRAP (ferric ion reducing antioxidant potential) method.

RESULTS

The mean (SD) dietary TAC of the studied type 2 diabetes patients was 10.86 (3.42) mmol/day. Correlation analyses showed a positive association between dietary TAC and the consumption of healthy food groups, such as fruits and vegetables. Tea and coffee beverages (38.6%), vegetables (21.9%), cereals and pulses (18.8%), fruits and fruit juices (12.4%) were major food sources of dietary antioxidant intake. The relatively short list of twenty food items that contributed most to dietary TAC presented an important explanation of roughly 94%. These included tea, coffee, broad beans, artichoke, pepper, beetroot, sweet potatoes, pomegranate, mandarin, figs, strawberry, orange juice, olives, cashew nuts, almonds, sunflower seeds, dchicha and white beans.

CONCLUSIONS

This study supplies baseline dietary TAC data for Moroccan T2DM patients that may help to elucidate which aspects of the eating habits and behaviours require improvement and provide the opportunity to develop dietary guidelines as part of the nutritional diabetes management.

Effectiveness, Weight Changes, and Metabolic Outcomes on Switch to Generic Dolutegravir/Lamivudine Among People with HIV in Western India: An Observational Study

We assessed the effectiveness and safety of switching to generic dolutegravir/lamivudine (DTG/3TC) among People living with Human Immunodeficiency Virus (PWH) in Western India. In this single-center, retrospective observational study, PWH, who switched to DTG/3TC, were followed for virologic, immunologic, and clinical effectiveness, and safety, including weight changes, hyperglycemia, and dyslipidemia. Multivariate linear mixed-effects models were used to predict average change in weight adjusted for age, sex, duration of previous antiretroviral (ARV) regimens, and baseline weight. From May 2017 to July 2022, out of 434 PWH switched to DTG/3TC, 304 with at least 1 follow-up visit were included. Median [interquartile range (IQR)] age was 54 (IQR 49-61) years and 70.1% were male. Prevalence of baseline comorbidities was 57.9% (hypertension-41.5%, chronic kidney disease-40.9%, and diabetes mellitus-18.8%). Reasons for switch were affordability (47.4%), desire for simplification (41.8%), ARV toxicities (19.1%), and concern about potential toxicities (10.2%). Median (IQR) duration of follow-up on DTG/3TC was 40 (IQR 31-49) weeks. No virologic failure was observed. Rates of virologic suppression [viral load (VL) ≤20 copies/mL or target not detected (TND)] at 12, 24, 48, 72, 96 and 120 weeks were 95.2%, 95.9%, 90%, 100%, 81.3%, and 88.4%, respectively. Only 9 (3%) PWH permanently discontinued DTG/3TC. Predicted adjusted mean weight gain of +3.3 kg was observed at 96 weeks. Switching from tenofovir disoproxil fumarate (TDF)/emtricitabine or lamivudine (XTC)/non-nucleoside reverse transcriptase inhibitor (NNRTI) and duration on DTG/3TC were significantly associated with weight gain. Apart from trend in worsening hyperglycemia (nine PWH with new onset diabetes), no clinically significant change in lipids and estimated glomerular filtration rate (eGFR) was documented. Switching to DTG/3TC is an effective and safe option among virologically suppressed PWH with high comorbidity burden in India. In view of the several advantages of DTG/3TC, it may be considered for potential scale-up in the right population, both in private and public health care settings in India.

Real-World Assessment of Personalized Approach With Voglibose Fixed-Dose Combination in Type 2 Diabetes Mellitus

BACKGROUND

Post-prandial hyperglycemia (PPHG) remains a complex aspect in the management of type 2 diabetes mellitus (T2DM) in the Indian population due to uncertainty in the optimal utilization of alpha-glucosidase inhibitors (AGIs) either as standalone therapy or in combination, whether initiated initially or as a sequential therapy.

METHODS

This was a post-approval, observational, multicentric clinical study conducted at 50 centers according to principles of the International Council for Harmonisation of Technical Requirements of Pharmaceuticals for Human Use Guideline for Good Clinical Practice (ICH-GCP) and Declaration of Helsinki and local ethics approval. Descriptive and analytical statistics were applied for conclusion and categorical variables using SPSS version 29.0.1.0 (171) (Armonk, NY: IBM Corp.).

RESULTS

Protocol analyses of 515 cases revealed baseline demographics as follows: age 57.35±10.04 years, weight 72.86±10.92 kg, and BMI 28.33±6.07 kg/m2. Comorbidities included hypertension (N=169, 32.82%), thyroid disorders (N=99, 19.22%), and heart failure (N=92, 17.86%). Concomitant oral antidiabetics (OADs) prescribed as DPP4i (9.50%), SGLT2i (19.20%), and DPP4i+SGLT2i (7.20%). Study drug reduced glycosylated hemoglobin (HbA1c) by 13.77% (1.25% mean change, p<0.01), fasting blood glucose (FBG) by 23.69% (44.61 mg/dL mean change, p<0.01), post-prandial blood glucose (PPBG) by 24.57% (70.46 mg/dL mean change, p<0.01), and body weight by 4.43% (3.21 kg mean change, p<0.01) over 12 weeks. A total of 161 patients accomplished targeted PPBG of <180 mg/dL (119.13 mg/dL mean change, p<0.01). Regression analysis considering PPBG and HbA1c ≤7.5% showed a weak correlation between them (R-value=0.13, R-squared value=0.02), whereas between PPBG and HbA1c ≤9% yielded moderate positive correlation (R-value=0.53, R-squared value=0.28). There were no adverse events reported or analyzed during the observation period.

CONCLUSION

Voglibose fixed-dose combination (FDC) demonstrates significant effectiveness at the initial dosage when started early in the management of T2DM and high PPBG levels. Moreover, it exhibits good tolerability, thereby contributing to higher compliance among Indian patients who consume a high-carbohydrate diet.

Observational, Multicenter, Retrospective, Study on the Usage Patterns of the Fixed Dose Combination of Glimepiride, Metformin, and Voglibose in Type 2 Diabetes Management

Objective This study aimed to evaluate and analyze the characteristics of Indian patients with type 2 diabetes mellitus (T2DM) in relation to the usage patterns of a fixed-dose combination (FDC) of glimepiride, metformin, and voglibose. Methods This retrospective, observational, multicentric analysis was conducted from March 2021 to September 2022. It involved adult patients (aged ≥18 years) with T2DM from 424 sites including a combination of hospitals and privately owned clinics across India to ensure comprehensive representation of the patient population The study included patients who had been treated with FDC of glimepiride, metformin, and voglibose of varying strengths for T2DM management. Data were collected through a pre-designed electronic form, which captured demographic details, medical history, T2DM history, and drug usage patterns from medical records. The collected data were then analyzed using descriptive statistical methods. Results This analysis encompassed a final cohort of 8,587 patients out of which 5,840 were males with a mean age of 54.91 years and a BMI of 28.41 kg/m2. Newly diagnosed T2DM cases were 35.23%, 54.79% had a family history, and 61.21% had risk factors such as smoking, sedentary lifestyle, and others. Dyslipidemia (13.94%) and neuropathy (14.48%) were common comorbidities. The most prescribed FDC was 1 mg glimepiride, 500 mg metformin, 0.2 mg voglibose (40.14%), the most preferred dosing frequency was once daily (52.92%) and the most common duration of treatment was one to three months (48.78%). Conclusion In routine Indian clinical practice, the triple drug FDC of 1 mg glimepiride, 500 mg metformin, and 0.2 mg voglibose, taken once daily for one to three months, was the most common treatment for both newly diagnosed and long-standing diabetes patients.

Society of Defence Anaesthesiologists review and recommendations for the provision of anaesthesia for elective dental procedures in various echelons of dental care

Oral diseases are a burden for developing countries such as India where owing to socioeconomic conditions cost is a factor in selecting the type of treatment. Dental care in India is provided at various levels of care including standalone clinics run by individual dental surgeons, multi-speciality dental centres providing specialist care under one roof including paediatric, prosthodontics, and so on and dental centres affiliated with hospitals having facilities for provision of operation theatre and anaesthesia services. Most dental procedures are performed as day-care procedures requiring local anaesthetics, oral, or moderate intravenous sedation and anxiolytics while maxillofacial procedures are carried out in a controlled operation theatre setting. Dental procedures are fraught with risks due to shared oral surgical space and airway leading to reduced field of visibility to dentists especially with the usage of supplementary oxygenation devices, mouth props, and so on. Various dental societies have proposed minimum standards of care for provision of anaesthesia to various dental procedures; however, there are no extant guidelines in our country. The authors propose these guidelines for provision of minimal sedation (anxiolysis) and moderate sedation/analgesia for various day care dental procedures at various levels of care, keeping the aim that no patient’s life is endangered during provision of anaesthesia services at all dental locations.

