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OHAs and Insulin: Permutations & Combinations

Apr 27 | 2:00 PM

The basic cornerstone of controlling Type 2 Diabetes Mellitus (T2DM) is good glycemic control, and hence it is critical to employ a patient-centered approach to guide the selection of pharmacological medications. Although oral hypoglycemic agents (OHAs) remain the mainstay in the treatment of T2DM, insulin therapy becomes inevitable in a substantial number of patients as the disease progresses. Join us LIVE on Medflix as we discuss the techniques and efficacy of combined insulin and oral hypoglycemic agents (OHAs) in regulating glycemic levels with Dr. Rohit Jacob, Consultant Physician & Intensivist at Craft Hospital & AR Medical Center, Cochin.

[Music] hi everyone good evening my name is dr tanvi and i welcome you all on the behalf of netflix team today we are gathered here for a very interesting session on ohs and insulin permutation and combination by doctor rohit shaker dr rohit jacob is a practicing consultant physician and intensivist with craft hospital and er medical center he's very passionate about teaching and has been a regular creator on netflix right uh good evening everyone thank you panvee for that introduction so uh today let's discuss about the most debated topic or probably what we can say is the most controversial topic that we experience in a day-to-day practice ohas and insulins permutations and combinations so before starting with the presentation let me tell you that we already know that diabetes india is actually the world's capital for diabetes and that's how it's developing into but unfortunately all we think about when a patient comes to a cabin with the fasting blood sugar and a postpartum blood sugar report is whether it falls into type 1 or type 2 but we don't bother to think further than that and think whether it could fall into any other category of diabetes and correspondingly we don't think about what kind of treatment we should provide apart from overchasing insulin so uh to start with first and foremost let's consider a patient of diabetes that comes who is let's say less than 30 years of age so what are the clinical assessment parameters that we do first is fasting glucose level gad antibodies hba1c c peptide ketones if glucose is more than equal to 15 millimole per liter i'm sure many of us might be thinking that in every patient we cannot go for gad antibodies or c peptide levels it's very natural to think that way and it's the correct thing to think but there are certain risk factors which we see like if age is less than 30 years very high blood sugar levels on the first wizard itself patient complains of abdominal pain and vomiting and you check that urine acetone is large moderate or trace so in such a scenario it is necessary that we find out whether it is a type 1 diabetes whether it is modi or anything of that sort now let's say that it is an acute presentation with ketones positive dka or beta cell antibody turns to be positive then definitely we categorize it without any doubt as type 1 diabetes but on the clinical assessment itself we find that the patient is completely hemodynamically stable ketones are negative beta cell antibodies are negative then we further check whether patient has got obesity insulin resistance acanthosis nigricans hypertension nafld dyslipidemia or pcos in short when the patient appears to be obese has a high lipid profile levels or high cholesterol levels or patient is having features of metabolic syndrome kind of picture then you can say that it is tied to diabetes let's say there is another category where patient is hemodynamically stable ketones are negative beta cell antibodies are negative and the bmi is normal with no insulin resistance but there is a strong family history of diabetes in such a case the hints or the clues that we have is young onset deafness and patient or family then it could be a mitochondrial diabetes if there is mild fasting hyperglycemia hba1c less than 7.5 asymptomatic then it is glucokinase deficiency or modi again you can rule it out by genetic testing or if the patient presents with glycosidia pre-diagnosis crp less than 0.5 and on treatment when you start with sulfonylureas the patient's sugar levels completely comes under control then you can say that is it it is type 4 body similarly if the patient has associated features such as renal cysts or genitourinary abnormalities with deranged lfts then you can say that there is an other type of mod that is hn f1b but there are in all at least 10 to 14 types of mod and it is very difficult to categorize each one of them all we need to know is broadly classifying into type 1 type 2 or modi for that matter once you get a hint that it could be modi then you can decide for genetic testing and of course in a day-to-day practice it's very difficult to remember each of the characteristic features that specialize or that differentiate between the types of model so this is a broad way by which we can approach diabetes mellitus now moving on to the next slide this is another short description which have taken from the british journal of medicine it states that if you have a high suspicion of maturity on the diabetes of the young then you can go for clinical assessments such as fpg oral glucose tolerance test hba1c ketone bodies gad antibodies other insulin auto antibodies znt8 and so on and so forth c peptide levels lipid profile and bmi if onset of persistent hyperglycemia before 30 years of age if clinical fight features are not compatible with type 1 diabetes or type 2 diabetes and if there is a family history of diabetes in all such scenario you can suspect that there could be modding rest of the parameters is as i said where we can categorize into the types of model now another thing that