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Pharmacological Management of Hyperglycaemia

Nov 15 | 1:30 PM

With a growing number of pharmacological agents now available, mounting concerns about their potential side effects, and new uncertainties about the benefits of intensive glycemic control on macrovascular complications, glycemic management in type 2 diabetes mellitus has become increasingly complex and, to some extent, controversial. Join us as Dr. Lt. Col. Ashutosh Ojha explains the pharmaceutical management of hyperglycemia.

uh good evening everybody uh so we are already a little late so i'll just skip through the intro uh quite quickly today we have with us doctor lieutenant colonel ashwa he did his mbbs from afmc nd in medicine from inhs mumbai super specialization in nephrology from kharti medical college and went on to do his diploma in health care management and medical legal system he is also a member of the royal college of physicians and a member of american diabetes association and we are so lucky to be hearing from you today it is a very important topic to manage the hyperglycemia and on the eve of the world diabetes day i want to highlight something which is very very unique and you must pay attention that you benefit with this presentation as we go through we will understand what is the importance how it is important to identify when to intervene with the pharmacological therapy and otherwise so please free to write comment i will be happy to answer the questions which is important for you to understand and simultaneously pay attention to the uh presentation and i am happy this platform post the present older presentation for long period of time your friends can benefit out of it so diabetes is exploding like anything there has been spreading for a long period of time and unfortunately with the infected people with the use of steroids or the bad effect of the virus itself even the diabetes has increased in the ovary times much more than anytime yet what we understand now that if there is the more of the diabetes there is more of the requirement of surgery more of the more illnesses and related microvascular and macrovascular complications that is why it is far important to understand it the common disorder many times so you will find that the hyperglycemia is there all the hyperglycemia is not diabetes so if there is some catastrophic event is happening some unusual thing is happening and you find the hyperglycemia don't think it is diabetes because this if you start treating every hyperglycemia the secondary causes we will land up in treating them so that is why all hyperglycemia is not diabetes you must understand this and that is the role of long-term evaluation and the recurrent evaluation and management so that is why i want to emphasize that all diabetes all hyperglycemia is not diabetes many times you know that there is the previous dysglycemia and when you they are coming for something else you will find that the people have got the diabetes or treatable hyperglycemia dangerous hyperglycemia for which you must offer treatment so these are the people this is the important study what they have found that 47 of the people who were gone for the things other than the diabetes had got the treatable displacing so that is why you understand that this event which is there can be actually identified when somebody is coming for something else for this reason we must understand that hb a1c should be done hba1c how it is done if you understand the first and foremost issue is it is the non-covalent relationship with the hemoglobin so what it is happening is that the this uh since glucose life is around 120 days 19 days it requires to 30 days requires to get a covalent bond so it tells you something like 90 days value and that is why this has been added in the diagnostic criteria of diabetes in some countries many it is not but it is advisable when you find that that is glycine hyperglycemia you do hba1c and to a certain that it is diabetes or it is a small episode which can be corrected on its own such as the steroid use or the other any event which is related to in those conditions you must identify and hba1c has got a good role in that so chronic glycemic evaluation you should have with the hba1c so it tells you something like three months readings of high revolutions second is the fructose amine serum through closer level that is gives you idea about three weeks of the glycemic content and acute control can be assessed with the glucose that is as serum glucose you do or plasma glucose you do in your bedside and you can know about that so when you know that why it is important to treat this glycemia the hba1c every one percent increase increases the risk of morbidity and mortality much significantly anything above seven percent has got negative prognostic value in unrecognized people and in recognized people again the better we identify earlier we identify and adequately we treat we are at the benefit and we must offer our this knowledge to our patient for the building capillary recent blood and capillary values if you go through it there is very good correlation so whatever you go with that venous blood or the capillary blood there is a good chlorination you must use that to your advantage and hardly is change in one millimole so what we want to say that the sugar levels hardly changes with the source of the blood you have taken it capillary blood at the bedside or the venous blood and the laboratories there is good correlation and it will give you fair value whether to treat how much to treat and like that so today i will concentrate myself okay what is the adequate treatment for mycology simultaneously i will tell you the ada glucose treatment