Identification of Genetic Variation Influencing Metformin Response in a Multiancestry Genome-Wide Association Study in the Diabetes Prevention Program (DPP)

Genome-wide significant loci for metformin response in type 2 diabetes reported elsewhere have not been replicated in the Diabetes Prevention Program (DPP). To assess pharmacogenetic interactions in prediabetes, we conducted a genome-wide association study (GWAS) in the DPP. Cox proportional hazards models tested associations with diabetes incidence in the metformin (MET; n = 876) and placebo (PBO; n = 887) arms. Multiple linear regression assessed association with 1-year change in metformin-related quantitative traits, adjusted for baseline trait, age, sex, and 10 ancestry principal components. We tested for gene-by-treatment interaction. No significant associations emerged for diabetes incidence. We identified four genome-wide significant variants after correcting for correlated traits (P < 9 × 10-9). In the MET arm, rs144322333 near ENOSF1 (minor allele frequency [MAF]AFR = 0.07; MAFEUR = 0.002) was associated with an increase in percentage of glycated hemoglobin (per minor allele, β = 0.39 [95% CI 0.28, 0.50]; P = 2.8 × 10-12). rs145591055 near OMSR (MAF = 0.10 in American Indians) was associated with weight loss (kilograms) (per G allele, β = -7.55 [95% CI -9.88, -5.22]; P = 3.2 × 10-10) in the MET arm. Neither variant was significant in PBO; gene-by-treatment interaction was significant for both variants [P(G×T) < 1.0 × 10-4]. Replication in individuals with diabetes did not yield significant findings. A GWAS for metformin response in prediabetes revealed novel ethnic-specific associations that require further investigation but may have implications for tailored therapy.

Insulin injection practice and health related quality of life among individuals with diabetes at Tikur Anbessa Specialized Hospital, Ethiopia: a cross-sectional study

BACKGROUND

Insulin therapy can be inconvenient, painful, burdensome, and restrict patients' daily activities and health related quality of life (HRQOL) due to improper injection techniques or the nature of administration.

OBJECTIVE

This study aimed to assess insulin injection practice, HRQOL and predictors among patients treated with insulin at Tikur Anbessa Specialized Hospital (TASH).

METHODS

An institutional-based cross-sectional study was conducted among diabetes patients on insulin therapy from May to June 2022. A structured questionnaire was used to collect patient characteristics and insulin injection practice. The validated Amharic version of an EQ-5D-5L tool was used to assess the HRQOL. The data was analyzed using SPSS version 26. The patient data were summarized using descriptive statistics. One-way ANOVA using Kruskal-Wallis H tests was used to assess factors that predict insulin handling practice scores. Multivariate linear regression analysis was used to assess factors affecting HRQOL among diabetes patients treated with insulin. The EQ5D-5L utility scores of the patients were calculated using disutility coefficients taken from the Ethiopian general population. Statistical significance was declared at p-value < 0.05.

RESULTS

Of 319 patients who agreed and completed the survey, 51.1% of them were males. Almost half of the participants (n = 158) were > 50 years of age. Among the study participants, 62.1% were only on intermediate acting insulin. A significantly higher proportion of participants 291(91.2%) in this study were taking insulin two times per day. Most of the participants 234(73.4%) had fair practice with a median insulin handling practice score of 38 out of 56. Patient characteristics such as age, educational status, occupation, disease duration, and type of diabetes were significantly association with insulin injection practice (p < 0.05). The mean ± SD utility score of patients were 0.89 ± 0.19 (ranged from -0.04 to 1). Being female (β = -5.42, 95%CI:-8.63,-2.21, p = 0.001) and treated for type-I diabetes mellitus (β =  + 9.04, 95%CI: 4.23,13.85, p-value < 0.0001) were significantly associated with HRQOL of patients on insulin therapy.

CONCLUSION

The study participants had fair practices in insulin handling, storage, and administration techniques, and it was seen that male and type one diabetes patients have a better quality of life compared to their counterparts.

Time to reposition sulfonylureas in type 2 diabetes management in Indian context: A pragmatic practical approach

Sulfonylureas (SU) continue to be a vital therapeutic category of oral hypoglycemic agents (OHAs) for the management of type 2 diabetes mellitus (T2DM). Physicians consider modern SU (gliclazide and glimepiride) as "safe and smart" choices for T2DM management. The presence of multiple international guidelines and scarcity of a national guideline may contribute to the challenges faced by few physicians in choosing the right therapeutic strategy. The role of SU in diabetes management is explicit, and the present consensus aims to emphasize the benefits and reposition SU in India. This pragmatic, practical approach aims to define expert recommendations for the physicians to improve caregivers' knowledge of the management of T2DM, leading to superior patient outcomes.

Content and quality of clinical practice guidelines for the management of type 2 diabetes in India: A systematic review

INTRODUCTION

Over the last few decades, India has witnessed an increase in the number of people with type 2 diabetes mellitus (T2DM). Consequently, several clinical practice guidelines (CPGs) have been developed to assist western and traditional Indian medicine practitioners in managing this disease. This systematic review aimed to evaluate and synthesize the content and quality of these CPGs.

METHODS

Several databases and sources were searched from inception to May 2022, to identify CPGs for managing adults with T2DM in India. The screening of titles and abstracts and full texts, data extraction and quality assessment were conducted by two independent reviewers. Any disagreements were resolved through discussion or by involving a third reviewer. A data extraction tool from a previous study was adapted to extract the content of the included CPGs, and the Appraisal of Guidelines for Research and Evaluation II tool was used to assess the quality of the included CPGs. A narrative synthesis was conducted.

RESULTS

Of 3350 records identified, 11 were retrieved for full-text screening and five CPGs were included in this systematic review-three focused on traditional Indian medicine (Ayurveda) and two focused on western medicine. These two western medicine CPGs contained comprehensive recommendations for managing T2DM but only one of these, the Research Society for the Study of Diabetes in India/Endocrine Society of India (RSSDI/ESI) CPG, was of high quality.

CONCLUSIONS

Only one CPG can be recommended for managing T2DM by western medicine practitioners in India. Future CPGs, especially for traditional Indian medicine practitioners, should be developed and updated using the standard CPG manuals and quality appraisal tools.

REGISTRATION

PROSPERO (CRD42021279499).

P, Unnikrishnan AG, Thacker H, Sethi B, Chowdhury S, Sugumaran A, Mohanasundaram S, Menon SK, Salvi V, Chodankar D, Thaker S, Trivedi C, Wangnoo SK, Zargar AH, Rais N. Two-year trends from the LANDMARC study: A 3-year, pan-India, prospective, longitudinal study on the management and real-world outcome in patients with type 2 diabetes mellitus

INTRODUCTION

There are limited data on the real-world management of diabetes in the Indian population. In this 2-year analysis of the LANDMARC study, the management of type 2 diabetes mellitus (T2DM) and related complications were assessed.

METHOD

This multicenter, observational, prospective study included adults aged ≥25 to ≤60 years diagnosed with T2DM (duration ≥2 years at enrollment) and controlled/uncontrolled on ≥2 anti-diabetic agents. This interim analysis at 2 years reports the status of glycaemic control, diabetic complications, cardiovascular (CV) risks and therapy, pan-India including metropolitan and non-metropolitan cities.

RESULTS

Of the 6234 evaluable patients, 5318 patients completed 2 years in the study. Microvascular complications were observed in 17.6% of patients (1096/6234); macrovascular complications were observed in 3.1% of patients (195/6234). Higher number of microvascular complications were noted in patients from non-metropolitan than in metropolitan cities (p < .0001). In 2 years, an improvement of 0.6% from baseline (8.1%) in mean glycated haemoglobin (HbA1c) was noted; 20.8% of patients met optimum glycaemic control (HbA1c < 7%). Hypertension (2679/3438, 77.9%) and dyslipidaemia (1776/3438, 51.7%) were the predominant CV risk factors in 2 years. The number of patients taking oral anti-diabetic drugs in combination with insulin increased in 2 years (baseline: 1498/6234 [24.0%] vs. 2 years: 1917/5763 [33.3%]). While biguanides and sulfonylureas were the most commonly prescribed, there was an evident increase in the use of dipeptidyl peptidase-IV inhibitors (baseline: 3049/6234, 48.9% vs. 2 years: 3526/5763, 61.2%).

CONCLUSION

This longitudinal study represents the control of T2DM, its management and development of complications in Indian population.

CLINICAL TRIAL REGISTRATION NUMBER

CTRI/2017/05/008452.

Expert Consensus Recommendations on Time in Range for Monitoring Glucose Levels in People with Diabetes: An Indian Perspective

Keeping up with the global scenario, diabetes prevalence is on rise in India. Inadequate glycemic control is a major cause of diabetes-related morbidity and mortality. The conventional standards of care (SOC) in diabetes, including self-monitoring of blood glucose and measurement of glycated hemoglobin, have supported achievement of glycemic control, yet there are a few limitations. With the use of current technologies and metrics, such as continuous glucose monitoring (CGM) and standardized CGM data reporting, the continuous real-time glucose levels can be measured, and importantly, the percentage of time above, below, and within the target glucose range can be calculated, which facilitates patient-centric care, a current goal in diabetes management. International consensus recommendations endorse the incorporation of CGM and CGM data reporting in SOC for diabetes management. The guidelines provide time in range (TIR) thresholds for different patient populations and different types of diabetes. However, extrapolation of these global guidelines does not aptly cover the Indian population, which has diverse diet, culture, and religious practices. In this context, a consensus meeting was held in India in 2021 with experts in the field of diabetes care. The purpose of the meeting was to develop consensus recommendations for TIR thresholds for different patient profiles in India. Those expert recommendations, together with an evidence-based review, are reported here. The aim of this agreement is to aid clinicians across India to routinely use CGM and CGM data reports for optimizing individualized diabetes care, by implementing clinical targets for TIR.