we need to remember is the acute onset the acute onset body where there is ketone positive get 65 antibody positive serum c peptide level is below 0.2 at diagnosis and stimulated c peptide below 0.2 at least 3 years after diagnosis if an acute onset is of these features are present then you can categorize it as type 1 diabetes next is the genetic testing or as we call it the whether to find it out whether it is a gck moddy or hnf1b moddy and so on and so forth so that's not of prime importance for us today so i'm just keeping that part now coming to the next slide now this i would say is the most important slide of this entire presentation where how do you approach a case of type 2 diabetes especially towards this treatment if you zoom in this picture with me the first step when a type 2 diabetes comes and you want to treat it is start with metformin and the comprehensive lifestyle management the indicators of high risk or established a cvd which we can do by using the air cvd risk calculator and so on and so forth where we can decide whether you need to start an anti-platelet whether you need to start and start a statin all these parameters also comes into the picture when a diabetic patient comes to your clinic now consider the independently the baseline hba1c values and the target you want to individually achieve with or without a metformin use now let's say a patient comes with type 2 diabetes with raised sugar levels with established ascvt risk score where there is age more than 55 years where there is carotid artery stenosis more than 55 or lvh or dyslipidemia pcos and so on and so forth in such a case glp one receptor analog with proven cardiovascular benefit is seen hdl t2 inhibitors is also a good option with proven cardiovascular benefit and if a1c is above target then along with glp1 receptor analog you can add an sglt2 or vice versa or you can add the thiozolitanitunes dpp4 inhibitor basal insulin or sulfonylureas we have multiple options to choose but it's important as to what we start with the american college of cardiology released its 2022 guidelines which states that even in a patient of heart failure the first line treatment is not diuretics is not ac arb inhibitors but the first line is sglt2 inhibitors yes that's right that heart failure is also prescribed as glp2 there are many trials where dapaglifocin or impact impactly forcing are used and it is proven that empirically forcing and depaglifying have very high uh prognostic benefit and have proven to reduce the moderate morbidity and mortality in patients of heart failure so that is why sdlt2 inhibitors form a very important baseline in today's generation for the management of type 2 diabetes now coming to the next part oh the next part is as i said that if a patient is having heart failure with lvf less than 45 percent hdlt2 inhibitors with proven benefit is already seen now coming to the next part where there is type 2 diabetes along with chronic kidney disease now let me tell you one thing that let's say a patient comes to your clinic with raised fasting and postprandial sugars and suddenly you see that when you do an rft urea turns out to be nearly 35 40 or creatures 1.5 do not suspect it to be ckd directly you can say that it could be a diabetic kidney disease or a new onset diabetic nephropathy which has occurred due to uncontrolled sugars but of course as we all know the primary and the most sensitive way of testing that is urine micro albumin create ratio but on a practical basis if you say the urine microalpha at ratio cost rupees 550 whereas an rft cost just 150 to 200 rupees so naturally we would think of doing a creatinine at first and then going for urine micro albumin create ratio but if you're working among affordable population then of course the best way is to do urine micro albumin create ratio now let's say a patient comes with diabetic kidney disease and albumin urea preferably sglt2 inhibitors with primary evidence of reducing ckd progression is seen or you can use sglt2 inhibitors or you can use glp1 receptor analogs if sglt2 is not tolerated now let's say if a patient is having type 2 diabetes with ckt that is egfr is less than 60 ckd uh according to the staging pattern then there is increased risk of cardiovascular element in such a case also glp one receptor analog is also used and sdlp2 is also used but glp one due to its cost and secondly as we all know that it causes symptoms of uh or it aggravates or you know it can cause side effects nucleotides that is why probably glp one receptor analog is not used very commonly but of course hglt2 inhibitors is one of the best drugs which are present for type 2 diabetes associated with different comorbidities now let's come to the next category where the iris cases are not there like a cvd is not there ckd is not their heart failure is not there in such a case if you see that there is ray sugar levels with a1c a1c levels are above the target then you can proceed like as follows either you can go for dpp4 inhibitors glp one receptor analogues hdlt2 inhibitors or thiazolidaenetunes and when you start one of these drugs again go for monitoring a1c levels and you can either add on another drug of a similar class add one or you can add two so if you're on sgl dpp four then you can add hdl t2 or tcd or if you're on glp one receptor analog you can add sglt2 or tcd if you're already on sglt2 then you can i can add glp one receptor analog or dpp4 or tcd and if you're on tcd you can add hdlt2 or dpp4 or glp one receptor analog in spite of adding all these medications if a1c still remains above the target then you can choose to add sulfonylurase or basal insulin now let me tell you that there are a lot of cases where we see that if a patient's fasting blood sugar levels is let's say 170 and post candle is nearly 240 so if