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CAD- DIABETES- CKD - GLP1a /DPP4/AGI

Feb 20 | 8:45 AM

Dr. Om Lakhani: GLP1a are the most proven therapy in such a high risk patient in such a scenario Dr. Pankaj Agarwal: DDP4 i are safer, oral, inexpensive and better alternative in such patients. Dr. Banshi Saboo: AGI/ Meglinitide analogue are safer bet in view of CKD

[Music] you can see that the temperature is already rising not only outside but also inside the cardio corn that we could see the last but i am sure this is going to be the hottest because stalwarts coming on the field and we have dr om lakhani he is a consultant endocrinologist uh at the zeidas might raise your volume please okay okay yeah before the temperature rises uh let's talk something i'm sure it's going to be a big fight very meaning of bout will be realized to the audience now that we have got dr umlakkha and dr sabu and dr and the topic is also such and dr kamal always puts one or two uh points in such a way that everybody takes advantage of it and so dr omlakhani is an endocrinologist at sanders hospital he has his mbbs md and dnb degree and he is having a president np gold medal in endocrinology and he has his own notes in endocrinology app and that's very useful to the practicing physicians the next speaker is dr pankaj agrawal he has his dm endocrinology degree and he is in gaza but he is a founder medical concept in hindi is his main innovations and he conducts online classes of integrated endocrinology for the postgraduate students in hindi he is a principal investigator in 29 global and five national studies he has 26 publications in international and national journals he is an examiner at the dm endocrinology in the universities next is dr bansi sabu i'm sure everybody knows him he's a chief diametrologist and chairman of the diabetes care and foreign he is an immediate past president of rssbi he is president of aiaro and if i continue giving his degree his time will be considered so i would better avoid and say he is dr bensis that should be enough and topic on which we are going to have the three different views are about an elderly gentleman with diabetes coronary disease ckd and we have to add the fourth drug in over and above the clarity and the metformin and one of the drugs so first doctor is going to talk about the case for glutathione uh thank you paul i would like to say a few words regarding this topic uh our topic is titled as cad diabetes ckd where glp a1 bpp4 inhibitors or agi out of these three which one the organizers have very intelligently omitted sulfonylureas and glutathiones in this discussion here the problem is that he is an elderly man he is obese his weight is 90 kg he is undergoing ptca he is suffering from ckd and heart failure with best medicine so far is on hdlt2 inhibitors metformin and glycine and diet and lifestyle modifications his diabetes is not under control so our main discussion today will be regarding how to control his diabetes well as far as his fasting ppvs and hb once he are concerned because by controlling his diabetes we can have some better outcome in this patient being elderly there may be other coexisting commodities and discussing this type of case he might have cognitive dysfunction he might have gastroenterology might have prostate problem he might osteoporosis and other things so i request the speakers to consider all these points of their time so very well we agree with that i also welcome all the chairpersons and whom and can i be allowed to share my slide yeah thank you yeah are my slide c yeah yeah okay thank you so you know i think the case is uh case has already been introduced to the uh you know to the audience and uh i'm going to talk about the uh glp one reception this is the financial disclosure and i'm going to talk from uh the perspective of dnp one receptor agonist as the uh you know the next choice for this patient but you know as all of you and a lot of you would have seen the movie three idiot you know uh these these three guys who end up in a marriage i'm actually trying to be more neutral and from science side right so that is what my focus will be so we have this patient who has already been introduced like i said uh 72 year old 90 kg weight its egfr is 39 hp 168.9 is fasting is 212 goes 2276 and lvf is 48 percent so this is the history with the past history of pttm now let's dissect this case further so what are the issues that we have in this question so naturally the patient has a poor glycemic control but i'd like to see the data more closely and i often see the delta value so delta value is basically the most random sugar minus the fasting sugar which is 64 over here but his fasting is 212. so keep this in mind i'll come back to this remember my science kit right okay uh the patient has an increased creatinine now see we have been told that the patient has ckd but we don't know the baseline creatine of this patient right we don't know the path is free we just know the current uh situation right and that is what happens with a lot of our practice uh we don't know the etiology for the increased creativity we have the patient having ahcbd he is having heart failure with reduced reduction fraction uh slightly reduce reduction fraction and he's having ongoing medicines which are basal insulin but forming with an sgt now these are the options which are given to us uh add a glp1 receptor agonist either a oral chemoglotide glutathione add a dpp4 inhibitor add an agi add a magnetic line because you know doctor banshee was going to speak on this and others so what is your answer well i'll let you allow you to think about it we'll come back to this in a discussion but my answer my answer is i said in the beginning i was to talk on glp one