A study to evaluate the knowledge, vaccination status and acceptance of adult vaccinations against respiratory infections in patients with type 2 diabetes in South India

Introduction

Respiratory infections like influenza and pneumococcus increase mortality, morbidity, hospitalisation risks and healthcare costs in people with type 2 diabetes which can be prevented by vaccinations. However, there is not much data regarding how many people with type 2 diabetes in India receive pneumococcal and influenza vaccinations.

Methods

This is a cross-sectional study conducted between March 2022 to May 2022 at a tertiary care centre in South India. Patients were interviewed through face to face questionnaire regarding awareness, knowledge of influenza and pneumococcal infections, availability and need of vaccines, vaccination status and the possible reasons for not receiving vaccines.

Results

A total of 388 patients were recruited in the study. Knowledge about influenza and pneumococcal infections were present only in 4.8% and 4.1% respectively. And 98.7% of patients had no awareness about the availability and need for vaccines. Only 0.5% and 0.7% of patients received influenza and pneumococcal vaccinations respectively. After counselling and spreading awareness, 76.2% of patients said that they would receive vaccination in the next visit. Also, 23.19% of the patients refused to take any vaccinations even after counselling. And 23.7% of patients feared complications after vaccinations.

Conclusion

Pneumococcal and Influenza vaccination uptake rates are extremely low in people with type 2 diabetes in India. Urgent measures are required to increase the awareness in patients and healthcare workers about the availability, need for vaccinations and effectiveness of vaccines which would lead to improvement in vaccination rates.

Evolution of Guideline Recommendations on Insulin Therapy in Type 2 Diabetes Mellitus Over the Last Two Decades: A Narrative Review

The prevalence of type 2 diabetes mellitus has been increasing worldwide. As the therapeutic options for type 2 diabetes mellitus have evolved over the last 2 decades, national and global guidelines related to type 2 diabetes mellitus pharmacotherapy issued by various organizations have tended to vary in their recommendations. This narrative review aimed to analyze the key recommendations by major global and national guidelines on the initiation of insulin therapy in patients with type 2 diabetes mellitus over the last 20 years. Strategies for insulin therapy for titration and intensification were also assessed. All guidelines recommend initiation of insulin (basal/ premixed/other formulations) when glycemic targets are not achieved despite lifestyle measures and oral antidiabetic drugs. In the recent decade, early initiation of insulin has been recommended when the glycated hemoglobin levels are >10% or blood glucose levels are ≥300 mg/dL (16.7 mmol/L). Initiation is recommended at a dose of 10 units or 0.1-0.2 U/kg. Titration is advised to achieve the optimal dosage, while intensification is recommended when glycemic targets are not achieved despite titrating to an acceptable level. Glucose monitoring at periodic intervals is recommended for adequate glycemic control. The guidelines further suggest that the choice of insulin should be individualized, considering the clinical status of patients with type 2 diabetes mellitus. The physicians as well as patients should be a part of the decisions made regarding the therapeutic choice of regimen, preparation, and delivery device.

Comparison of gliclazide vs linagliptin on hypoglycemia and cardiovascular events in type 2 diabetes mellitus: A systematic review

BACKGROUND

Cardiovascular outcome trials have demonstrated cardiovascular safety of glimepiride (a sulfonylureas) against dipeptidyl peptidase-4 inhibitor linagliptin. Gliclazide (another newer sulfonylureas) has shown similar glycemic efficacy and 50% decreased risk of hypoglycemia compared to glimepiride.

AIM

Considering the absence of cardiovascular outcome trials for gliclazide, we decided to conduct a systematic review of the literature to assess the car-diovascular (CV) safety by assessing the risk for major adverse CV events and hypoglycemia risk of gliclazide vs linagliptin in patients with type 2 diabetes (T2D).

METHODS

This systematic review followed the current Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to analyze all the clinical studies published from 2008 that compared the two drugs in patients with T2D with no risk of CV disease (CVD). We included only evidence designated high quality by the Oxford Center for Evidence-based Medicine-Levels of Evidence.

RESULTS

Eight clinical studies were included in the narrative descriptive analysis (gliclazide: 5 and linagliptin: 3). The CV safety of gliclazide in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation trial and of linagliptin in the Cardiovascular and Renal Microvascular Outcome Study With Linagliptin (CARMELINA) and CARdiovascular Outcome study of LINAgliptin vs glimepiride in patients with T2D (CAROLINA) trials were excluded from the comparative analysis as these trials demonstrated CV and hypoglycemia benefits in patients at high risk of CVD. However, since these are landmark trials, they were discussed in brief to show the CV benefits and low hypoglycemia risk of gliclazide and linagliptin. We did not find any study comparing gliclazide with linagliptin. Hence, direct comparison of their major adverse CV events and hypoglycemia risk could not be carried out. However, the literature meeting the inclusion criteria showed that both drugs were effective in achieving the desired glycemic control and had low major adverse CV events and hypoglycemia risk in adult patients with no history of CVD.

CONCLUSION

Gliclazide can be considered an effective and safe glucose-lowering drug in T2D patients with no established CVD but at high risk of CVD due to their T2D status. Future randomized controlled trials comparing gliclazide with linagliptin or dipeptidyl peptidase-4 inhibitors can confirm these findings.

Insight into the physiological and pathological roles of the aryl hydrocarbon receptor pathway in glucose homeostasis, insulin resistance, and diabetes development

The aryl hydrocarbon receptor (AhR) is a ligand-activated transcriptional factor that mediates the toxicities of several environmental pollutants. Decades of research have been carried out to understand the role of AhR as a novel mechanism for disease development. Its involvement in the pathogenesis of cancer, cardiovascular diseases, rheumatoid arthritis, and systemic lupus erythematosus have long been known. One of the current hot research topics is investigating the role of AhR activation by environmental pollutants on glucose homeostasis and insulin secretion, and hence the pathogenesis of diabetes mellitus. To date, epidemiological studies have suggested that persistent exposure to environmental contaminants such as dioxins, with subsequent AhR activation increases the risk of specific comorbidities such as obesity and diabetes. The importance of AhR signaling in various molecular pathways highlights that the role of this receptor is far beyond just xenobiotic metabolism. The present review aims at providing significant insight into the physiological and pathological role of AhR and its regulated enzymes, such as cytochrome P450 1A1 (CYP1A1) and CYP1B1 in both types of diabetes. It also provides a comprehensive summary of the current findings of recent research studies investigating the role of the AhR/CYP1A1 pathway in insulin secretion and glucose hemostasis in the pancreas, liver, and adipose tissues. This review further highlights the molecular mechanisms involved, such as gluconeogenesis, hypoxia-inducible factor (HIF), oxidative stress, and inflammation.

Insulin pumps in children - a systematic review

BACKGROUND

Insulin pump therapy is a real breakthrough in managing diabetes Mellitus, particularly in children. It can deliver a tiny amount of insulin and decreases the need for frequent needle injections. It also helps to maintain adequate and optimal glycemic control to reduce the risk of metabolic derangements in different tissues. Children are suitable candidates for pump therapy as they need a more freestyle and proper metabolic control to ensure adequate growth and development. Therefore, children and their caregivers should have proper education and training and understand the proper use of insulin pumps to achieve successful pump therapy. The pump therapy continuously improves to enhance its performance and increase its simulation of the human pancreas. Nonetheless, there is yet a long way to reach the desired goal.

AIM

To review discusses the history of pump development, its indications, types, proper use, special conditions that may enface the children and their families while using the pump, its general care, and its advantages and disadvantages.

METHODS

We conducted comprehensive literature searches of electronic databases until June 30, 2022, related to pump therapy in children and published in the English language.

RESULTS

We included 118 articles concerned with insulin pumps, 61 were reviews, systemic reviews, and meta-analyses, 47 were primary research studies with strong design, and ten were guidelines.

CONCLUSION

The insulin pump provides fewer needles and can provide very tiny insulin doses, a convenient and more flexible way to modify the needed insulin physiologically, like the human pancreas, and can offer adequate and optimal glycemic control to reduce the risk of metabolic derangements in different tissues.

Correlation between Estimated Average Glucose Levels Calculated from HbA1c Values and Random Blood Glucose Levels in a Cohort of Subjects

Objective Hemoglobin A1c (HbA1c) level remains the gold standard test for the assessment of glycemic control, and it reflects the mean glucose values in the previous 3-month period. HbA1c is expressed as a percentage, whereas the monitoring and treatment of diabetes are based on blood glucose levels expressed as mg/dL. It is appropriate to make it easy for the patient to understand both random blood sugar (RBS) and estimated average glucose (eAG) expressed with the same units. This will enhance the usefulness of eAG. This article determines the statistical correlation between eAG derived from HBA1C with RBS values both in diabetic and prediabetic subjects.

