CME INDIA Presentation by Dr. Rajeev Chawla, MD, FRSSDI, FRCP (Edin, London) FACE(USA), Senior Consultant Diabetologist, North Delhi Diabetes Centre, Immediate Past President RSSDI, President DIPSI.
Pearls in Diabetes Management.
RSSDI ESI Clinical Practice Guidelines 2020 caused ripples in the turbulent sea of Diabetes Management. It is a unique Indian contribution to the medical science – simplifying the puzzle of choosing the Anti-Diabetic drugs. RSSDI-ESI Wheel is now recognized the best way to proceed to treat diabetic patients.
Factors relevant to the Indian context
Recommendation for MNT (Medical Nutrition Therapy) in patients with T2DM
RSSDI-ESI Therapeutic Wheel 2020
Individualized Treatment for T2DM
ABCD (EFGH) approach for diabetes management
A (Age)
B (BMI)
While prescribing pharmacological treatments for overweight or obese patients with T2DM: Consider medications which cause either weight loss or weight neutrality.
| Drug Class | Effect on weight |
| SGLT2is | Loss |
| GLP-1As | Loss |
| AGIs | Neutral |
| DPP4is | Neutral |
| Modern SUs | Do not result in weight gain |
| Insulin | Gain |
C (CKD)
- Evidence suggests that two oral hyperglycemic agents DPP-4 inhibitors, SGLT2 inhibitors, GLP1A exert Reno protective effects in patients with diabetes.
- SGLT2 inhibitors are indicated to improve glycemic control in adults with T2DM by reducing the reabsorption of filtered glucose. They can also lower the renal threshold for glucose, thereby increasing urinary glucose excretion.
| Drugs | eGFR | Concerns |
| Repaglinide | Across all stages of renal insufficiency | Watch for hypoglycemia |
| Pioglitazone | Can be used at any eGFR | Fluid retention and CCF |
| SGLT2is | Preferred for Reno protective action | |
| Canagliflozin | eGFR up to 45 (100 mg for eGFR 45 to < 60) | eGFR < 45: Avoid Use (ADA up to 30) |
| Dapagliflozin | eGFR up to 60 | eGFR < 60: Avoid Use |
| Empagliflozin | eGFR up to 45 | eGFR < 45: Avoid Use |
| GLP-1As | Recommended up to eGFR 15 | Owing to their GI adverse effects, use in renal insufficiency is practically limited |
| Insulin | Safest at Any stages of renal insufficiency | May require dose reduction with falling eGFR and individualized HbA1c targets |
D (Duration of Diabetes)
Early phase of diabetes
- Tight glycemic control is important
- As it leads to glycemic memory
- Protecting from micro and macro vascular complications
- SU + Met are the most suited for tight glycemic control
Long standing diabetes
- Patients with long-standing T2DM have deficient β-cell function & other comorbidities including renal impairment
- Insulin addresses insulinopenic states
- Incretin-based therapies, particularly GLP-1 agonists preferred over DPP-4 inhibitors
- SGLT2i as their insulin independent action
- AGI’s effective sometime owing to their beta-cell independent actions.
E (Established Cardiovascular Diseases)
- In patients with established CVD, GLP-1 analogues and SGLT2i with proven efficacy may be preferred.
- In patients with heart failure and CKD, SGLT2i or GLP-1 agonists may be preferred unless contraindicated.
- Pioglitazone has been shown in few studies to reduce
- CVD risk, however, pioglitazone should not be used in patients with subclinical heart failure or patients with low ejection fraction.
- Linagliptin, glimepiride and gliclazide MR can be preferred over conventional sulfonylureas in patients at increased risk of CVD or with CVD.
F (Financial Concern)
- Considering that many Indian patients do not have medical insurance and treatment needs to be continued lifelong, cost of therapy also plays a crucial role in T2DM patients from Indian subcontinent.
- Sulphonylureas can be good partner to metformin considering their cost in the light of recent CAROLINA trial demonstrating the CV neutrality of glimepiride compared to linagliptin.
- Pioglitazone or inexpensive DPP-4 inhibitors or SGLT2i can also be considered when combinations of SUs and metformin cannot achieve the desired target.
- Conventional insulin can be used at any stage considering its efficacy and cost.
G Glycemic status (Worsening Glycemic control)
| Drugs | Glycaemic efficacy |
| Insulin | High |
| GLP1As | High |
| SGLT2is | High |
| Pioglitazone | High |
| DPP4is | High |
| Modern SUs | High |
| AGIs | Moderate |
| Glinides | Moderate |
H (Hypoglycaemia)
- Important limiting factor in treatment of diabetes.
- All patients with risk of hypoglycaemia should be enquired about.
- Patients along with their family members should be well educated about identification and management of hypoglycaemia.
- Especially night-time hypoglycaemia.
- Strictly managed and monitored in special situations.
- Elderly, pregnancy, fasting, and metabolic disorders.
| Drugs | Risk of hypoglycemia |
| Insulin | ++ |
| DPP4is | – – |
| AGIs | – – |
| SGLT2is | – – |
| Pioglitazone | – – |
| GLP1As | -/+ |
| Modern SUs | + |
When you see a patient in your clinic…
How to use the RSSDI-ESI Therapeutic Wheel?
- Prescribe lifestyle intervention to all (Diet/Exercise/CV risk factor reduction)
- Metformin to most patients in the inner core of the wheel
- Identify the 2/3 most important concerns / factors (from ABCDEFGH) you feel should influence your choice of antidiabetic agent e.g. Age / DKD / Finance etc.
- Identify the best choices available from the outer rings
- Further fine tune your choices if more concerns exist
- Make a rational final choice with an ‘individualised approach.’
- Identify complication and its management strategy
RSSDI-ESI therapeutic wheel is designed to be a simple user friendly approach to decide the appropriate antidiabetic agent to be used in Type 2 Diabetes Mellitus
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My opinion regarding the ‘white gap’ shown with Metformin should be rather ‘ eGFR dependent’ or ‘ as per eGFR’; or else the PCPs might have some confusion on this band (?).,,
Regards
Shown with Metformin against C for CKD..
Among the SU , gliclazide and glimipride shows different efficacy and safety .. should they be placed seperately