receptor but my answer is none of the other i'm not going to add this patient on a [Music] all i'm going to do in this patient is to fix the pathway first i think that is the method which should be going today right the answer in my opinion and scientifically the answer is none of them the patient does not need any of these medications all the patient needs here is to correct the basal insulin dose transmission right that is all we need to do remember no matter what the dose the patient is taking right there is a lot of wrong concepts about basal insulin we don't know what those this patient is taking but whatever the dose is taking the best thing about insulin is that you can always do right so you can easily give this patient more basal insulin titrate the basal insulin correctly there is no upper limit of what basal insulin you can give remember basal insulin is going to be the safest drug as well right because you know the patient has ckd you know there are very few contraindications of basal insulin this patient is already on basal insulin all we need to do is iterate the basal insulin that is all we need to do right no other fancy medicines are required here right that is the time speaker of sample right so no new medicine we see this type of patients very commonly in our practice all you need to do is first of all review the patient's basal insulin technique and teach the correct technique every single day i see patients with high doses of insulin multiple doses of insulin sugars are not under control and you see this patient having big lipohyphotrophies on their abdomen right patient is taking injection at the same side every day right initially the sugar was controlled for a few days after that the sugars are not undergo half of the patients are not are not aware that they are supposed to change their pen needle they don't know how frequently to change their pen needle they don't know the correct technique for insulin injection that's the most important thing that is what we should be doing right so each patient are correct uh technique take the patient's technique and teach the patient the right technique increase the dose of basal insulin ask the patient to report the fasting sugar daily by whatever means target to fix the fasting target a range of 90 to 130 and like perfect let's keep it hundred right keep it 100 to 130. what this will do is remember the delta gap delta gap of 64. if i just bring the fasting down to let's say 100 right 100 plus 64 is 164 the patient's postpending will also come down to less than 180 right and if you do the hp1c after three months patient's experience will be easily less than seven right so remember the most important thing right in any patient always especially patients with high experiences whenever you have higher experience the contribution of the fasting sugar is higher to the overall expectancy and hence in all these patients the important thing is to fix the fasting first right in this patient the fasting itself is 212 you don't need to do anything just fix the fasting first and we need basically right an agent which improves the fasting and in this case the patient is already on the best agent which can control the fasting that is right this is i think this is the i would say the correct answer but we have to choose one of the drugs as we have been told right an entire scenario right let us look at the other option right so your glp one your dpp before agi mentally tonight well answer two three and four are all wrong answers because remember we need a drug which corrects the fasting and amongst all these four options the only drug which has predominantly at good action or not predominantly it's a good action on fasting is glp one receptor one is that is a long-acting glp one right so we need a long fpg glp one something like either a lyric blue type or a oral schema glutathione which can have access to the fasting blood sugar pp4 mainly has action on postpartum agi only as action of postpartum regulatory has only action of postpartum patients fasting is 212 square foot pendulum is 264 which are available the only viable option right forget cardiovascular risk forget ckd everything the only viable option is to either increase the basal infrared dose or to add a glp one reset back on it these are the only options that we have right now the other big question here is is the patient's you know should the metaphor will be continued now this question society similar guidelines are followed all across the world right i chose the korean one because it's the most well written right remember it is said that metformin can be used in full therapeutic doses when the egfr is more than 45 right if the patient is already on metformin and egfr is less between 30 to 45 then you should can continue metformin but the dose should be less than one gram and if the patient egfr is less than 30 then you do not initiate metformin right so that's the broad guideline so in this case we don't know the goals of the platform in the patient is taking but the patient's egfr is 39 that means up to one gram of metformin we can safely give to this patient so metformin i will continue if the patient's nose is more than one gram i'll reduce it to one gram but i will continue second important question and dr kamal sharma is like a mentor and teacher to me right i've learned a lot from this book uh and i'm you know i knew that if this question is asked there will be an attitude there right i'm sure you know you know he's a uh you know big proponent of a very this very good molecule right should you continue scalp that's also important right so in this case now we know that the patient is ckd but we don't know whether this is acute or chronic or this is just a chronic kidney disease we