CME INDIA Presentation based on a case by Dr. Meena Chhabra, MD, Diabetologist, New Delhi and CME INDIA Discussion.
Part-1:
See this Urine Report:
Dr. Meena Chhabra, Diabetologist, Delhi:
- 50 yr., Type 2 diabetic male with history of burning in micturition.
- Please see the above report.
- Is this a contaminant?
- Shouldn’t the pathologist report if he saw budding yeast or pseudo hyphae?
- Presented with chills and I gave empirical antibiotic after sending urine for culture sensitivity. He is better. Temperature- 99 centigrade. Lesser burning in urine
- Does he need antifungal?
- Did he have UTI?
- Culture no bacterial growth.
Dr. Ambrish Mithal, DM Endo, Delhi:
- If the patient has symptoms, it may be prudent to use fluconazole. Although contamination cannot be ruled out, she does have symptoms and its worth giving a trial of antifungal.
Presence of urinary ketone is not a contraindication to use SGLT2i?
Dr. Meena Chhabra Diabetologist Delhi:
- He had burning in micturition which is less after antibiotics. I gave Fosfomycin. Two sachets.
- Why ketones in Urine?
- He is on Sglt2 inhibitors.
Dr. Awadhesh K. Singh DM endo. Kolkata:
- Remember this important point, presence of urinary ketone is not a contraindication to use SGLT2i. Ketonuria on SGLT2i without Ketonemia is very common.
Dr. Ambrish Mithal, DM Endo, Delhi:
- Yes agree. I ignore it usually.
Dr. Noni G Singha, Dibrugarh, Assam:
- Wiser to repeat urine RE.
- If urine finding persisting then better to start fluconazole as Dr Mithal Sir also opined.
- How two sachet was given Madam?
- Recommended dose in MDR or Complicated is 3 gm sachet every 2-3 days for one week(3doses). Same dose for Prostatitis.
- Off level in Prostatitis – 3gm daily for 7 days.
- As male patient, better to get USG KUB + Prostate done.
Dr. Meena Chhabra Diabetologist, Delhi:
- One.
- Then repeated the next day.
- Any UTI in male is usually complicated UTI.
Dr. Raju Sharma, Sr. Physician, Jamshedpur:
- First UTI in male and second in a female should be evaluated to rule out structural problems.
Dr. Vijay Arora, Consultant physician, Max hosp. Delhi:
- Again, emphasize about the need of a proper Gynae check-up in all married female patients with recurrent UTI, recently encountered a78 yrs. elderly diabetic female who was getting treated for repeated Urine cultures positive by different colleagues— was found to have pyometra & cervical Malignancy.
Dr. Raju Sharma, Sr Physician, Jamshedpur:
- I can recount an obese lady who when asked repeatedly about the method of collection told me that she would first collect in a “mug” and then transfer the urine to the sterile bottle!!! She was having a report of “full of pus cells” on repeat testing.
Dr. P. D. Gokhale, Jamshedpur:
- Only due to this, how pus cells can be persistently high. Bacteria may multiply in mug but not pus cells. So, lady is genuinely having recurrent UTI but needs education regarding proper mode of sample collection.
Now Discussion moves to SGLT2-Inhibitor and UTI/GTI
Dr. Ambrish Mithal, DM Endo., Delhi:
- It’s true that SGLT2 inhibitors are a very important drug discovery.
- But it’s also true that every day I stop these drugs for 3-4 patients at least, because of side effects.
- If I don’t stop them, the patient does.
Dr. Awadhesh K. Singh DM Endo. Kolkata:
- Out of how many?
Dr. Ambrish Mithal, DM Endo, Delhi:
- I will collect the data. This is just an observation. But the number is significant.
- And it can’t be dismissed like- you don’t give them proper instructions etc.
- The Indian medical fraternity needs to look at side effect profile too.
- These points are often not discussed adequately and GPs are often shy of sharing their concern.
- Several patients have been advised circumcision by their physicians and some have gotten it done too. Others are forever on Fluconazole.
- Some cardiologists are prescribing left and right in frail elderly patients- some of whom now have a BMI of 18 or less. And are unsteady on their feet.
Dr. N. K. Singh:
- In my experiences, these issues are very less. UTI and GTI varies 5 to 12 percent. Your experience matters, eDKA, improperly selected cases. In my thousands of patients, over 80 percent are on SGLT2i. Even In frail patient, low BMI cases, I have not found much problem. Now, there is study frail patient do tolerate well.