many uh in a scenario which is very commonly seen is that a fasting sugar of 170 and a post candle sugar of 240 and we directly prescribe a metformin along with the but today let me tell you in the market there are better drugs than sulfonylureas especially glybenclamide or glimepride which we commonly use better than that there are hdlt2 inhibitors even glyptons glyptons also play a major role the dpp-4 analog dpp-4 inhibitors these also play an important role in the management of type 2 diabetes today now coming to the next category where if you have no co-morbidities with race sugar levels and there is a compelling need to minimize the weight gain or promote weight loss you can again go for glp one receptor analogues or hdl two inhibitors and if a1c is still above target you can add sglt to and or glp one receptor analogues or preferably we can go for dpp4 inhibitors because it is based on a weight neutrality regimen that means it may not cause weight gain or it may not neither cause weight loss now if dpp4 inhibitors are not tolerated or contraindicated or patient is already on glp one receptor analog you can add sulfonylureas pcbs or basal insulin i think easy these are becoming more out of the picture today probably because of its increased chances of causing edema and aggravation of symptoms in cardiac failure liver cirrhosis and so on and so forth so naturally we have basically we have metformin we have sulfonylureas we have dpp4 we have hdlt2 inhibitors as the most common and most important drugs from which we can choose to control our sugar levels now coming to the practical scenario let's say that cost is a major issue in such a case the option we have left is sulfonyl uts or tcds and if a1c is above target you can switch over or you can add on any one of these and if still a1c is above target then you can go for insulin therapy basal insulin with lowest acquisition cost or consider other therapies based on the cost so this is a small summary of how we should go about choosing an oha or starting an oha therapy and modifying it accordingly now we have another slide which states that if lockdown that every 3 to 4 out of 10 diabetic patients in india reported moderate to severe worsening of their glycemic status during and post lockdown there are many factors which may have contributed to these one among them would be the lack of physical inactivity that patients still remain inside the house they try to take in all kinds of junk food and they do not follow a healthy lifestyle and more importantly mental health issues let me tell you there is nothing worse than sitting at home and doing nothing so when a person sits at home and does nothing that aggravates mental stress and we cannot measure it but still that also plays a role in modifying or increasing our sugar levels now let's run the poll that we have so i just want to know your opinion as to what are the answers to these questions what is your biggest fear of increasing insulin doses fear of weight gain fear of hypoglycemia fear of repeated pricking what is your biggest fear of increasing insulin doses right so as per my final results the biggest fear of increasing insulin doses is as expected fear of hypoglycemia in 81 of the votes that we have so can we go to the next question also what do you prefer to initiate in your daily practice for hba1c more than nine options only ohas ohas plus one dose insulin ohas plus twice daily insulin basal bolus regimen that is only insulin without any ohs what do you prefer to initiate in your daily practice for hb a1c more than nine please give a practical answer please don't give me my guidelines so what you face on a daily scenario please give that that answer so plus those insulin is plus twice daily 22 and only oh is 29 basal bolus regimen 9 right okay so i will discuss these questions as and when with the presentation now moving ahead to our next slide there are two kinds of patients that come to us basically the first category is overall anti-diabetics patients are having highly uncontrolled sugars even after you give three to four drugs one side wild glypton is going on underside metformin is going on underside top ugly foreign is going on glimmer pride two milligrams twice a day is going on and you have already uncontrolled patients and you have not given or not started insulin yet now coming to the second category where you have mixed start going on mixed start insulin let's say it's going 30 by 20 or you have another category where you're giving lantis around 25 units and you have giving you know let's say you have given boneless regimen of acrobat let's say 10 10 10 still sugar still remain uncontrolled so these are the two most common categories of patients that we see in a daily practice let's come to the first category where you have oads and highly uncontrolled challenges in having or challenges in insulin initiation are two most common things that we face one is challenging challenges with monitoring of blood glucose levels and second hb a1c levels are more than nine percent so when we have these two scenarios we are always doubtful in our mind whether to go with oads or whether it should start with insulin or still modify or increase oad doses or whether to initiate an insulin therapy now the solution and tips for insulin initiation is prefer the insulin which requires less monitoring that is your secret towards starting an insulin the safe and convenient insulin regimen requiring less monitoring is the one to be preferred insulin initiation using disposable pens to reinforce simplicity and ease of insulin therapy changing of cartridges and needles for a reusable pen may be confusing for beginners so one trick that we should commonly use is use a pen device use a flex pen device where patient can take an insulin and discard the device