don't know the prior creatine of this patient so we are assuming that the patient is having pkd and we are assuming that the patient's creating an sp table right but what do you do if it was not right so if you see the kd ico guidelines about ckd the kdr guidelines says again we talked about metformin already but about jupiter it says that if the egfr is less than 30 do not initiate sgmp2 if the patient is not dialing with this continuous mp2 but in other conditions you can either continue hcl2 or add sd2 in this case patient is already on hdf20 you can continue that right and added to that the other options you have are glp vp4 insulin agi and so on right but if you see the guidelines very clearly it says the preferred drug is glp1 so again right i may say anything but the guidelines clearly say that the next preferred drug in this patient should be a glp1 receptor which of course you know uh is the thing right and again uh in simple terms any patient with sglt2 uh you know with pkt remember if egfr is more than 30 you can give right at any level of hyperglycemia so you can give hdf22 in this pressure continuously when you discontinue now what happens is you add an scalp and there will be it's an acute drop of egfr which is often hemodynamic in origin if this drop is more than 30 percent you discontinue the uh you know sglp2 and reactions the patient but if the drop is less than 10 percent you can continue using the drug so in this patient you review the patient's past egfr values if you have that value access whether there is a recent drop in egfr if there is no recent drop in egfr you can continue your sgmp if the recent drop in egfr is more than 30 you need to con you need to discontinue last one million yes sir okay uh what is the diff you know uh so with conclusion with sgt2 you can continue as yet be two in this fashion now coming to glp1 receptor right we need to consider two things here first thing tell the patient effort is glp1 second is can the patient tolerated right any patient you start a patient or glp these two considerations should be there assuming that both these considerations are there the arguments in favor of tlpr you have good glycemic control it helps in weight loss it prevents ckd progression and most importantly prevents future cardiovascular events right if you see overall in terms of you know the uh weight loss the weight losses of coral sigma fluid is definitely more sharper than right uh but you can clearly see from this data right and again if you talk about cardiovascular benefit here remember this patient has a hpv cardiovascular disease and the drug which is the best drug for preventing the progression of atrocious cardiovascular disease as we have seen from data earlier is a glp one receptor acronis particularly in this station of victosa right so this is the point here experience reduction is also the sharpest again with coral sigma protein and most importantly oral sigma glucose can be given at any egfr value you can give it to any patient in respective egfr and it can be easily given and it is completely safe right uh so you can give it at varying degrees of linear impairment and no dose adjustment is required in fact it is effective in patients with uh higher rates of ckd also uh and it prevents the inner detoxation also right so again we are all aware about the cardiovascular benefits of uh of uh glp1 receptor god is writing you know i'm sure dr banji sabo will also agree with me that if cost is not an issue then glp one receptor economy would be a great choice for this station right so again uh these are the other things we'll not go into details about how you know glp one receptacle system you are all aware of this right but let us look at glp1 from a perspective of this being an ideal agent right introduces hp1c fasting and postprandial it will produce minimum hypoglycemia it will reduce the weight it will have cardiovascular benefit especially cardiovascular benefits generally side effects profiles are tolerable except for gi side effects no dose requirement is requiring old age and those those verification is required in this cpd situation so there's no doubt about it that gfp is a ideal drug only factor is the cost here right that is the only factor in mind right so just to summarize in this patient remember like i said my scientific pattern in this case the best idea is to fix the fasting first all the patient needs basically is proper basal insulin dose titration the metformin can be given up to one gram in patients with egfr between 30 to 45 hclt may be continued of course the benefit is definitely more than the risk in this patient and can be continued glp on the cell electrochemist is a great choice provided the patient two things each patient can afford it and patient control both these things are taken into consideration clp is a great choice for this patient and obese patient glp provides additional benefit of weight loss and remember in terms of atrocious glp1 is the best agent for the exothermic prevention and remember in this patient a combination of elp1 with an hdlp to from a cardiovascular point of view will be as a lot of us would say and as dr pankaj home also spoke for others i mean he was covering others topic as well he has made things clear for everyone now yes sir dr pankaj [Music] foreign um [Music] [Music] [Music] foreign [Music] foreign there is no statistical increased risk foreign foreign um foreign [Music] [Music] these agents can be we will go to the next speaker dr bansi yes and then dr jesh you are always ready yes first of all thanks kamal for giving me an opportunity and om was talking for first five minutes that case is wrong i agree that you know the fasting sugar was not controlled and let us assume that glycine