algorithm i will review and update you about the diabetes therapeutics and identify the people who need to be appropriately treated with the incident therapy because insulin is a therapy which is deferred for nothing which is the most physiological thing to offer so that is why i want to say about that and when we come to that in u.s there is a huge number of people who are diabetic and what you will notice that this data is 20 2014 and surgeon general report in 2019 it further to increases the number of percentage of the people who are diabetic if you understand that with the pandemic lack of exercise the diabetogenic effect of the virus use of steroids and other things have further worsened the scenario if the disease is more the inadequate treatment people are more and that is why this whole exercise is aimed to reduce the morbidity with the knowledge this is the ominous update of the diabetes what you are find here is that the you find that the hyperglycemia has got multiple thing so you find that there is the decrease in creatine thing increase lipolysis there is the dopaminergic hypo regulation there is the increased hgp which promotes the dyslipidemia and further to gluconeogenesis there is the increased glucagon release there is the impaired insulin secretion due to beta cell problem and then inflating effect so there are the eight things which are occurring and the whole therapy aims to adjust that this ominous activity should be broken and earliest and adequate so this is the way we have to think on that and what we i want to emphasize here this is again from the diabetes association slides what do you understand that the obesity and the pre-diabetes diabetes and uncontrolled the hyperglycemia what is your finding here you are finding that it is a gradually worsening situation means that the more the duration the more the disease progresses secondly you also find that the insulin resistance builds up and this gradually building of insulin resistance that is which is as early as 10 year before the diagnosis of the diabetes it remains static and the beta cell gradually phase and ultimately the insulin level goes far below to the requirement of the adequate eu glycemia so what you are noting here that is the gradual increase of insulin resistance and then after persistent insulin resistance and gradually feeding beta cells of the pancreas and it keeps increasing the glucose load and it is causing micro vascular and macrovascular complications so that is the way it takes place so what is the impact of inadequate treatment so if you understand what is the this is the four five large studies which has been done and one in most of the them the most exhaustive one uk pds this is the father of the all the studies what do they have to know that the it causes microvascular complication adequate treatment and the macro vascular complications are reduced and then after the uh long-term follow-up mortality can be used similar with the diabetes control trial accord trial advanced trial and video trial which is the in which what they have noted that the v that is the microvascular complications are going down there is the it goes without saying that the microvascular complication macrovascular complication and mortality all are reduced with adequate treatment when you understand this what is the target so what is the target is always stringent and this is further to uh liberalized by some societies but i do agree that this target are achievable and it should be individual to reach this target in the benefit of the patient so what is the glycemic target hba1 should be less than seven percent that is the ada and american college of clinical endocrinology they go through the 6.5 preprender level should be less than 140 postprandial glucose should be less than 180 there is with the avoidance of hypoglycemia this is very important the more is the glucose fluctuation it has been proved that the more is the mortality so that is why it is important second is the uh individualization is the key all the patients behave differently all have a different form of morbidity so that is why the therapy individualization is the key through which you can achieve adequate control more is stringent control to six to six point five in short duration it can be healthier with no cbd because what is happening though more stringent you go for the chances of hypoglycemia and associated and the people who have got short life expectancy limited resources support and uh motivation is questionable so these are the people in which 7.5 or 8 is also important particularly the people who are in the higher age group and with the limited uh life expectancy so when you come to that the individualization is the aim if there is some pilot or if somebody uh nano gerain generion who is working as a teacher or who is relaxing at home the same thing does not imply it is something like e which is individual for the addict a specific law this is very important observation which has come from american college of diabetes american diabetes academy what is import association what is important how many people have got percentage that is less than seven percent of the goals this is the multi-registry insurance data all over the united states so what you are noting that the this percentage of people having eu glycemia is far far less and everywhere it is increasing there is one very scary data which has come from the canadian diabetes association they have said the 67 percent of their people who have got diabetes have got not adequate control so if we compare the similar issue in india we don't have a ban national registry but our population with limited resources i believe that they will be even less people who have gotten