or complete the dose and directly discard the device rather than using a pen with a cartridge and removing the cartridge fixing the needle so to start initially it reduces the inertia you can call it you can it reduces the inertia among patients as two years have to take an insulin again i have to change the needle i have to see that the needle does not prick my finger and things like that so the best way to avoid it is give a flex pen for the initial days now let's go to the category one so evidence says that in type 2 diabetes patients with hba1c more than eight percent which component should be attacked for achieving glycemic targets whether it is fasting or whether it is post friendly if you see here the asian data suggests that as the hba1c increases majority of those cases have raised faster plasma rpg forms a major contributing factor towards rising hba1c levels so the answer lies here when you have a patient with high fasting and high post randle follow the simple strategy of fix fasting first fix fasting first as and when you fix the fasting blood sugar levels automatically as you can see in the picture the postprandial glucose levels peaks come down so just say let's say you have a fasting blood sugar level of 180 and post candy of 250 if you give an insulin which reduces or which targets the fasting sugar levels automatically the peak of postprandial sugar comes down hence basal insulin is the best insulin to initiate an insulin therapy for a patient who has uncontrolled sugars on multiple oats that are used now when i think in my experience the majority of patients that come to my clinic are already taking mcstart 2010 or 30 10 or 25 10. so majority of them are already started on mixed up let me tell you this is a very old generation or outdated practice where mixed art is used or what you can say an isofane insulin or twice daily regimen is used more commonly than a basal insulin the studies have shown that basal insulin are high in efficacy reduces the risk of hypoglycemia reduces the risk of weight gain and there is more treatment satisfaction due to one's daily pricking these are the merits of basal insulin therapy that we have come across in today's research so it's important that you initiate an insulin therapy with a basal insulin rather than starting a twice daily regimen now let's go to this important slide where how do you the global guidelines where transitioning to basal insulin is important if you can zoom into the picture if above a1c target is seen that is hba1c more than 9 then add a basal insulin the basal insulin should be started at 10 units per day or 0.1 to 0.2 units per kg per day now when you try to titrate it set a fasting plasma glucose target choose evidence-based titration algorithm which i'll show you ahead increase two units every three days to reach fpga target without hypoglycemia i'll repeat again increase two units every three days to reach fpg target without hypoglycemia for hypoglycemia determine the cause if no clear reason then lower the dose by 10 to 20 percent now assess the adequacy of basal insulin dose consider clinical signs to evaluate for over visualization and need to consider adjunctive therapies example basal dose more than 0.5 units per kg elevated bedtime morning and or post friendly differential hypoglycemia aware and aware so in short you just need to check whether there's a possibility of dawn or somogyi phenomenon now coming to the next part where if still above a1c target is seen consider glp receptor glp1 receptor analog if not already in the regimen or you can add a prandial insulin that is the boneless insulin which you give before each mean so this you can start at four units a day or ten percent of basal insulin dose if a1c is less than eight percent consider lowering the basal dose by four units a day or ten percent of the basal dose again after starting the basal dose you can titrate it by increasing the dose by one to two units or ten to fifteen percent twice weekly for hypoglycemia again determine the cause and if you're finding no other cause decrease the dose by ten to twenty percent now if let's say your patient is on bedtime in ph consider converting that bedtime nps to twice daily nph so initiated as total dose is equal to 80 percent of the current bedtime nph stores two third given in the morning and one third given at bedtime understood so this is one way where as suggested by the 2021 ada guidelines that adding basal insulin is your first priority and that that and this guidelines does not endorse the use of premixed insulin in the entire management algorithm so if even if you go by guidelines or if you go back practical purpose also basal insulin is your first insulin that needs to be used in a patient who is already uncontrolled and you want to initiate an insulin therapy now coming to the next one where we have a big question that let's say you start a basal dose insulin does the sugar gets controlled and another question that we have is if basal insulin is given and sugar does not get controlled then we have to break three four times yes that's a very valid question so we have come with a solution by the ada 2021 guidelines that does one dose fit all the global guidelines say that if a1c is above target start basal insulin at point one to point two units per kg body weight or ten units per day ten units a day continue oeds at the same dosage or downtime rate if required now let's say you initiate basal insulin with metformin and other agents and you find that there are two categories where hba1c drops to less than eight percent or hbmc is still more than eight percent in both the cases you can either continue basal insulin with 10 units per day or 0.1 to 0.2 units per kg body weight in less than eight percent and if hpa1c is more than eight percent you can go