is given in full dose and let us consider that fasting sugar is 112. and kamal and dr apurva had referred the patient for control of the sugar with eight point nine even so now understand that this patient is already on insulin full dose and he's having fasting sugar 112 with 276. already dr pankaj has talked about the dpp4 but he agreed that glp1 is the best and that we as far as science is concerned we agree and we will go with the guidelines also but where i will place that should i put the patients on a glinites or on alpha glucosidase inhibitor in combination because patient has been referred from cardiologist and nephrologist for a good control of diabetes with 8.9 is not acceptable even the patient may be a 72 year old guy or he is having a patient with a post ptca or his lv dysfunction so this is the case we all know now i did not need to discuss more about it so the guideline approach fully i agree that this patient should have achieved the events of around 7.5 and there should not be further weight increase which glp one will be best radio original prospective anti-diabetic agents if patient is already on hdlt2 inhibitor we would like to put the patients on glp1 and glycine will take care of the fasting sugar but in real world it does not work and that is what even after next five minutes again we could not convince that patient should be started on glp one or not are we adding to the guidelines which is recommended therapy and this is the data which is published in 2019 and even from the western world where the these molecules are available to the patients free of charge and still the clinicians are not writing the way they should write or the is therapy here you can see less than 10 of the patients with type 2 diabetes with cardiovascular disease received guidelines recommended therapy for cv risk reduction even in developed world and this is the data which i am showing which is published in 2019 now attending a1c for this patient i am sure all of you will agree that patients should achieve a event of less than 7.5 if not very good tight control we don't want hypoglycemia but definitely hb1c should be around 7.5 hyperglycemia itself leads to a lot of problem even in a person who is not having cardiovascular disease or somebody who is having already cardiovascular disease because ppsg is a post prandtl hyperglycemia associated with hyper probability including increasing platelet activity and activating platelets and there are multiple other reasons for which postpartum hyperglycemia has to be controlled not only just for getting a1c to get control if i just put the list of all the anti-diabetic agents which are available to us and this patient is already on sglt2 and metformin can we give the patient sulfonylurea risk of hypo is more glitter zone may precipitate heart failure hdlt2 patient is already there glp1 yes it's a choice of drug but the gi issue the cost pencatitis needle prick even then now it is available in oral form but the cost is a major challenge alpha glucoside is inhibited safely can be given with egfr up to 25 this patient is having 39. the glenoids can be given even in the patient with ckd and and staginal disease you can give up to 0.5.5 can be given further broken in half tablet as for the dose as patients should not develop the hypoglycemia and at the same time post meal glucose has to be controlled now this is the data i'm sure all of you agree and you know it also that which anti-diabetic therapy can be given in different stages of ckd and it is the glenoids which can be given in the patient even his egfr is less than 25 even we can give it even in end stress real disease where the egfr is even less than 15 also so this is safely can be given in the patient with ckd and this patient is having a progressing uh chronic kidney failure now as far as efficacy is concerned now this patient is 8.9 considering the fasting sugar is 112 and glands in those is full given still the events is not getting control now what molecule would you like to give you have a choice of glp 1 and dpp4 with the average a1c reduction in the third line again will be point five to one point one and you can see here with the sulfonate and glenites and alpha glucosidase they are highly efficacious right because now this patient's major concern is a postprandial hyperglycemia if i can achieve the glycemic control or the post build glucose level from 250 to 150 the a1c reduction will be almost in the tune of 1.5 for 1.3 and that you can achieve only by agi or glenites or a short-term sulfonylurea which will not be possible with dpp4 and glp1 analog and that's the reason the patient can be for a good glycemic control that glynate and alpha glucosidase inhibitor can be a choice of therapy is post prandtl glycemia is a harmful we all know it international diabetic federation had come out with a special booklet which is talking about the post-meal hyphen hyperglycemia is a harmful and it should be addressed and what they are talking the several class of pharmacological agents which can preferentially lower the ppg but it is agi and glinids are the choice of therapy when we are trying to talk about only post meal glucose to get control the american diabetic association recommends even they don't talk about the post meal glucose so much and they don't talk about the agi but they talk that it is clear that post prandtl glucose level like preprinted hyperglycemia it contributes to elevated even sea level and its relative contribution is being greater when even c is closer to seven so when you are looking at the patient whose events is around eight or eight point five try to control the post meal glucose level also along with fasting control if your fasting is controlled and still the events is around