Methods The RBS and HbA1c levels of 178 males and 283 females (12–90 years) were obtained and the eAG levels were calculated using Nathan's regression equation. The samples were divided into four groups based on HbA1c levels—group 1: HbA1c greater than 9%, group 2: HbA1c 6.5 to 9%, group 3: HbA1c 5.7 to 6.4%; and group 4: HbA1c less than 5.7%.

Results There was a statistically significant positive correlation between RBS and eAG values for the study group 1 and 2. Also, the median values of RBS and eAG showed a significant difference (p < 0.001).

Conclusion As the association between the RBS and eAG levels is strong in a fairly and poorly controlled diabetic population, reporting the eAG level together with the HbA1c level at no additional cost may assist in effective blood glucose control in clinical care. However, eAG and RBS values cannot be used interchangeably.

Safety of sodium-glucose cotransporter 2 inhibitors in Asian type 2 diabetes populations

The prevalence of type 2 diabetes mellitus continues to increase in many Asian countries, with possible contributing factors, such as younger-onset disease, diabetes development at lower body mass index, higher visceral fat accumulation and poorer β-cell function, among Asian populations. Sodium-glucose cotransporter 2 inhibitors have been shown to confer favorable effects in type 2 diabetes mellitus patients, such as improved glycemic control, weight and blood pressure reduction, and importantly, cardiorenal benefits. Sodium-glucose cotransporter 2 inhibitors are generally well-tolerated, and have a well-defined safety profile based on evidence from numerous clinical trials and post-marketing pharmacovigilance reporting. To our knowledge, this review is the first to provide a comprehensive coverage of the adverse events of sodium-glucose cotransporter 2 inhibitors, as well as their management and counseling aspects for Asian type 2 diabetes mellitus populations.

RSSDI Guidelines for the management of hypertension in patients with diabetes mellitus

Hypertension and diabetes mellitus (DM) are two of the leading lifestyle diseases in the Indian and South Asian populations that often co-exist due to overlapping pathophysiological factors. Obesity, insulin resistance, inflammation, and oxidative stress are thought to be some common pathways. Up to 50% of hypertensive cases in India are diagnosed with type 2 diabetes mellitus (T2DM), which defines the need for a comprehensive guideline for managing hypertension in diabetic patients. These RSSDI guidelines have been formulated based on consultation with expert endocrinologists in India and Southeast Asia, acknowledging the needs of the Indian population. Ambulatory blood pressure monitoring and office and home-based blood pressure (BP) monitoring are recommended for the early analysis of risks. Cardiovascular risks, end-organ damage, and renal disorders are the primary complications associated with diabetic hypertension that needs to be managed with the help of non-pharmacological and pharmacological interventions. The non-pharmacological interventions include the nutrition education of the patient to reduce the intake of salt, sodium, and trans fats and increase the consumption of nuts, fresh fruits, vegetables, and potassium-rich foods. It is also recommended to initiate 50 to 60 min of exercise three to four times a week since physical activity has shown to be more beneficial for hypertension control in Indian patients than dietary modulation. For the pharmacological management of hypertension in patients with T2DM, angiotensin II receptor blockers (ARBs) are recommended as the first line of therapy, demonstrating their superiority over other antihypertensive agents such as ACEi. However, most of the global hypertension guidelines recommend initiation with combination therapy to achieve better BP control in most patients and to reduce the risk of adverse events. For combination therapy, calcium channel blockers (CCBs) are recommended to be administered along with ARBs instead of beta-blockers or diuretics to avoid the risk of cardiovascular events and hyperglycaemia. Among the CCBs, novel molecules (e.g. cilnidipine) are recommended in combination with ARBs for better cardiovascular and reno-protection in diabetic hypertensive patients.

Scientific advisory on nocturnal hypoglycemia in insulin-treated patients with diabetes: Recommendations from Indian experts

INTRODUCTION

Insulin is one of the commonly prescribed glucose lowering agents in diabetes. Hypoglycemia is the most common complication, and severe hypoglycemia is the most serious complication of insulin therapy. Almost half of all severe hypoglycemia episodes (HEs) occur at night. However, patients are often unaware of their nocturnal hypoglycaemia (NH) risk. Additionally, both healthcare professionals and patients find it difficult to manage NH. The purpose of this expert group meeting is to improve NH awareness and provide guidance for the physicians to recognize and manage NH.

METHOD

The panel of experts in an e-board deliberated extensively upon the available literature and guidelines on hypoglycemia and NH discussed the consensus on definition, detection, reporting, monitoring, treatment, and optimization of therapy in NH.

RESULT

& Conclusion: Though there are many guidelines on the management of HEs in patients with diabetes, very few touch the topic of NH. This scientific advisory on management of NH in insulin treated patients with diabetes is formulated to address this gap in understanding regarding management of NH. The experts provide recommendations for the nocturnal window, defining NH based on blood glucose values, recognition, prevention and management of NH.

Evaluation of the performance and usability of a novel continuous glucose monitoring system

Background

Continuous glucose monitoring (CGM) can help manage diabetes mellitus (DM) and prevent hypoglycemia. This study aimed to evaluate the performance and usability of a novel SiJoy GS1 CGM system.

Methods

This multicenter trial enrolled participants with DM. Based on the comparison of glucose values measured by SiJoy GS1 CGM and venous blood glucose test, the 20/20% consistency and mean absolute relative difference (MARD%) were calculated, as well as Clarke and consensus error grid analysis. Product usability was evaluated by questionnaire completed by participants. Any occurrence of adverse events (AE) was documented.

Results

Seventy participants were included in the study. The mean age of participants was 41.5 ± 13.2 years, among which 29 (42.0%) were male, with the DM course of 8.6 ± 7.5 years. A total of 39 (56.5%) of them had type 1 DM, 24 (34.8%) had type 2 DM, and 6 (8.7%) were others for DM. The 20/20% consistency achieved 91.82%, which was higher than the target 65%. The percentage of A + B zones of Clarke and consensus error grid was 99.22% and 99.90%, respectively. The MARD value was 8.83% ± 4.03%. The mean score of usability questionnaire was 86.59 ± 5.17 out of 90. AE were observed in only one participant (mild fever), and no severe AEs occurred.

Conclusions

The SiJoy GS1 CGM system achieved satisfactory performance and usability. No severe AEs occurred and mild AE was reported in only one case.

Sjögren syndrome is a hidden contributor of macrovascular and microvascular complications in patients with type 2 diabetes

OBJECTIVE

To investigate cardiovascular risk among diabetic patients with Sjögren syndrome.

METHODS

This study was a nationwide population-based case-control study from 1997 to 2013, in which the association between autoimmune diseases and diabetes was investigated. The study population consisted of individuals with newly diagnosed type 2 diabetes with macrovascular or microvascular complications with at least two outpatient visits or one hospitalization as the outcome variables, and the exposure variables included traditional risk factors, medications, and autoimmune diseases. The odds ratio of cardiovascular events among each prevalent autoimmune disease and hydroxychloroquine's effect on cardiovascular risk were analyzed.

RESULTS

The study included a total of 7026 individuals with diabetes with microvascular and macrovascular complications and the same number of patients in the control group. Sjögren syndrome was significantly higher in the diabetes complication group than in the non-complication group (0.8% vs 0.5%, P = 0.036). By using multivariate analysis, we found hypertension, hyperlipidemia, and Sjögren syndrome to be three independent risk factors for diabetes vascular complications (odds ratio [OR] 1.96, 95% confidence interval [CI] 1.82-2.10; OR 1.53, 95% CI 1.42-1.64; and OR 1.67, 95% CI 1.06-2.65; respectively, all P < 0.05). Treatment with traditional statins and aspirin might be able to overcome the increased risk of developing cardiovascular events while comparing between diabetes patients with and without Sjögren syndrome.

CONCLUSION

Sjögren syndrome is an unrecognized independent risk factor for cardiovascular events among diabetes patients, which indicates that patients with diabetes combined with Sjögren syndrome require closer follow up regarding cardiovascular complications in clinical settings. Treatment with hydroxychloroquine might not be enough to lower the cardiovascular risk significantly in diabetes patients with Sjögren syndrome.