for 0.2 to 0.3 units per kg body weight as the body weight increases the insulin dosage required also increases so let me tell you that increasing the insulin dose does not only depend upon your sugar levels it also depends upon the body weight so this is something which is an important parameter that ada 2021 guidelines recommends so when you know these guidelines it is necessary you will realize that you see an obese patient naturally you will know you should know at the back of your mind that 10 units is not going to work you have to increase to 15 to 20 units so this is one strategy that we can use that will help us save days of uncontrolled in sugar levels and patient will also not get exhausted of coming to the clinic with ray sugar levels and coming and telling you sugar control if they keep saying keep telling you that thing they will also get irritated so if you can know the weight of the patient and correlate with the sugar levels and then increase the insulin dose or probably initiate an insulin dose then that would help save time and at the same time give a better sugar control now coming to the next category that is uncontrolled on existing insulin you see this graph in this graph it is shown that as you increase the amount of chlorine 100 plasgen is of course a basal long acting insulin as you increase that large in dose you can see hba1c reduces from 9.3 to 6.6 percent and the fasting sugar levels also reduces from 211 to 113 milligram per deciliter so this is a graph which was done in a study uh that that showed that basal insulin gave a better sugar control in fasting as well as postpartum levels so finally to conclude let me brief out the entire thing that we learned today first is oeds oral anti-diabetics the best drugs which are available in the market right now are glp1 receptor analogues dpp4 inhibitors sglt2 inhibitors so these are the ones which should be commonly used followed by adding of a sulfonyl urease and of course metformin should be continued now let's say if you have a patient without any comorbidities and only ray sugar levels you can start with metformin with sulfonylureas or with hglt2 or glp one receptor analogues and keep adding one or more drugs as and when it goes ahead transitioning to basal insulin if you have raised sugar levels even on oeds then you can switch to starting a basal insulin let's say you start with large 100 with 10 units per day at bedtime once you start the insulin you can monitor fasting as well as postprandial levels and accordingly we can reduce or increase the oral anti-diabetic drugs which can give a better sugar control if you have a patient with uncontrolled sugar levels and already on isophane twice daily insulin then try to add a basal insulin and continue with only basal insulin regimen that might help you give a better sugar control and then adding on to a bolus insulin will help achieve your glycemic target thank you so that's what all i wanted to cover about oral anti-diabetics and insulin the deaf different permutations and combinations thank you dr rohit for such an amazing session we had a lot of insights with the topic and i would request the audience to put on their questions and queries in the comments section so uh this is the question by dr madhav that is it true that the higher a1c higher the even c higher the chances of hypoglycemia first and foremost higher a1c and higher chances of hypoglycemia is not very valid because it depends upon what kind of sugar control that you're giving okay let's say your hba1c level is about 11 or 12 and you give something called as a basal insulin and along with that you give glimmer pride of two milligram morning and two milligram night naturally patient will have hypoglycemia let me tell you the common misconception and the common thing uh common mistake that everyone does is that you give a basal incident like land is 10 units and patient has taken a combination of metformin and limit pride one milligram morning and evening next day patient comes with a sugar level of 32 the mistake that we doctors do is that we reduce the basal insulin dose remember that glimmer bright causes more hypoglycemia than any insulin so reduce the chlamy paretos or switch off the glyphobride and continue insulin and metformin it will really help so the risk of hypoglycemia is not dependent on hba1c it depends upon the treatment that you are offering okay i hope that resolves the query of doctor he asked another uh question as well that after how many oed usages we can start the insurance okay there's no fixed no such fixed rule as such but let's say you have an a patient who is taking metformin and glimmer flight combination then your patient is taking tap ugly forcing then your patient is taking buildup glypton and still you're saying that your sugar levels are let's say 250 300 or hba1c is more than nine then definitely you should start an insulin but there's no fixed rule as such it is all about trial and error and different permutations combination sometimes you can see that hba1c is more than nine and uh you start an insulin automatically sugar gets controlled with just one basal dose even without metformin so all you can do is start an oad or start combination of oeds what i do in my practice is i start with metformin and glimmer pride and then i go for dapaglifosan or will that lipton even after that if sugar levels are 250 300 300 350 i go for starting an instant this is another question for dr that in a patient with diabetic food is metformin contrary indicated see it's not like that metformin ah diabetic foot a patient has let's say patient has got diabetic ulcer the chances of sepsis are more and metformin tends to cause more lactic acidosis so in such a case then definitely we have to weigh the pros and cons and see but sugar control should be