Dr. Ambrish Mithal, DM Endo, Delhi:
- All that I am saying is – we need to pay more attention to the side effects. Sometimes with the waves of good news coming every day, we tend to get carried away
- 5 to 12% is not a small number if it’s repeated infection. Generally, I treat minor infections or first infections. But discontinue in repeated infections.
- A former India captain got so stressed by the weight loss and skinny look that I had to discontinue despite there being a cardiac history and clear indication for use.
- A minister’s mother was hospitalised every 2 months for a full year for UTI. All I did was discontinue SGLT2 and she has been fine ever since.
Dr. Rajiv Kovil, Diabetologist, Mumbai:
- Sometimes patient is on 2 brands of dapagliflozin.
- One prescribed by physician one by cardio.
Dr. Awadhesh K. Singh, DM Endo., Kolkata:
- All the concerns raised are valid including people undergone circumcision, some had little too much weight loss, some had recurrent UTI etc.
- But that’s the known S/E. Thankfully there are not too frequent. We always remember if something happens with the drug but we also forget that it didn’t happen in 90% of the cases.
- We all have experienced those known S/E but that shouldn’t be the reason to disregard all those merits!
- At least I never felt that S/E are too much despite nearly 99% of my T2D patients are on SGLT2i for past 10-11 years.
Dr. Ambrish Mithal, DM Endo., Delhi:
- Of course, we don’t forget the 90% cases. That’s why we prescribe it daily and regularly. In fact, it has become first line treatment in many cases. But we need to be alert to the side effects.
- A patient will not tolerate significant side effects for a perceived long-term benefit. An important aspect of medicine is about keeping the patient free of discomfort also. We should not forget that.
Dr. Ambrish Mithal, DM Endo., Delhi:
- Circumcision being needed for balanoposthitis a few years ago was exceedingly rare. Only if there was an anatomical abnormality, usually.
- Genital infections disappear.
Dr. Prabhat Agarwal, Agra:
- I always asked my every patient on every visit to clean their private parts.
- But GTI is very less in combination with gliptin.
Dr. S. K. Goenka, Begusarai:
- Deposits of Smegma under the foreskin and over the glance, if not removed regularly leads to such problems. It is a natural deposit, but need to be removed frequently.
Dr. Awadhesh K. Singh, DM Endo., Kolkata:
- Long deposited Smegma will cause fibrosis even without diabetes. Presence of sugar due to diabetes even without SGLT2i just accelerate this fibrosis and so is SGLT2i use.
Dr. Basab Ghosh, Diabetologist, Agartala:
- So, the recurrent genital infection of SGLT2i is due to the presence of high sugar in the urine?
Dr. Awadhesh Kr. Singh:
- Of course!!!
Dr. Basab Ghosh, Agartala:
- Good urine hygiene counselling is the solution.
Dr. Awadhesh K. Singh, DM Endo., Kolkata:
- Please note that highest benefit of HF (both prevention and treatment) with SGLT2i is in elderly. Thus, don’t deny benefit to them.
- It’s different story that we stop SGLT2i in people with recurrent UTI just for the sake of safety.
- Similarly, quantum of benefit with SGLT2i is more in more frail people where we don’t wish to prescribe. Amazing and unbelievable but fact remains fact.
- There is a dedicated published paper on SGLT2i in frail – from DELIVER trial.
Dr. Ambrish Mithal, DM Endo., Delhi:
- Yes, and the data about protection is convincing. Not surprising.
Dr. Awadhesh K. Singh, DM Endo., Kolkata:
- Similar positive data in frail people was also there in DAPA-HF. Thus, benefit across the spectrum of HF is clearly evident in frail.
Dr. Vinod Mittal, Diabetologist, Delhi:
- Even Empa has shown better CV outcomes esp. less hHF in elderly people > 65 yrs. vs. < 65 yrs. of age.
Dr. Awadhesh K. Singh, DM Endo., Kolkata:
- Yes, in Emperor-Preserved but not in Emperor-reduced.
- Similar positive data in frail people was also there in DAPA-HF. Thus, benefit across the spectrum of HF is clearly evident in frail.
Dr. Ambrish Mithal, DM Endo., Delhi:
- Yes, it is.
Continued in Part-2:
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