equipment and that is why i will invite all of you that why not there is so much water we should reach it out and extend in the benefit of my specific patient so how to go with the anti-hyperglycemic therapy the first and foremost first and foremost is the lifestyle modification the lifestyle modification it has been proved beyond doubt can can reduce the hba1c as high as five percent it is a huge benefit this is the without any side effect it improves the longevity it improves the endothelial function and there is lot many weight so for macro therapy before you land up you must understand that there is a huge room for the lifestyle modification by diet exercise and modification of the lifestyle such as cessation of smoking alcohol so this is why when we come to that when we come to the fact that within the lifestyle modification more than three b months is not a yielding then you can think of going to the format and for macro therapy should be started with the cheapest drug most available drug most benefiting drug and it should be individualized with that and gradually you add on the drugs and if the drugs are insufficient then you can add on the injectables and further to how to go about that we will come to that so if you go to the ada guideline what it starts with the metformin and metformin is the cheapest drug very good drug it has got endothelial functions preserving properties it is it has got good moiety the issues are with the intolerance which we will come to that then after you come to the sulfonylureas they are sulfur drugs they have got inherent problem of hyperplasia hypoglycemia they have got long acting and there are associated weight gain so these are the issues with that then are the the benefits of uh sulfonylurea it reduces the hba1c as much as four percent if adequately and planned correctly is offered then come the other therapy in which you can add on the dpp for inverters you can add antagonist and last is the add to be added is the uh you reduce the postprandial hyperglycemia you have got a carbos glucosidase inhibitors you have got magnetites and these are the things we will come to that but if you come to the strategy first strategy is adequate diet exercise lifestyle modification then after is the metformin and then after comes the sulfonylureas in adequate process and then after comes the dpp for inhibitors you can call dapa you can go for sld and there are a lot many components so coming to that there are the no fixed thing but the one is starting point definitely [Music] agreed as possible is that we must start with the lifestyle modification and dietary modification then comes the metformin then comes the other drugs which is affordable convenient to the patient so when we start the basal insulin the benefits of basal insulin are farming the what is that it is the most physiological secondly long actings are available it prevents the glycemic peaks and troughs and then after it decreases the fill load and it has got many other benefits so a basal insulin if you have to start you have to think about that how to how much and light there are condition in which you can't trust the ohs or hypoglycemic regime in these conditions what acting insulin are required when there is a severe major organ dysfunction particularly in the cases like the liver failure renal failure severe sepsis and otherwise in those conditions you have to go with the short acting insulin for the benefit of the these are the way you have to go with that we coming to the huge number of drugs we have we have got diagonite sulfonylurea and we gradually place them as the therapeutic agent as we move ahead in our lecture so if you can see if you understand there is the very good side which is again taken from ace resource center american college of clinical and uh what is the good thing you want the good things are the the very many drugs which are which can give the adequate glycemic control are c such as sunlight which is given by god for free is very good but in diabetes there is nothing like sunlight but definitely there are drugs which give the good glycemic control are cheaper ones that is metformin you find one point five to two this is a sulfonylureas it is 1.5 to two and you see all of them the smaller ones they can offer very marginal for such a gambling for possible that is its equation these are the ones who have got the minor drugs but it can be used when they are indicated as we progress we basically when you see in age-adjusted uses particularly in u.s what you are finding there are huge number of people who are on drugs only but gradually you know that the this drug and the insulin dependent what is happening that the as the depletes the beta cell there is the requirement of the insulin and that is why drugs pills plus the insulin has got the long benefit and they have got the other things the pure only insulin is the specific group of people who are on this and particularly the diabetes is complication so these are very small group of people who are there so what is the ages adjusted percentages you find that the age has just percentage is far higher for the overall pills the oral pills should be offered to the patients first adequate and insisted so that is the way insulin only have very few indications and if the patient is required you can offer it but insulin and pills are the wicked thing that is the which is must it has to come in this condition you should not sigh away from the insulin and you must offer this to your patient coming to the big nights these are the cheapest ones the best available is the net form the mate forming is low cost weight neutral the side effect can range from 30 to 5 and what is that it requires slow titration it has to be administered