In Vivo and In Vitro Comparison of the DPP-IV Inhibitory Potential of Food Proteins from Different Origins after Gastrointestinal Digestion

Dipeptidyl-peptidase IV (DPP-IV) plays an essential role in glucose metabolism by inactivating incretins. In this context, food-protein-derived DPP-IV inhibitors are promising glycemic regulators which may act by preventing the onset of type 2 diabetes in personalized nutrition. In this study, the DPP-IV-inhibitory potential of seven proteins from diverse origins was compared for the first time in vitro and in vivo in rat plasma after the intestinal barrier (IB) passage of the indigested proteins. The DPP-IV-inhibitory potentials of bovine hemoglobin, caseins, chicken ovalbumin, fish gelatin, and pea proteins were determined in rat plasma thirty minutes after oral administration. In parallel, these proteins, together with bovine whey and gluten proteins, were digested using the harmonized INFOGEST protocol adapted for proteins. The DPP-IV half-maximal inhibitory concentration (IC50) was determined in situ using Caco-2 cells. The DPP-IV-inhibitory activity was also measured after IB passage using a Caco2/HT29-MTX mixed-cell model. The peptide profiles were analyzed using reversed-phase high-performance liquid chromatography tandem mass spectrometry (RP-HPLC-MS/MS) with MS data bioinformatics management, and the IC50 of the identified peptides was predicted in silico. The in vitro and in vivo DPP-IV-inhibitory activity of the proteins differed according to their origin. Vegetable proteins and hemoglobin yielded the highest DPP-IV-inhibitory activity in vivo. However, no correlation was found between the in vivo and in vitro results. This may be partially explained by the differences between the peptidome analysis and the in silico predictions, as well as the study complexity.

Foot Self-Care Behaviour among People with Type 2 Diabetes mellitus Living in Rural Underserved Area of North India: A Community-Based Cross-Sectional Study

The objective of this study was to ascertain the foot self-care behaviour and its associated factors among people with type 2 diabetes mellitus (T2DM) living in the rural resource-constrained health setting of Punjab, North India. A community based cross sectional study was undertaken in the randomly selected underserved rural area of District Fatehgarh Sahib, Punjab, North India. A pre-validated Nottingham Assessment of Functional Footcare (NAFF) scale was administered to assess foot self-care behaviour, and participants were classified based on the percentage of a maximum possible score of 84 on the scale, as poor, if the score was <50%, satisfactory if score 50%-70% and >70% good foot self-care behaviour. A total of 700 participants' responses were recorded. The study results revealed that 84% (588) of the respondents had poor, 16% (112) had satisfactory, and none were following good foot self-care behaviour. An outcome of multivariable logistics regression suggested satisfactory foot self-care behaviour was significantly associated with foot self-care education, with an adjusted odds ratio (aOR) of 2.83 (95%, CI:1.62 - 4.93; p <0.01) among respondents who had received foot self-care education, literate than illiterate (aOR 2.50 95%, CI:1.31- 4.74; p <0.01) and women compared to men (aOR 1.69 95%, CI: 1.06 -2.70; p -0.26). This study revealed that foot self-care behaviours were alarmingly low among people with T2DM living in rural resource-constrained health settings of Punjab, North India, suggesting an urgent need to disseminate foot self-care education to prevent diabetes foot related complications.

Preparation and hypoglycemic effects of chromium- and zinc-rich Acetobacter aceti

BACKGROUND

At present, there is no ideal method to cure diabetes, and there are few reports on the treatment of diabetes with probiotics.

AIM

To propose a method for preparing a new type of chromium- and zinc-rich Acetobacter aceti (A. aceti) and explore its ability to enhance the hypoglycemic effects of probiotics in the treatment of diabetes.

METHODS

A. aceti was cultured in a liquid medium that contained chromium trichloride and zinc chloride, both at a concentration of 64 mg/mL, with the initial concentration of the bacterial solution 1 × 10⁴ CFU/mL. After the bacterial solution had been inducted for 48 h, the culture media was changed and the induction was repeated once. The levels of chromium and zinc in the bacteria were detected by inductively coupled plasma mass spectrometry, and the contents of NADH and glucose dehydrogenase were determined using an NAD/NADH kit and glucose dehydrogenase kit, respectively. Streptozotocin was used to establish a mouse model to evaluate the hypoglycemic effects of the proposed chromium- and zinc-rich A. aceti. Ten-times the therapeutic dose was administered to evaluate its biological safety. The effect on MIN6 islet cells was also assessed in vitro.

RESULTS

The levels of chromium metal, metallic zinc, NADH coenzyme, and glucose dehydrogenase in A. aceti prepared by this method were 28.58-34.34 mg/kg, 5.35-7.52 mg/kg, 5.13-7.26 μM, and 446.812-567.138 U/g, respectively. The use of these bacteria resulted in a better hypoglycemic effect than metformin, promoting the repair of tissues and cells of pancreatic islets in vivo and facilitating the growth of MIN6 pancreatic islet cells and increasing insulin secretion in vitro. Ten-times the therapeutic dose of treatment was non-toxic to mice.

CONCLUSION

Chromium trichloride and zinc chloride can be employed to induce the preparation of chromium- and zinc-rich A. aceti, which can then promote the hypoglycemic effect found in normal A. aceti. The bacteria biotransforms the chromium and zinc in a way that could increase their safety as a treatment for diabetes.

Role and importance of high fiber in diabetes management in India

BACKGROUND & AIMS

India is facing a triple burden of pre-diabetes, diabetes, and obesity. Unhealthy eating habits and physical inactivity have been linked to the onset and progression of type 2 diabetes mellitus (T2DM). Despite dietary recommendations, individuals consume inadequate amounts or unsuitable type of dietary fiber (DF) which needs correction. An Expert group attempted to review and report on the role and importance of high DF in the management of T2DM and offer practical guidance on high fiber use in daily diet.

METHODOLOGY

Twelve diabetologists and two expert dietitians from India were chosen to ensure diversity of the members both in professional interest and cultural background. The authors convened virtually for one group meeting and actively participated in a detailed discussion. Multiple reviews of the draft document followed by focused teleconference calls & email helped to reach consensus on final recommendations between Aug 2021 and Dec 2021.

RESULTS

Evidence has shown that medical nutrition therapy (MNT) is a valuable approach and an essential component of T2DM prevention and management. Studies have shown that fiber rich diabetes nutrition (FDN) has multi-systemic health benefits, including, improvement in glycemic control, reduction in glucose spikes, decrease in hyperinsulinemia, improvement in plasma lipid concentrations and weight management in T2DM patients.

CONCLUSION

A high fiber diet is vital for people with diabetes and associated conditions. Increasing fiber intake, preferably through food or through dietary supplement, may help. Fiber rich diabetes nutrition (FDN) is recommended in order to prevent and manage T2DM.

Prescribing Patterns and Response to Antihyperglycemic Agents Among Novel Clusters of Type 2 Diabetes in Asian Indians

Aim: To assess the prescribing patterns and response to different classes of antihyperglycemic agents in novel clusters of type 2 diabetes (T2D) described in India. Materials and Methods: We attempted to replicate the earlier described clusters of T2D, in 32,867 individuals with new-onset T2D (within 2 years of diagnosis) registered between October 2013 and December 2020 at 15 diabetes clinics located across India, by means of k-means clustering utilizing 6 clinically relevant variables. Individuals who had follow-up glycated hemoglobin (HbA1c) up to 2 years were included for the drug response analysis (n = 13,247). Results: Among the 32,867 participants included in the study, 20,779 (63.2%) were males. The average age at diagnosis was 45 years and mean HbA1c at baseline was 8.9%. The same four clusters described in India earlier were replicated. Forty percent of the study participants belonged to the mild age-related diabetes cluster, followed by insulin-resistant obese diabetes (27%), severe insulin-deficient diabetes (21%), and combined insulin-resistant and insulin-deficient diabetes (12%) clusters. The most frequently used antihyperglycemic agents were sulfonylureas, metformin, and dipeptidyl peptidase-4 inhibitors apart from insulin. While there were significant differences in HbA1c reduction between drugs across clusters, these were largely driven by differences in the baseline (pretreatment) HbA1c. Conclusions: In this new cohort, we were able to reliably replicate the four subtypes of T2D earlier described in Asian Indians. Prescribing patterns show limited usage of newer antihyperglycemic agents across all clusters. Randomized clinical trials are required to establish differential drug responses between clusters.

Position of Sulfonylureas in the Current ERA: Review of National and International Guidelines

Sulfonylureas (SUs) are one of the commonly prescribed oral anti-hyperglycemic agents (AHA) in low- and middle-income countries (LMICs), either in combination with metformin therapy or alone. However, concern about cardiovascular safety has limited the use of SUs in the management of type 2 diabetes mellitus (T2DM). Additionally, lack of uniformity in the national and international guidelines regarding the positioning of SUs in the management of diabetes has also been reported. The objective of this review was to assess the various national and international guidelines on diabetes management and understand the recommendations specific to SUs in various scenarios. A total of 33 national and international guidelines on the management of T2DM published in English were evaluated. These guidelines have considered the latest evidence and suggest the use of certain second-generation SUs as second-line therapy or in combination with other AHAs in select population and specific scenarios. Identification of the appropriate population, classification based on underlying risk, thorough assessment of the comorbid conditions, and a step-wise approach for the selection of appropriate SUs is essential for the effective management of T2DM. Additionally, cost-to–benefit ratio should be considered, particularly in LMICs, and SUs could continue to play an important role in such settings.