eight or eight point five try to achieve the tighter control of the glucose also the rss we also recommend the same that post male glucose level should be less than 160 it is agi glp 1 dpp 4 all of them are also working on post build glucose level but glenites and short acting sulfonylurea are recommended in a patient with ckd who have a post glucose level or height now let me talk about this combination where the talk is given to me what recognite and voglipose does rapid and short-acting insulinotropic oral hypoglycemic azan and azi is a class of agent which is competitive inhibitor of engine needed to digest the carbohydrate in a very simple language this combination takes you know both the parts and they can be combined in the patients who is uh only the post-field glucose is not getting consumed that fungicide is a glucose dependent it does not cause so much longer hypoglycemia it restores early phase of insulin secretion improves post meal glycemia reduces lipolysis and it is recommended by various societies and particularly when ppg is associated with diabetes and ctd the glenites is the choice of therapy it exerts direct action on a pancreatic beta cell but it is unlike sulfonylurea so the chances of hypoglycemia with glenoids are very very less it has got a pseudotropic action at a glance but there are other benefits it improves beta cell function it restore early phase insulin secretion and rapid onset of action with short life hypoglycemia effect and it's like glucose and those dependent in pseudonotropic effect it is other like a glimmi pride it does not cause long acting hypoglycemia and it is only controlling the post because glucose excursion only but the point is here whether it can be given in a patient who is post ptca is 72 year old guy republican is more efficient than controlling the post will glucose accuracy and it has got a beneficial effect on reducing cardiovascular risk factor for which i will show one more paper that reprograms cv safety data reparaglinite associated with lower cardiovascular risk than any other insulin cycle so if out of all sulfonylurea if i put then the glenoids i am not comparing here it with the glp one or sgt2 so mind well but here out of all the sulfonylurea if we want to control the glinites are safe as far as no previous myocardial infarction those patients cardiovascular days or the patient who have mi stroke or cardiovascular day the burglary bose it inhibits absorption of carbohydrates from intestine the inhibitory activity on maltose in sucrose is 190 to 200 times 70 times higher than the carbohydrates it reduces oxidative stress coglibose lowers the daily glycemic excursion it increases the release of glp1 and has got a better safety profile in compared to other oral hyperclasification voglipose prevents post-meal glucose excursion it is reduces post glucose excursion delay dispel intestinal absorption and carbohydrates it also increases the glp1 level which helps in delaying the gastric and tying and decrease appetite and there is a weight loss also why repugnant vaguely bose combination can be given the combination provides better efficacy compared to monotherapy it is a rational for doubt in patients who have brand new regulated are needed agi modified rapid insulin release which is induced by repuling with different mechanisms of action both the molecules actually they supplement each other and there is no evidence of clinically significant pharmacokinetic interaction between unites and vaguely bones if you just see the data that along the united states compared to that if you put the repugnant in vaguely balls there is a significant decrease in the post build glucose level as far as hypoglycemia is concerned if you combine both instead of only rapidly right the frequency of hypoglycemia is significantly decreased because sudden chance of post meal hypoglycemia will be decreased by adding the body bones so the combination have less risk of hypoglycemia and a better control also so in which condition or useful condition when it can be used the typical condition is a type 2 diabetic patient with care definitely the patient with irregular milk pattern or the patient who have high carbohydrate content even after explaining the patient on nutrition counseling has been done to summarize my talk repuglinite with alpha glucoside is inhibitor the smugly bones will provide better efficacy to control post field hyperglycemia both of them have a different mechanism action therefore combination will have a synergistic action and no evidence of clinically significant pharmacokinetic interaction between repugnant and vaguely most combination was wet neutral had fewer hypoglycemia event than in compared to monotherapy to take away from this uh complete debate we all understand that diabetes and cardiovascular disease are both global epidemics and we have to accept that that as a person with diabetes with the 72 years old guy the patient should be given a choice of a therapy which is more serious safe and severe benefit the post meal glucose level itself is a problem with the patient with ckd and it is again higher associated with seven mortality risk and additional risk factor of hypertension and this lipid by adding alpha glucoside is inhibitor we are benefiting the surrogate markers of cbd and may be youthful drug for reducing cardiovascular risk by reducing postprandial hyperglycemia by decreasing glycemic excursion it improves vascular health lose oxidative stress and prevents endothelial dysfunction it promotes weight loss it improves blood pressure and decreased risk of hypertension it inhibit platelet activation and it improve that dysbiosis in real world data it demonstrated significant lower risk with the use of aza and glenoids combination