with means and longer acting extended release ones are the better ones which can give the better control so that is why extended one are available then what is the challenge is it prevents the v12 absorption it is also known to preserve the endothelial function and it is a cardio protector so there are huge amount of scientific evidence in favor of this drug i have listed only few but if you understand this is the starting point of the pharmacotherapy of the diabetes and updated guidelines what they speak about the metformin is that it is contraindicated when egfr less than 30 ml and the provisions who are having egfr 30 to 45 ml per million should not be recommended you should not start that and you should obtain egfr at least annually and more often as the risk impairment of inner impairment is increasing you should discontinue any time when you find that egfr less than 30 and the formula to be used in the clinical practice is the cost of craft and world formula what ada recommends that ckd epi formula should be used and to detect the egfr please know this formula is different and but it is available in the most of the calculators and you please use it i always discourage my residents to use the coffroft and world formula and i encourage them to do it which is most scientifically evidence based what is the challenge with this metformin i would iodine contrast one you have to be very careful because these diabetics have got the lot of competition and if you have to give we have to reevaluate adequately hydrate and then after if you have to give out genetic transfer surgery your intervention radiological it has to be adequate if we had rehydration and we start only after 48 hours of so that is the way you have to think about that coming to the sulfonylureas most of the sulfonylureas you find that the red ones are freely available in the healthcare system and the 12 butamide you will be surprised to know in the many of the centers the tall butamide is available uh for free for the national health program and it is also in the essential list of the national drug policy and it is only challenges it is short-acting it causes hypoglycemia and that is why many of the patient avoid it particularly the people who observe ramadan but if you find in mumbai there are all the municipal hospitals they offer this free to their citizen and they are using it limi pride long acting one it is good one it has got plenty of benefits lipizide is a short acting one and lipid cr is used in the condition such as in renal failure and other condition in which there is the risk of hypoglycemia how do they act they act at the sodium potassium atpase they cause the fasting hyper i can target fasting hyperglycemia post transient hyperglycemia and how do they improve they improve with the more of the this insulin secretion these are the ways they go around and they help with the patient so what are the problems there is the secondary failure rate what is happening it depletes it causes the beta cell sclerosis it causes hypoglycemia in elderly imperial function ill regular musical people it can cause hypoglycemia it is known to cause the weight gain they are low cost and it is also known that they increase the cardiovascular risks so these are the challenges with this but if you think of the population we have with the amount of public health we we have to think about sulfonylureas remain the mainstay and metformin so you have to understand it you judiciously and then after extend coming to thiosolidome these are the ones ppar pathway they increase the insulin reduce the insulin resistance they are good in targeting both fasting and postprandial hyperglycemia what is the advantage they don't cause hypoglycemia there is no renal metabolism indirect markers of cbd can be impaired and they are also known in animal model to preserve beta cells the human data are limited but the animal model it has been too beyond doubt that they preserve the renal cell and that is why they are used what are the challenges the challenges are they cause weight gain they cause they cause the [Music] bone fractures they are there are association of bladder cancer cardiovascular effect particularly with the five liters on is that there is the heart failure can take place and that is why the specific enzyme problem is there so if you tend to prescribe you should think about it and you adjust it the trio in charitable combinations if this drug becomes under drug and pharmaceutical control order and the triple combination drugs are far cheaper than the individually prescribed one so what you find that the 15 milligram of glutathione added to different drug combinations such as metformin glucose so you can prescribe with that also but they have got good effect the challenge is that they are weak hypoglycemic agent they don't offer much of the sugar control the mostly we can at the max can offer one gram to trans one percent decrease of the hbo so that is the problem megalithinites are the drugs which target postprandial hyperglycemia why it is important because the glucose fluctuation is known to cause more of the mortality and morbidity so you cannot allow postprandial hyperglycemia and for these are the drug of choice they have got very good action in that what they do they simulate stimulate insulin secretion we are rapidly acting they are short rapid onset and short acting there is hardly drug adjustment for renal insufficiency there is hardly hypoglycemia and above all the sulphur allergy patients can also be offered these drugs so what is the benefit they are short acting hyperglycemia can be only targeted alpha glucosidase inhibitors they are very good drugs they target again postprandial hyperglycemia then inhibits