Knowledge, Attitude, and Practice of Bee Venom Acupuncture Therapy on Rheumatoid Arthritis Among Patients in Saudi Arabia

Introduction

Bee venom acupuncture therapy (BVT) is an alternative therapy used worldwide by patients with different chronic diseases due to its therapeutic effects on conditions such as rheumatoid arthritis (RA). Previous studies have illustrated the clinical effects of BVT on RA, but such a study has yet to be performed in Saudi Arabia (SA). It is important to evaluate BVT awareness among citizens of SA to measure the feasibility of conducting clinical trials of BVT in patients with RA in SA. This study aims to measure the knowledge, attitude, and practice (KAP) of BVT on RA and other chronic diseases in SA. This will help determine whether patients with RA have sufficient knowledge to be enrolled in clinical trials.

Patients and Methods

A cross-sectional study of 180 patients with RA in SA was conducted using a KAP questionnaire on BVT. Individuals completed an online questionnaire using the Survey Monkey website. Data were obtained by self-completion of the online KAP questionnaire regarding BVT.

Results

A total of 180 patients with RA and other chronic diseases, with a mean age of 45 years (18–70 years), participated in the study. The results of the questionnaire showed that 55% of the participants demonstrated a good knowledge of BVT treatment; however, they also reported a poor attitude (55%) and practice (55%). Participants with RA demonstrated higher severity of disease (80%) than those with other chronic diseases. Participants with RA showed better KAP responses towards BVT than those with other chronic diseases. Participants with school education only and those who were beekeepers demonstrated significantly better KAP responses (P < 0.05) compared to participants who had received university education and those who were not beekeepers, respectively.

Conclusion

Participants with strong RA knowledge may prove that patients from SA can be enrolled in BVT clinical trials. The participants’ poor attitudes and practices may be due to BVT being expensive and unavailable in many cities in SA.

Indian Phenotype Characteristics Among Patients with Type 2 Diabetes Mellitus: Insights from a Non-interventional Nationwide Registry in India

Background: Indian patients with type 2 diabetes mellitus (T2D) constitute one-sixth of affected adults globally. Here, we evaluate the association of body mass index (BMI) with body fat percentage (BF%) and glycated haemoglobin (HbA1c) levels among patients with T2D in India. Method: This was a cross-sectional Indian registry study across 845 geographically diverse zones between December 2017 and August 2019. Results: Of 37,927 patients, 55.6% were men, with a mean ± standard deviation age of 54.2 ± 11.5 years and HbA1c of 8.3 ± 1.71%. Mean ± standard deviation BMI and BF% were 27.0 ± 4.6 kg/m2 and 32.0 ± 8.0%, respectively. Overall, 15.4% of patients were overweight, and 25.0% were obese. Despite fewer males (20.7%) having BMI-based obesity than females (31.2%), around three-quarters of both sexes had BF%-defined obesity (males 77.2%; females 71.2%). One-third of males (34.6%) and 41.9% of females had BF%-defined obesity despite normal BMI. The association was substantiated by a moderately significant correlation (r=0.51) between BMI and BF% in the overall population (p<0.0001). Conclusion: This pan-India registry presents a real-world reflection of the Asian Indian phenotype: high BF% despite lower BMI in people with T2D. This highlights the importance of primordial and primary prevention, and may guide decisions on the choice of agents for glycaemic control, with a preference for drugs that promote weight loss or are weight neutral.

One-year trends from the LANDMARC trial: A 3-year, pan-India, prospective, longitudinal study on the management and real-world outcomes of type 2 diabetes mellitus

Introduction

Longitudinal data on management and progression of type 2 diabetes mellitus (T2DM) in India are scarce. LANDMARC (CTRI/2017/05/008452), first‐of‐its‐kind, pan‐India, prospective, observational study aimed to evaluate real‐world patterns and management of T2DM over 3 years.

Methods

Adults (≥25 to ≤60 years old at T2DM diagnosis; diabetes duration ≥2 years at enrolment; controlled/uncontrolled on ≥2 anti‐diabetic agents) were enrolled. The first‐year trends for glycaemic control, therapy and diabetic complications, including those from metropolitan and non‐metropolitan cities are reported here.

Results

Of 6236 enrolled participants, 5654 completed 1 year in the study. Although the overall mean glycated haemoglobin (HbA1c) improved by 0.5% (baseline: 8.1%) at 1 year, only 20% of the participants achieved HbA1c <7%. Participants from metropolitan and non‐ metropolitan cities showed similar decrease in glycaemic levels (mean change in HbA1c: −0.5% vs. −0.5%; p = .8613). Among diabetic complications, neuropathy was the predominant complication (815/6236, 13.1% participants). Microvascular complications (neuropathy, nephropathy and retinopathy) were significantly (p < .0001) higher in non‐metropolitan than metropolitan cities. Hypertension (2623/6236, 78.2%) and dyslipidaemia (1696/6236, 50.6%) continued to be the most commonly reported cardiovascular risks at 1 year. After 1 year, majority of the participants were taking only oral anti‐diabetic drugs (OADs) (baseline: 4642/6236 [74.4%]; 1 year: 4045/6013 [67.3%]), while the proportion of those taking insulin along with OADs increased (baseline: 1498/6236 [24.0%] vs. 1 year: 1844/6013 [30.7%]). Biguanides and sulfonylureas were the most used OADs. The highest increase in use was seen for dipeptidyl peptidase‐IV inhibitors (baseline: 3047/6236 [48.9%]; 1 year: 3529/6013 [58.7%]). Improvement in all glycaemic parameters was significantly (p < .0001) higher in the insulin vs. the insulin‐naïve subgroups; in the insulin‐naïve subgroup, no statistical difference was noted in those who received >3 vs. ≤3 OADs.

Conclusions

First‐year trends of the LANDMARC study offer insights into real‐world disease progression, suggesting the need for controlling risk factors and timely treatment intensification in people with T2DM.

Pneumococcal Vaccine Recommendations for Old-Age Home Indian Residents: A Literature Review

Advancing age is accompanied by decreased immunity, poor health, and physiological changes, which render the elderly population highly susceptible to infectious diseases. We aim to identify the guidelines for pneumococcal vaccines in old-age facilities in India. We performed an extensive review of Indian literature (indexed and non-indexed publications) from 2010 to 2020 using search strings “Pneumococcal vaccine AND Recommendations AND India,” “Pneumococcal vaccine AND Guidelines AND India,” followed by a hand search to identify the most updated versions of recommendations. We reviewed immunization guidelines recommended by nine medical associations and societies in India—Association of Physicians of India (API), Geriatric Society of India (GSI), Indian Society of Nephrology (ISN), Mass Gathering Advisory Board Consensus Recommendation, Indian Medical Association (IMA), Indian Chest Society and National College of Chest Physicians (ICS-NCCP), Research Society for Study of Diabetes in India (RSSDI), Indian Association of Occupational Health Guidelines for Working Adults (IAOH), and API guidelines for immunization during COVID19 pandemic. All bodies recommend pneumococcal vaccines, sequence and preference of which depend on factors such as age, underlying conditions, and immune status. Integration of society recommendations and their implementation into public and private vaccination programs are required to promote adult immunization.

Diabetes Mellitus Increases the Risk of Significant Hepatic Fibrosis in Patients With Non-alcoholic Fatty Liver Disease

Background

Diabetes mellitus is associated with an increased risk of development of non-alcoholic fatty liver disease (NAFLD). However, the risk posed by diabetes mellitus in progression of liver disease is uncertain. This study compared the severity of hepatic fibrosis in patients with NAFLD with and without diabetes mellitus.

Methods

Consecutive adult patients with NAFLD undergoing transient elastography [FibroScan Touch 502 (Echosens, Paris, France)] at a tertiary care center in north India were analyzed for severity of hepatic fibrosis. The aspartate aminotransferase (AST) to platelet ratio index (APRI), fibrosis index based on 4 factors (FIB-4), and NAFLD Fibrosis Score (NFS) were calculated. The degree of hepatic fibrosis as determined by FibroScan and non-invasive serum fibrosis models in patients with and without diabetes mellitus were compared.

Results

A total of two hundred patients [118 (59%) males, mean age 50.30 ± 11.13 years] were enrolled. Significant hepatic fibrosis was present in 86 (43%) patients [mean age 50.66 ± 10.96 years, 56 (65.11%) males]. The mean FibroScan, APRI, FIB-4, and NFS scores were 9.86 ± 2.97, 0.75 ± 0.47, 2.41 ± 1.41 and -0.24 ± 1.43 in patients with diabetes compared to 5.31 ± 1.09, 0.49 ± 0.27, 1.55 ± 0.85, and -2.12 ± 1.88 in patients without diabetes, respectively (P=<0.0001). There was a fair correlation between FibroScan and non-invasive serum fibrosis models (P=<0.0001).

Conclusion

Presence of diabetes increases the risk of significant hepatic fibrosis in patients with NAFLD. FIB-4 correlates fairly with FibroScan in patients with diabetes and can be used as a screening tool to detect significant hepatic fibrosis.