your primary target if you give metformin and that is helping you achieve better sugar control then naturally you can control continue with it without any problem that is my personal opinion [Music] examples of pre-mixed insulin examples of premix insulin one is mixed art where you have isofine insulin where there is a 30-70 combination and you give twice daily regimen then there are new generation premixed insulin which i don't know whether you might have heard of it it's called novomix so novomix is a combination of lispro plus this pro protamine something like that so combination it lispro is actually a fast acting insulin but they have genetically modified that insulin to a combination which increases its duration of action so novomix is a new generation twice daily pre-mixed insulin that provides better sugar control than the routine isofine or nph so these are different kinds of pre-mixed insulin okay one question was asked by dr chandani as what is the cost factor for basal insulin what is the cost factor so um let's say the commonly used basal insulin is large in hundred which is comes as brand name of basogen or lantis so one while or one hundred units of land this will cost nearly 780 to 800 rupees but there is a new market new uh drug which has come up which is called as doji so tojio is again large insulin but there are 300 units concentrated insulin so it's like one molecule has got more concentration of insulin compared to the routine glycine this costs 1500 but the dosage required in such a case will be half or probably three-fourth of the routine large and dose that is taken there is another type of insulin which is called as rhizotic that is big glue deck plus asphalt so it is a new generation insulin where one dose at bedtime includes a fast acting as well as a basal long-acting insulin that is more costly about thousand two hundred two thousand three hundred rupees so this is the cost range of insulin that i am aware of okay i hope that was also now uh then there's this question by dr karuna nidhi that uh can vilda will that leptin be added as a third drug to patients already on metformin glyphoid and insulin yes definitely definitely it can be added let me tell you wildecliptin is one of the best drugs that i know because it has very less chances of causing hypoglycemia in the poll that we ran where we where we saw that majority of the people or doctors here are more scared of hypoglycemia that is why they are scared to start an insulin therapy so basal insulin is something which advocates that there is very less chances of hypoglycemia happening similarly is the case of buildagliptin that buildupgliptin has come into the market for that reason that it has caused relatively very negligible cases of hypoglycemia okay or these this question by dr cadill that if the patient is on med form in two grams uh glim uh pyrite three milligrams pio glitters on 15 mg aceta klepton 50 mg still the sugar is not controlled and the patient is not ready for insulin what can be done next okay so first and foremost you need to tell me whether which sugar is uncontrolled whether it is fasting or postprandial let's say your only postprandial sugars are uncontrolled then remove the pioglitazone combination and switch to metformin limit right plus both lipos this will help you control um this will help you control the post friendly sugars better or what you can do is uh at bedtime you can increase the metformin dose from 500 to 1000 this will help you achieve a better fasting sugar control now one important aspect that i forgot to cover and that is necessary because this question came up is that let's say despite giving these kind of medications you find that sugar levels are uncontrolled let's say fasting sugar is uncontrolled let's say your fasting sugar level comes to 130 or 140 the best thing to do is check your midnight 3 a.m sugar let's say your midnight 3 a.m sugar is also 130 140 then increase your night dose of insulin or increase your night dose of ohs that will help you control your midnight 3m sugar levels automatically your fasting sugar will get controlled this is called as dawn phenomenon let's say at morning 7 a.m your fasting sugar levels are 130 140 but your midnight pm sugars are 60 and 70. then do not increase the insulin dose at bedtime just to control fasting sugars you need to reduce the dose of insulin if you reduce the dose of insulin then your midnight 3m sugars will increase and it will not cause rebound hyperglycemia so when a patient comes with raised fasting sugars tell them to monitor their 3 a.m sugars i'll just repeat once again midnight if you have a morning fasting sugar which is raised tell them to monitor their 3 a.m sugars for next 3 days if 3m sugars are persistently high increase your nitros of weighties or insulin if your 3 a.m sugars are persistently low reduce the dose of insulin and reduce the dose of oats this will help you achieve your fasting placement target okay okay dr dr ashwini has asked that what are the cutoff values of serum creatinine and lfd to start mid-forming cut off values of okay so a creatinine let me tell you more than two more than two is a relative contraindication to go for metformin because creatine because a diabetic nephropathy can usually increase your creatinine level up to one to one point five let's say one point six two but metformin should not be used if your creatine level is more than two so that is not recommended then uh about lfts lfts it is actually said that if more than five times the level of enzymes are present then you should not take metformin but again that's again a relative concept what i usually do is that if your creatinine is more than two then i don't prescribe metformin but if uh lfds are mildly deranged then also i go for continuing with medform okay dr