saccharides in the small intakes time and if the saccharide is inhibited less glucose is absorbed and then after the hyperglycemia can be prevented so what is the challenge in the drug there is very high rate of flatulence diarrhea and nausea vomiting there is no hypoglycemia there is no weight again but the treatment of on these are the these drugs are they are less tolerable and that is why it is not so much use and a carbos is a cheap drug it is freely available but the challenge is very few patients are rated and that is why it is not so frequently used burgly bose has got the less side effect similar effect small amount is required and they can be offered to the patient with similar vectors this is dpp4 inhibitors they are the ones which are very very advertised they are also we think they are added ones they can be adjunct they cannot be offered as solo therapy except in very early stages so what is happening if you would see physiologically after meals intestinal mucosa releases glp1 and gip release which activates the glp1 and the gip which is destroyed by gpp-4 enzymes and that is why this molecule is no more available for longer periods of time so what it does it prevents that enzyme to destroy this element uh molecule and it prevents the uh mix available insulin for longer period of time so that is how it helps in that so what is the advantage the advantage is in the placebo control trial what you note here that is the in beta glyptons and the placebo what you note there the glucose control is much better insulin availability is as good or even more than that and glucagon is again suppressed much more so there are multiple pathways through which the dpv4 inhibitors work and this jostling side is very very important if you see of ominous update three arms are addressed to with the dpp the foreign are there is no significant hypoglycemia or weight again most adverse effect is the upper respiratory tract infection use of pharyngitis and there is not many pharma driven information which is being circulated in the medical profession as well as the patient this one is better this one is poor we don't have any head-to-head trial there is no concern of the cvs and the ca outcome and ckd also and there is one drug lina gifting which in which this can be used safely even in esrd and ckd so that is the benefit of that the challenge is that it is a weak drug it can reduce the hba1c by only one percent so that is the way you have to understand this so what are the problems the pancreatitis reports were reported initially and i have given the data from the cb fda they are now come with that this caution which was prevalent before now they have withdrawn they say there is no causal relationship known with the pancreatic pancreatitis or pancreatic cancer second issue is he there was 80 000 patients analysis post marketing research and they didn't find any much significant risk there is increased risk and there is not not much very very severe so this is a safer drug the safety has further been enhanced with rs the sodium glucose co-transporters they were initially used for other purpose they are repositioned in the benefit of the diabetic and there is lot many industry given data which is flowing if this offers this that and like that but if you understand the pathophysiology what is happening it prevents the reabsorption of glucose from the tubules and where does it act it acts at the proxy uh [Music] descending arm of the loop of family and here the problem is the glucose absorption is stopped and that is how the sugar which is there is gradually going along and it is drained so what is happening the absorption is prevented and sugar is lost in urine so is it a very significant pathway no so it is a weak drug it can only reduce sugars by less than one gram one percent and what is that it is known to improve the diabetic kidney disease and also known to benefit little between the cardiovascular heart failure fishing the data which is given are now building up but today with the cost of 25 rupees tablet in this poor population i am the stream to use it much and i don't discourage you to use but definitely you use the risk benefit and then after you prescribe the mechanism is non-insulin dependent it reduces bp and the weight that is the one thing which has been claimed in animal studies human studies there are sparse data and they can not be used in the patient who have got low egfr particularly less than 30 and hyperkalemia adrenal insufficiency hypotension severe ldl elevation they are also contraindicated you should not use in these patient so what is uh the challenges the challenges is this can cause the diabetic ketoacidosis you glycemic type bladder cancer is known it causes genital infections there is amputations are higher in turnoff frozen and there is the this cv benefits with the impact glyphosate with the established cbd disease this is very important one particularly after this any gm article in 2017 and 15 it has got huge boost by the pharma industry in for for the sale of these ones centrally acting one particularly bromocrapting dopaminergic drug what does it do it increases the dopaminergic activity they have got the low morning level of hypothalamic property and it is thought to lead to hyperglycemia and so it has got the postprandial glucose reduction it increases plasma insulin secretion and what is the benefit that it is it does not cause hypoglycemia because it is not directly acting on the insulin and that so it is a good agent add-on therapy to achieve the postprandial hyperglycemia and that is that it is position is that how much it can reduce it can again reduce the hba1c by 0.5 to 0.7 percent it is not much what is the problem it causes dry mouth dizziness