for risk of hypoglycemia particularly in patients of ckd with this i think but i'm sure the patient is referred to us the patient with the adding the aegi and glinites with the fasting sugar which is well controlled with uh insulin glycine which is uprighted and getting the even fasting sugar less than 130 if the patient sugar is remaining more than 200 i think it is best choice to add these patients on glinids or pga combination without increasing the risk of hypoglycemia if patient is not accepting the glp one analog and which is in most of the situation a person with a 72 year old with the history of ckd will not accept the injectable and the costly therapy so with this i end my case but i'll be very happy with that discussion thank you so the house is open for discussion i think market side want to tell something would you like to add something you were yes sir please ah see first of all i would say i enjoyed all the three speakers extraordinary discussion and let me tell you one thing that as the life expectancy has increased now we see large number of diabetes type 2 patients with multiple morbidities so it's a case for case by a case dependent issue see basically uh very difficult to guide give a guideline for one particular drug in one particular condition because we come across large number of patients with large number of diseases in a multiple combination so uh which drug is to be given which drug is not to be given sometimes very very difficult but let me tell you very frankly i entirely agree in this particular given case because data's givens are not that complete what is the dose of metformin i don't know so mad for first of all i would say metformin according to the egfr should be modified then you increase the basal inflamed and then glp one analog probably i would give the only factor i would say is cost that gives me a little bit apprehension whether i should do it or not and then in that case entirely with one c yes the combination would have been better but still i would like to have a drug which is effective on fasting blood sugar that is the only thing thank you otherwise as i say you have to go case my case that's very important thank you sure i think this was this was a topic over debate but there was no debate there is one thing that everybody is talking of science and we expected more across the corrections only disappointed but kamal physicists are always looking at one side and not looking back that's what i'm telling the physicians are always going by the science and they don't model too much like our counterparts you know whom we are talking about but anyway the point that is not discussed is about the sclk2 you pick as a whole but do we have the all seal two we can give it at the egfr of 30 40. that is what i would ask the doctor who is with us that is yeah yes less than 40 30 when up to 25 also can be given so now the new indication that sgt2 inhibitor can be initiated even even below 30 the lattice data is up to 28 can be continued before that it was there that before below the easier power of 45 it should not be initiated but if somebody is already on that then it can be discontinued up to 30. with the data of napa ckd now it is shown that even the benefit is continued it is not as in glycemic benefit but you think of the benefit of ckd progression horn and that's a much better benefit of sglt2 inhibitor so here is the case with the 39th sglt2 inhibitor has to be there it was already there the patient was already on their metformin and i'm sure it must be on reduced dose of metformin unluckily i think the fasting plasma glucose return is very high and that should not be case the glycine if it is already there the glycogen has to be up to the dose when the fasting glucose level should be less than 130 by all means efficient with 130 but in patient with ckd you may see a patient with a post build glucose level of more than 250. so you believe that a patient with a more than 250 with a fasting glucose control and still eight point nine or eight point five even see now what to do for post meal glucose yes already in another session before but the point i was willing to raise has been touched by banshee that as glt2 inhibitors they are excellent drug and they work very well even in gfr less than 30 and the advantages of hdlt2 inhibitors are more in the field of their cardiovascular benefit as well as renal benefits in egfr below 30 glycemic benefits goes down below 30 but real benefits actually goes up the problem is whenever we are using cancer 2 inhibitors at dfr of less than 30 it can lead to a precipitous drop in blood pressure and may not be tolerated very well by the candidates so the expertise of a doctor or the doctor should be very high very good at that level of future power to justify its uses over there glycemic benefits um [Music] this patient does not require tight control of blood sugar looking at his age and the conditions but the 7.5 is required secondly by increasing the doses of glycine insulin we may invite hypoglycemia at any time because we do not know how it is taken and secondly his weight may increase with the increasing doses of insulin so there we have to take extra precautions so as to prevent these problems second thing that these type of patients are many times gastroparesis they cannot audit glp1 so easily so that required good explanation and to convince the patient that they have to consider like this or did if i am to treat this patient by doing this i would have added glp one if patient is according plus agi and if not according i would have added gdlp one dpp for individuals plus ati any of these could have given the better results but uh it has been observed that uh the ppp4 and emitters they are losing durability after some