Pattern of uropathogens and antibiotic sensitivity in diabetes patients attending to out - Patient department and diabetes clinic of a teaching hospital: A cross-sectional study

Introduction:

Diabetes mellitus is the most common endocrinological disease associated with different life-threatening infections. Urinary Tract Infection is one of them which may lead to Intensive care Unit admission and even death. In this study, we would like to find out the spectrum of uropathogen and its antibiotic sensitivity, so that we can choose empirical antibiotics early to save lives.

Aim and Objectives:

To find out spectrum of uropathogens in Diabetic patients attending to Diabetes Clinic of a tertiary hospital and to find out the Antibiotic sensitivity pattern in isolated bacteria.

Material and Methods:

In this cross-sectional observational hospital-based study, consecutive patients of any age and gender having Diabetes mellitus and symptoms of Urinary Tract Infection, who attended Out-patient Department and Diabetes Clinic of General Medicine Department from August 2020 to October 2020, were included. After taking consent and brief history, mid-stream clean catch urine sample was collected in sterile container and sent to a Microbiology laboratory for culture of micro-organism and sensitivity to antibiotics.

Results:

Among 202 diabetic patients recruited in our study, 138 (68.31%) were female and 64 (31.69%) were male. The mean age of all participants was 50.23 ± 11.45 years. Culture confirmed UTI was 24.3% and patients showing classic UTI symptoms were 32.7%. Compared to male, most of the culture-positive and symptomatic patients were female (26.0% and 37% respectively). Culture-positive patients who showed classic UTI symptoms were 42.42%; however, we found 15.44% asymptomatic patients who showed culture positivity. The mean HbA1c level was 7.5 ± 1.6%. Subgroup analysis revealed that patients with HbA1c >7.5% were at a significantly higher risk of developing culture-positive UTI (P < 0.00001, Odds ratio 21.71). Prevalence of gram-negative and gram-positive bacteria were 65.3% (32 out of 49) and 28.57% (14 out of 49), respectively. The major organism isolated were Escherichia coli (39%), Klebsiella spp. (19%), Enterococcus spp. (12%), Staphylococcus aureus (12%), and Candida spp. (6%). The sensitivity pattern of the gram-negative bacilli showed the presence of Extended-spectrum betalactamases (ESBLs) in 36.84% (11 out of 32 isolates). The bacteria grown were most sensitive to Piperacillin-tazobactam (100%), Cefoperazone-sulbactam (100%) and Meropenem (100%) whereas Fluoroquinolone and Co-Amoxyclav showed least sensitivity (43.8% and 37.5% respectively). The Staphylococcus spp. showed 100% sensitivity to Vancomycin, Teicoplanin, Linezolid whereas Penicillin-G and Ampicillin showed 12.5% sensitivity. The Enterococcus spp. revealed 100% sensitivity to Vancomycin, Teicoplanin, Linezolid, and Fosfomycin. Drug resistance is emerging in clinical isolates. Prevalence of ESBL in Enterobacteriacea was found to be 34%.

Conclusion:

All patients with diabetes must be searched for urinary tract bacterial colonization by simple routine urinary culture even though they are asymptomatic. Resistance to common antibiotics, particularly to oral formulations (especially Fluoroquinolones and Ampicillin) is increasing day by day due to indiscriminate use of antibiotics. This study highlighted that the policy makers should formulate antibiotic policy for rational use of antibiotics, which could help clinicians to prescribe proper antibiotics. However, regular monitoring of susceptibility pattern of urinary pathogens is essential.

Safety and tolerability of linagliptin in Asians with type 2 diabetes: a pooled analysis of 4457 patients from 21 randomized, double-blind, placebo-controlled clinical trials

BACKGROUND

Safety and tolerability of glucose-lowering drugs is a key consideration for use in type 2 diabetes (T2D). We evaluated the safety and tolerability of the dipeptidyl peptidase-4 inhibitor linagliptin in Asian patients with T2D.

RESEARCH DESIGN AND METHODS

This was a post-hoc, descriptive pooled analysis of 21 randomized, double-blind, placebo-controlled clinical trials of linagliptin in T2D patients lasting ≤52 weeks. We evaluated adverse events (AEs) and laboratory parameters in Asian participants living in Asia, both overall and in the East Asian subgroup.

RESULTS

This analysis included 4457 Asian patients overall (2712 receiving linagliptin; 1745 receiving placebo) and 3057 (68.6%) East Asians. AEs were reported in 1510 (55.7%) Asian patients receiving linagliptin and 1032 (59.1%) receiving placebo but were considered drug-related in only 13.0% of each group. Serious AEs occurred in 109 (4.0%) linagliptin patients and 90 (5.2%) placebo patients. The most common AEs were nasopharyngitis (6.4% linagliptin, 7.3% placebo), upper respiratory tract infection (5.7% linagliptin, 6.5% placebo), and hypoglycemia (7.3% linagliptin, 6.3% placebo). One linagliptin patient had pancreatitis; none had bullous pemphigoid. No clinically relevant mean changes in laboratory parameters occurred. These findings were consistent in East Asians.

CONCLUSIONS

Linagliptin is well tolerated in Asian T2D patients, including East Asians, with low risk for AEs.

Autoimmune diseases in patients undergoing percutaneous coronary intervention: A risk factor for in-stent restenosis?

BACKGROUND AND AIMS

Despite the relation between autoimmune diseases and increased atherosclerotic risk is established, the influence of autoimmune disorders on in-stent restenosis (ISR) after percutaneous coronary intervention (PCI) is only partly known. ISR is an aberrant reparative process mainly characterized by an increased number of vascular smooth muscle cells and excessive deposition of extracellular proteoglycans and type III collagen. Chronic inflammation, always present in autoimmune diseases, modulates the endothelial response to PCI. Aim of this review is to resume the current evidence on the association between ISR and autoimmune diseases, focusing on pathogenic mechanisms and therapeutic targets.

METHODS

We conducted a comprehensive review of the literature on the relationship between ISR and insulin-dependent diabetes mellitus (IDDM), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), antiphospholipid-antibodies syndrome (APS), inflammatory bowel diseases (IBD), and Hashimoto's thyroiditis (HT).

RESULTS

Patients affected with IDDM, RA, SLE, APS, IBD and HT proved to face higher rates of ISR compared to the general population. The endothelial dysfunction seems the principal common pathogenic pathway for ISR and is attributed to both the immune system disorder and the systemic inflammation. Some evidence suggested that methotrexate and anti-tumor necrosis factor treatments can be effective in reducing ISR, while antibodies against vascular cell adhesion molecule-1 and intercellular adhesion molecule-1 showed to reduce neointimal hyperplasia in animal models.

CONCLUSIONS

Autoimmune diseases are a risk factor for ISR. The study of the potential cardiovascular benefits of the current therapies, mainly anti-inflammatory drugs, and the pursuit of innovative treatments appear of paramount interest.

Sulfonylureas in the Current Practice of Type 2 Diabetes Management: Are They All the Same? Consensus from the Gulf Cooperation Council (GCC) Countries Advisory Board on Sulfonylureas

Since their inception in the commercial market in the mid-twentieth century, sulfonylureas (SUs) have remained a therapeutic option in the management of type 2 diabetes (T2D). Despite their established glucose-lowering effects, there is no consensus among global experts and modern guidelines regarding the priority of SUs in relation to other therapeutic options, given the lack of evidence that SUs are associated with a low risk of macrovascular events and excess mortality. However, findings from recent trials and real-time observations have resolved this contentious issue somewhat, albeit to varying degrees. The present consensus discusses the role of SUs in contemporary diabetes management in the Gulf Cooperation Council (GCC) countries. Regional experts from these countries gathered virtually to formulate a consensus following presentations of topics relevant to SU therapy with an emphasis on gliclazide, including long-term efficacy, cost, end-organ benefits, and side effects, based on up-to-date evidence. The present narrative review reflects the conclusions of this assembly and provides a platform upon which future guidelines for the use of SUs in the GCC can be tailored.

Developing Adult Vaccination Ecosystem in India: Current Perspective and the Way Forward

Introduction

A high burden of vaccine-preventable diseases, increasing elderly population, immunosenescence, and emerging drug resistance emphasize the need for robust adult immunization in India. While immunization guidelines from various societies exist, there is inadequate implementation of the same.

Aim

We undertook this narrative review of the adult vaccination ecosystem in India to (i) gain insights into existing adult vaccination practices, (ii) identify barriers to adult vaccination and possible solutions, and (iii) improve collaboration between various stakeholders to help establish adult vaccination centers in the country.

Results

Besides the high cost and lack of insurance coverage, the lack of adult vaccination centers contributes to the low coverage of adult immunization.

Discussion

These challenges can be addressed through multiple approaches including community awareness and immunization programs, setting up mobile vaccination vans, patient/consumer education, and adequate training of healthcare providers. Successful implementation of these strategies requires active collaboration between the government, hospitals, different stakeholders, and policymakers.

Effect of reflexology on ankle brachial index, diabetic peripheral neuropathy, and glycemic control in older adults with diabetes: A randomized controlled trial

OBJECTIVE

The purpose of this study was to determine the effect of foot reflexology on ankle brachial index, diabetic peripheral neuropathy and glycemic control in older adults with diabetes.