fatigue and heating exhaustion and like that that is why it is not much use but in trying situations we have to use it bile acid sequestrants are again coming up they reduce the ldl cholesterol mechanism is not very clearly understood the side effects are dyspepsia nausea vomiting they caused increased triglycerides so these are the newer drugs list nothing much but definitely they are to come with big bang and it is expected very soon including you come to these are the drugs which have been in us very easily used so how does it they act the glp ones received secreted from guard it acts on the brain in brain it reduces appetite with good intake it delays gastric empty and then after it increase the rate of decrease the grade of the plasma absorption and plasma glucose is further reduced further too it reduces glucagon activity and it also promotes the insulin release so there are the multiple way to tax takes place and these benefits are it reduces weight as high as by 10 in six months and even more than that in a year and what are the challenges the challenges are they are the costly drugs acute drugs and there are a lot many head-to-head trial in which they have been established which is better one and which is the one the hba1 reduction you find in all of them the glue diagram and the beer glutide have got maximum and xna tide and other half of lower so there are two particularly award um trials and harmony triad ones which have established it to a great extent and how much beta growth causes the weight loss you can find at least 2 kg and if in 2 to 1 to 2 years it can be as high as the 10 percent of the weight it is recorded so what are the challenges it causes nausea vomiting diarrhea headache injection size reactions it can cause renal impairment and it is it can cause gastroparesis also because the other pathways are not as inhibited hypoglycemia is only noted when there is given along with insulin or sarcomere otherwise it does not cause hypoglycemia hypersensitivity reaction and the ngod myanophylexis and that acute pancreatitis is noted initially with one percent now the safety concern is lower with the fda the guidelines the one challenging thing is the medullary carcinoma of the thyroid and it is known that the liver glucose has been associated with that so there is the sea cell related tumors in animal studies and that npc but india it is not so popularly used but in u.s it is a hot kick people are using it and they are done in creating and if you go with that what it is it is helping the ingredients where are they working when the beta cellar these are the places where they have what a myelinating they have got the pre-insulin goals and clean insulin levels oral hypoglycemic pre-insulin are the places like that for that you have to understand the patient's psych affordability understanding and then only you can go with that otherwise you go with the conventional because i have to give a practical guideline rather than that so what is the emeline it increased inhibits the post cranial glucagon secretion slows gasoline promotes satiety and contraindicated with very high hvac gastroparesis uh hypoglycemia and these are the condition and it has to be given twice a day hypoglycemia is noted with the permitting prominence and they are available in very select sector sections with us now come the gold standard the insulin we have to give it there are lot many insulins available and the best one and most life-saving is the regular regular one particularly the human and that is why you have to do that the insulin it comes to the two things we must remember the life saving is the basal that is the regular and the morbidity preventing is the basal and that is why there are in between there are a lot the time has come when the inhaled insulin is also coming up and as it comes you have to go with that the diesel analogues particularly detrimental glargine they are available they are very good ones they hardly cause hypoglycemia but the issue is the cost because many of our patients don't afford it and that is why we have to be sustained to the regular premise and like that the insulin therapy must is the condition in which you should immediately start particularly significant hyperglycemia presentation very high 600 700 you can't go with the overdrive lot of glucose toxins hyperglycemia intolerance to the oral therapy particularly the patients who are intolerant to metformin foreign glucosidase inhibitor so these are the challenging case you have to straight away take on surgery pregnancy unable to afford again the issue is there there are people who are can get insulin but can't afford and in decompensated state adequate injury infection mi is stroke sepsis these are the conditions in which you have that and when there is lot of ketone in the ketosis is there again the insulin is the drug there are patients who have got the severe weight loss it is anabolic in nature what it does it prevents the uh oxidative strain inflammatory history and it helps in the beat game these are the condition it is absolute indication we must offer insulin and use of diabetes medicines particularly steroids you all have used in the corona period good number of steroids and in this hyperglycemia insulin is the drug of choice so how to go about that the ultra rapid one then the rapid one the short acting you have to plan it and with that you have to go with them this is a separate class in itself my presentation is available on the initiation continuation of insulin you will find in youtube but i will definitely emphasize this is the most physiological this is so pillar made with the use of technology that many and many people can benefit and then after you can use it so this is a very