parrikshith has asked is it sglt2 inhibitors plus diuretic or does this cause severe dehydration okay uh let me tell you that stlt2 inhibitors have a very common side effect that everyone says that it causes high levels of uti but in my practice what i do is whenever i give hdlt2 i tell them to take lots of water so the patients who are on regular follow-up with me who take double forcing or empathy forcing very rarely they come with utl although theoretically undocumented it is that there is high risk of util but frankly i have not seen many cases of uti with double glyphosate in my practice so if let not coming to the question where sglt2 with diuretic if you give there are increased chances of dehydration yes that's a very true thing so it is necessary that you tell them to drink plenty of water with the medication uh dr vijay patel has asked is pioglitazone safe pioglitazone is safe but only problem is that it has a very restricted use so restricted use like if you have congestive cardiac failure if you have nephrotic syndrome or if you have liver cirrhosis patient is grossly idiomatic in such a case myoglitazone is again contraindicated so in my practice i have stopped using pioglitazone i don't use it at all what i do is i use only vaguely pose bogulipose is one of the best drugs again that i've seen so that gives voglibose metformin and glimepride combination is one of the best drugs compared to metformin limibride and pioblitazone [Music] so dr kaushik has asked uh does the dose of landis and told you uh for clergy and administ administration will be same or different no it yeah they have different concentrations but the only thing is that glycine is sorry doji has got nearly 300 units in glycine has got only 100 units so you start with the same dose it will not cause hypoglycemia but dojio will last longer so glargin if you are using 100 units it may get over in 10 days but dojo will get over in 15 to 20 days so the cost of paying 1500 can help you last the insulin longer rather than buying frequently and it has a better action also because it is concentrated insulin has asked how do we shift from h extra bit to h mixtape how do we switch from h actor to hmm okay so let's say your patient comes with your sugar levels are high and you're fixing a factor but those as 20 20 and sorry 25 25 and 20 okay so 25 in the morning you're giving 25 in the afternoon and 20 at that time so how to switch to mixture take two third dose in the morning and one third dose at bedtime so 25 sorry 20 20 and 25 if you're taking so total units come to about 65 so if you calculate and see nearly 40 units you can give in the morning and 20 five units at bedtime so two third one third is what you switch from acrobat to mixtape uh moving on to dr ashok uh he has asked that like uh glycoside an excellent substitute so uh glycolysis is a very good sulfonyl uvs especially because the chances of hypoglycemia are less with likelihood compared to glimmer so if you see uh what i have done in the past one month is because of the ramzan i what i do is that if patient is already on glimmer pride then i stop limit right and they switch over to glycolysis so that really helps to control hypoglycemia or reduce the risk of hyperglycemia from hypoglycemia compared to glimepride so glycoside is a very good drug if you see even in cost-effective ways as well as as an initiative dr sana is asked that can we use sdlt2 inhibitors in case where fluid restriction is present okay as tf2 inhibitors you can use even in case where fluid restriction is present let's see okay i'll give you an example a patient of cardiac failure comes a cardiac failure patient is told that you need to restrict your fluid intake to 1 to 1.5 liter per day but let me tell you that sdlt2 benefits hdlt2 inhibitors have shown to reduce morbidity and mortality in cardiac failure patients so in cardiac failure patients the first line drug not for sugar control but for heart failure is sgld2 inhibitors so sgl 2 inhibitors plays a major role even if fluid restriction is advised because that is not only giving you better glycemic control but also giving you cardiovascular benefit doctor parikshit has asked again that modification ah that's a very controversial question because many now if you see there are many lifestyle medicine doctors that have said that diabetes can be reversed i would say yes if it is an initial stage but let's say diet plays an ultimate and the most important role in control of sugar levels and hba1c levels yes that is true that if you give lifestyle and diet modifications patients who are already on medications come completely to no medication and only on diet and lifestyle control definitely that's a very apt statement but causing diabetes reversal completely such that you stop those dietary lifestyle modification and then you can live and eat lays and still not have any raised sugar is not what is true you have to follow those dietary and lifestyle modifications lifelong then you can see your diabetes so it's again a very controversial question dr manju has asked that please explain somoki and dawn phenomenon yeah so that's what i just said so uh let's say a patient is having morning hyperglycemia of 130 and if you see that your midnight 3m sugar is also 130 140 that means it is normal or raised then you need to increase increase your night dose of insulin or oral anti-diabetic drug this is called as dawn phenomenon but in case a patient is having morning fasting sugars which are raised and night 3m sugars are low that means it is causing rebound hyperglycemia so in such a scenario you need to decrease the dose of insulin or oads at bedtime such that your night hypoglycemia reduces automatically your fasting sugar comes under control this is called as somophenol so that's the difference yeah so dr kaushik