time if so then we may have to think something else this is what so far i've come across 279 let us understand that this pressure is 279 post field glucose level and by by adding only alpha glucosidase inhibitor you will not able to decrease the post meal glucose by 100 milligram here you have to think that you have to keep the target post meal glucose less than 180 i am not putting the patient should go in hypoglycemia the fasting i am keeping almost around 110 230 and alone egi will not be effective to decrease from 278. now let us understand if i put the patient on bpp4 and eca in a combination along with metformin and with the hdlt2 even if you put the dpp4 and ega also combinedly you will not able to get this patient so if i'm putting the definitely given situation it may not be it's a complete hypothetical situation but still it will require a short acting and that's the reason the glinites and the combination of carbons or bugley balls will be real effective to control the post field glucose level and my target for this patient is 110 and 180 we don't want to decrease the i1c less than 7.5 by any condition patient should not go in hypoglycemia then all points are well taken but still we want to achieve the a1c of less than 8 at least not 7.5 patient is referred to us by a nephrologist or cardiologist patient himself had come to diabetologist only for getting control he knows that his cardiovascular safety has already been taken care by kamal sharma his kidney is already taken care by a pool parent he had come to us only for a glucose control i don't want my patient to go in hypoglycemia but at the same time patient sugar has to be in control otherwise why he has to come for a diabetes specialist there is no reason for that why i agree the whole point of creating this debate was that we need to define not only that the sugar needs to be controlled but how do you control also matters now just the way it mattered in cardiology and hypertension now i think we also know in diabetology what drugs you will use to control sugar will also matter uh we can hear our nephrologist friend what does he think about the three therapies i completely agree with completely i i have a question for all the endocrinologists we change the glassine to either a high potency glycine or different long acting insulin to control both fasting and dbvs oh no sir i would not do it i think largely is a good insulin uh i think you know there is a lot of noise level from other instruments uh to say that a is better than b in my experience as long as you titrate to patient 2 like dr manchester said you know to when fasting sugar of 110 or 120 you are not inviting hypoglycemia that this patient would not have hypoglycemia if the basal insulin is titrated effectively i am i'm not worried about that uh i'm you know and one thing you know i'll say that in my opinion the newer basal influence give more of convenience rather than uh you know the edge in terms of glycemic control i think glycine is good enough for the insulin to control the you know the fasting sugar and i think it should be the only thing we need is a good titration here uh you know and that is that is the main thing we should be doing here i think you know dr banchi said i don't know if you noticed this uh maybe a few years back we are having a debate uh similar debates unfortunately on the second generation basal insulin they are not more potent rather than i will also go continue with the glycogen and here there is an advantage this patient is already doing 1.7 so you know that glycogen will also act for more than 24 hours so there is no reason why you should change the basal insulin just because patient had a creatine of 1.7 if you are worried of midnight hypoglycemia if there is a documented hypoglycemia if you are putting the patient on continuous glucose content and you are finding there is a hypoglycemia and then you want to change to the newer basal insulin analog that's fine otherwise glycine is good enough and there is no reason as he told very rightly that in some of the patients where we use newer insulin are only for the purpose of flexibility because that's for convenience they don't want to take the insulin at the same time every day and that's the only reason why we go for the instead of glands in uh maybe glands in 300 or degluted one is small point i would like to add with the permission of chair is the concern with all insulin is hypoglycemia the major concern is to rule out midnight hypoglycemia so in such type of triglycerides where midnight hypoglycemia could be very much deleterious we can use and i regularly use lentus or gladly insulin in morning hours i i understand that the effect on the fasting hyperglycemia the hepatic glucose output would be lesser when it is used in morning hours but it reduces number one midnight hypoglycemia chances number two it increases it gives an edge over the postpartum control as well in the after lunch hours or so so in all patients at risk of midnight hypoglycemia this incident can very well be used in morning hours it will be safer and in offering post tender control it will become more efficacious as well

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dr. Om Lakhani

Dr. Om Lakhani

Consultant Endocrinologist, Ahmedabad

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dr. Banshi Saboo

Dr. Banshi Saboo

Chief Diabetologist & Chairman of Diabetes Care & Hormone Clinic at Ahmedabad

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dr. Om Lakhani

Dr. Om Lakhani

Consultant Endocrinologist, Ahmedabad

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dr. Banshi Saboo

Dr. Banshi Saboo

Chief Diabetologist & Chairman of Diabetes Ca...

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