METHODS

A randomized controlled, parallel-group trial study was conducted at the outpatient elderly health center in Bolu, Turkey. 48 adults aged 65 and over enrolled in the elderly health center were randomized into two groups in a ratio of 1:1 (experimental, n = 24; control, n = 24). Foot reflexology was performed for 12-week in the experimental group, whereas the control group continued their routine treatment and follow-up. The outcome measures included: (1) ankle brachial index, (2) diabetic peripheral neuropathy measured by a comprehensive foot exam, and (3) glycemic control by a glycated hemoglobin A blood test at baseline and after 12 weeks.

RESULTS

Post-test diabetic peripheral neuropathy scores (p < 0.001) and glycated hemoglobin A levels (p = 0.002) decreased in the experimental group and increased in the control group. There was no significant between-group difference regarding post-test ankle brachial index scores (p = 0.726). Foot reflexology had a medium effect size on diabetic peripheral neuropathy (95% confidence interval 0.003-2.24; d = 0.51; p < 0.001) and glycated hemoglobin A (95% confidence interval 0.72-1.22; d = 0.52; p = 0.002).

CONCLUSIONS

A foot reflexology practice can be a useful for improving the glycemic control and diabetic peripheral neuropathy in the older adults with diabetes.

TRIAL REGISTRATION NUMBER

NCT04416503.

CNN-Based LCD Transcription of Blood Pressure From a Mobile Phone Camera

Routine blood pressure (BP) measurement in pregnancy is commonly performed using automated oscillometric devices. Since no wireless oscillometric BP device has been validated in preeclamptic populations, a simple approach for capturing readings from such devices is needed, especially in low-resource settings where transmission of BP data from the field to central locations is an important mechanism for triage. To this end, a total of 8192 BP readings were captured from the Liquid Crystal Display (LCD) screen of a standard Omron M7 self-inflating BP cuff using a cellphone camera. A cohort of 49 lay midwives captured these data from 1697 pregnant women carrying singletons between 6 weeks and 40 weeks gestational age in rural Guatemala during routine screening. Images exhibited a wide variability in their appearance due to variations in orientation and parallax; environmental factors such as lighting, shadows; and image acquisition factors such as motion blur and problems with focus. Images were independently labeled for readability and quality by three annotators (BP range: 34-203 mm Hg) and disagreements were resolved. Methods to preprocess and automatically segment the LCD images into diastolic BP, systolic BP and heart rate using a contour-based technique were developed. A deep convolutional neural network was then trained to convert the LCD images into numerical values using a multi-digit recognition approach. On readable low- and high-quality images, this proposed approach achieved a 91% classification accuracy and mean absolute error of 3.19 mm Hg for systolic BP and 91% accuracy and mean absolute error of 0.94 mm Hg for diastolic BP. These error values are within the FDA guidelines for BP monitoring when poor quality images are excluded. The performance of the proposed approach was shown to be greatly superior to state-of-the-art open-source tools (Tesseract and the Google Vision API). The algorithm was developed such that it could be deployed on a phone and work without connectivity to a network.

Pharmacological treatment of type 2 diabetes in Saudi Arabia: A consensus statement from the Saudi Society of Endocrinology and Metabolism (SSEM)

BACKGROUND AND AIMS

The list of available treatment options for managing blood glucose in patients with type 2 diabetes (T2D) has grown over recent years making the task of choosing between traditional and newer glucose-lowering agents a difficult one for healthcare providers.

METHODS

We summarize treatment algorithms developed by popular professional societies and propose a patient-centered and culture-driven recommendations for selecting diabetes medications for people with T2D in Saudi Arabia.

RESULTS

Though most professional societies recognize patient's adherence to medications as an important factor in achieving glycemic targets, published algorithms schemes do not formally enlist adherence to medication as a deciding factor in the choice of glucose-lowering agents. Medication appeal to patients, an important determinant of medication adherence, is influenced by several factors including lifestyle, common beliefs, customs and traditions, health literacy, perception of health and disease, socioeconomic and cultural backgrounds, and religious commitments and obligations. In Saudi Arabia, poor adherence to therapy is a major obstacle to effective management of local people with T2D.

CONCLUSIONS

The Saudi population has a unique socioeconomic and cultural background that widely respect adherence to religion and culture; and the applicability of international guidelines for the management of T2D to the Saudi population has been called into question. In this consensus statement, we propose patient-centered and culture-driven recommendations that integrate medication-adherence and medication-cost into overall selection of diabetes medications for people with T2D in Saudi Arabia.

Economic costs of hospitalisation and length of stay in diabetes with coexisting hypertension with correlation to laboratory investigations: Where does India stand? A 5-year ground report

INTRODUCTION

The coexistence of diabetes mellitus (DM) and hypertension (HTN) worsens clinical outcomes and contributes to increased morbidity and mortality.

OBJECTIVE

This study aims to analyse the length of stay and healthcare costs by calculating the direct and indirect costs of diabetes with coexisting hypertension in North India.

METHODS

A prospective observational study was conducted at the medicine department of the three different hospitals.

RESULTS

The patients' mean age was (M = 53.8, SD = 11.5) years. Out of 1914 patients, 53.65% were female. Our study revealed that the median cost of medical supplies and equipment was 21.2 $. The median cost of dialysis was 47.5 $; the median cost of hospitalisation was 142.6 $. The treatment's median direct cost was 188.5 $, followed by the overall median cost of 295.6 $. The maximum overall cost of treatment was observed at 603.9 $. It was observed that maximum LOS was 14 days for patients having BPS between 140 and 159 mmHg and BPD between 110 and 119 mmHg, and minimum LOS was found 3.5 days.

CONCLUSION

The present study highlighted that diabetes coexisting hypertension poses a high-economic burden on patients. This study explored that highly significant result for BPS, BPD, FBS and HbA₁ c, whereas the significant results were obtained when RBS is compared with LOS and treatment costs. Our study concluded that mean difference of 9.24 $ in patients having FBS was 261-290 mg/dL and >290 mg/dL. The LOS is increased by 6.57 days for patients with BPS between 140 and 159 mmHg compared with BPS between 180 and 209 and above mmHg, which lowers treatment costs by -21.31$.

Consensus Recommendations by the Asian Pacific Society of Cardiology: Optimising Cardiovascular Outcomes in Patients with Type 2 Diabetes

The Asian Pacific Society of Cardiology convened a consensus statement panel for optimising cardiovascular (CV) outcomes in type 2 diabetes, and reviewed the current literature. Relevant articles were appraised using the Grading of Recommendations, Assessment, Development and Evaluation system, and consensus statements were developed in two meetings and were confirmed through online voting. The consensus statements indicated that lifestyle interventions must be emphasised for patients with prediabetes, and optimal glucose control should be encouraged when possible. Sodium–glucose cotransporter 2 inhibitors (SGLT2i) are recommended for patients with chronic kidney disease with adequate renal function, and for patients with heart failure with reduced ejection fraction. In addition to SGLT2i, glucagon-like peptide-1 receptor agonists are recommended for patients at high risk of CV events. A blood pressure target below 140/90 mmHg is generally recommended for patients with type 2 diabetes. Antiplatelet therapy is recommended for secondary prevention in patients with atherosclerotic CV disease.

The Position of Gliclazide in the Evolving Landscapes and Disease Continuum of T2DM: A Collaborative Delphi Survey-Based Consensus from India

INTRODUCTION

This Delphi study aims to provide evidence-based expert opinion on the usage and current position of gliclazide in type 2 diabetes mellitus (T2DM) management in India.

METHODS

The single interaction modified Delphi-based methodology was used to collect opinions on gliclazide usage and its position in diabetes management from 338 endocrinologists/diabetologists who have had clinical experience with gliclazide. Participants, using a 9-point scale, were asked to rate eight statements comprising a total of 52 items on the related topics.

RESULTS

The Delphi consensus suggests that in drug-naïve patients with T2DM, intolerant to metformin or in whom metformin is contraindicated, dual therapy of gliclazide/gliclazide-modified release (MR) should be considered along with a dipeptidyl peptidase 4 (DPP4) inhibitor if glycated hemoglobin A1c level is greater than 7.5% and with insulin if the A1c level is greater than 9%. If the patients are inadequately controlled with metformin (A1c greater than 6.5% after 3 months of therapy), gliclazide/gliclazide-MR shall be added on to the treatment regimen to achieve greater and sustained reductions in A1c levels. However, it was not preferred over other antidiabetic classes in such clinical settings except alpha-glucosidase inhibitors (AGI). Early addition of gliclazide/gliclazide-MR shall be preferred over the up-titration of metformin beyond half-maximal dose for effective management of T2DM. Gliclazide/gliclazide-MR can be used safely in patients with diabetes and cardiovascular and chronic kidney disease. It can be used in older patients with T2DM as it does not have active metabolites and has a low risk of hypoglycemia.

CONCLUSION

The expert panel proposed consideration of monotherapy or dual therapy of gliclazide as an ideal choice in patients with T2DM because of its efficacy, long-term glycemic control, favorable renal outcomes, cardiovascular safety, and an optimal safety profile.