has asked how come glimmer pride causes more hypoglycemia than insulin okay now let me tell you glymepride if you see in the market and if you see the theoretical basis itself glymepride is found to have caused more hypoglycemia because insulin has a patent duration of action okay now let me tell you how do we how does one decide whether to go for oha whether to go for insulin it's about its way of action some drugs they have an action like this it goes to a peak the action of the drug is such that it goes to a peak and the peak falls so when the peak when the drug action is at its peak the sugar levels are at its lowest when the drug action is at its base the sugar levels are at the highest we have to choose a drug or an insulin that provides more of a plateau okay the which provides more of a plateau such that the sugar levels neither go to a peak neither fall below so that is why insulin maintains that plateau and that is the reason it does not cause more hypoglycemia but glimmic right provides a peak that is why when glimmer pride action goes down uh sorry is that glyph right action is at its peak sugar level goes down hence insulin does not cause as much hypoglycemia as glimmer uh dr satyajit has asked that injection fast can it can it be used to control pve bs yes definitely fiesta is a boneless insulin so if you have a basal insulin like large in along with that you use fiasco as price daily regimen for bolus control automatically postponed sugars will get controlled so psp definitely can be used for ppbs control moving on to a doctor dr kaushik has asked what glp1 would you like to prefer uh see frankly i have not used much of glp1 analogues in my practice but repuglinite i have heard that it is good there is a molecule which is called i think bogelix are or something voguely bose plus republic combination so it is something which has come newly into the market and i think it is coming into practice too but i have not used dlp one analog in my practice rest all the drugs have lost so that is not much info i can give you on a practical basis okay so doctor has asked that should be should metformin be used if egfr is less than 20 no definitely no because it is ckd stage five in such a scenario metformin is not recommended because it is relatively contraindicated in stage 5 ckd and dr ashok has asked is there anything like primary and secondary failure okay maybe i'm not aware of it probably it's a little theoretical so i don't remember much about it okay i'll just check if i've left any question okay so uh dr rapurva has asked that what to give in hyperglycemic emergency in patients already on oda wait okay if a patient is having hyperglycemic emergency on oral anti-diabetic medications then of course insulin is the best way so if uh best way is to start with an atropine okay so a triplet is a short-acting insulin and if the sugar levels are let's say very high about 500 or 600 best way to is to start with iv infusion so if you give an iv infusion and monitor your sugar levels throughout the day you can actually check the requirement of insulin that is there throughout the day and then you can fix the dose so that is a good strategy that you can use for hyperthysemic emergency irrespective of whether it is decay or hhk hs i hope that resolves the query so dr deepu rajan has asked that is there any role of sliding scale yes actually uh sliding scale is something which uh is uh is people say that it is really outdated in practice because uh sliding scale was used long back and now people directly prefer to start insulin so let's say a patient comes with raised sugar levels you put injection edge attributes up to tds according to sliding scale 151 to 204 units 201 to 256 units so this is a routine practice which was followed earlier nowadays people prefer to start injection intact a bit six morning six afternoon six night monitor the sugar levels and up titrate or down titrate the toes but sliding scale provides good health but it's always better to switch to a fixed dose regimen so that is better uh dr apollo has asked that uh the dosage for acrobat rosage for atropine uh dosage for activate actually varies from person to person if you're calling about if you're talking about sliding scale sliding scale is something which is not a fixed regimen let me tell you many people prefer their own sliding skills and they make it on themselves like in my example it says when i use sliding scale for some patients i start with 151 to 200 as 4 units 201 to 250 6 units 251 to 308 units but in some patients who are very high uncontrolled sugars i start with 151 to 206 units so it's a very personalized regimen so you can decide accordingly such that it does not cause hyperglycemia and remember one thing that actually is short acting so it will require price daily regimen yeah i think it's such a vast topic there are so many questions it's difficult to cover everything in one shot yeah but it was an amazing session and uh you also solved a lot of queries of the people and they are you know they were commenting continuously so it was very insightful session and we thank you for this amazing topic that you have chosen to talk and looking forward to you know having you more on this platform thank you church thank you so much you niva thank you for the entire support it was great being here

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dr. Rohit Jacob

Dr. Rohit Jacob

Consultant Physician & Intensivist at Craft Hospital & AR Medical Center, Kodungallur, Cochin | General Physician MIT Mission Hospital, Kodungallur, Cochin Senior Resident at Dept of Medicine, Al Azha...

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dr. Rohit Jacob

Dr. Rohit Jacob

Consultant Physician & Intensivist at Craft H...

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