important this inhaled insulin has come the peak action is very fast addresses issue of dexterity phobias contraindicated in chronic lung diseases this is not so freely available it is not approved and available but these are the therapy of coming back so these are the spectrum of options we have with the insulin and there are far more things which are coming up the day before yesterday chinese study has come with the gluco kinase inhibitors and what it is that they are the ones which increase the uptake of the muscles and [Music] sugars in the muscle and can be used as the hypoglycemic agent they have published the paper which has been randomized controlled time and it is it is heartening that there is hardly any complication with active matched population so there is a huge amount of beta which is coming up with the gtis and then after the it is a good hole so today i want to emphasize that the glucose and therapy must be i have talked about almost all the molecules the challenge is an opportunity in each of them and then after you have to individualize the therapy goal and follow-up with each and every patient you have to think of diet exercise education these are the key cornerstones on which the macrotherapy is occur unless contraindicated the metformin should be first line run and then after anything else after mid forming the combination of data are meaning but the benefits are of them will be going to ultimately so these are the few words i want to offer and i expect the comments about my presentation or anything you want to know i have tried to be as evidence-based as possible and particularly i am emphatic that you have to think individually your patient who is sitting in front of you should be targeted it is not that what is the call of the day what is adsa what is the chinese study says your patient unless the drug is therapy adequately understood adequately explained with the availability the whole exercise has gotten with these few words i do expect some questions if you have any please ask we do have a lot of questions if anyone wants to come on stage and ask a question uh face to face then you can just uh click on the rails hand gesture and i'll mention until then i'll just take some questions in the comment section uh so someone is asking you to explain inhaled insulin yes inhale insulin is on the trial level it is not much available at the program and we are lucky that in mumbai we had this trial the adequate hypoglycemia which is achieved was something good something like 2 percent was the hba1c reduction the challenges were that the patient were having the respiratory diseases and the screening for the naturopharyngeal allergy was understood and after that they were offered now at present we don't have available of the self but as it comes up with more data we will definitely show okay so sanjay patel has raised his hand yes hello sir yes please so when we are like uh on a patient is on overall hypoglycemics and we need to start on add on insulin also also like how we start insulin like what we select and like what what will be the starting disease very nice question if you can go with my [Music] or the short acting insulin if you are say you are treating somebody with the uh steroid and for short term you want to start so you go with the algorithms which are available for the in hospital care of the hyperglycemia and then after you go the cat in that what is there 0.6 0.1 unit per kg and then after every 100 you keep adding on four units that is the hospital based guideline given in marine so what do you go with that if you want to start somebody insulin say with the oha failure and persistent hyperglycemia you want to achieve two percent uh hba1c reduction in this condition you should go with 0.02 international unit per kg and you go with long acting instruments such as [Music] this is the way you should start if you want to shift somebody on the insulin then you have to plan understand his dietary habits whether it will best with the 50 50 or 30 70 and then after you calculate the insulin requirement and then you divide it into two parts if that is before breakfast and up before dinner so that is the way you have to do that so insulin therapy itself is a chapter in itself but suffice to say if you are for the acute reasons go with the inhospital insulin regime given in merino or any of the standard text group if you go with the long acting insulin for the inappropriate control diabetics in this condition you go with the long acting insulin and the doses i have prescribed you call that so this is the way you start it okay uh dr millen grouse is asking how to control intraoperative hyperglycemia in a diabetic patient hosted for surgery so you usually you know the insulin requirement before that your patient is fasting most of the time so you start with the you know the free operative glucose value you usually do you also know the hba1c of that patient what is the glucose and then you will start with the sort acting incident and what we use usually is done is the insulin glucose drip is started so that the nutrition is not suffered and simultaneously hyperglycemia so that is the way we have to go with the perioperative you can see my presentation last time i have spoken about the variability management it is available on the same platform how to fix the insulin dosage other than sliding scale other than sliding scales sliding skill sliding skill basically is out why it is out because if you are treating the previous reading there is the prospective skill which is now used the in-hospital scale is available in the most of the centers in merino also it is there the ada has come with the scale which is there in that so you don't follow sliding skills because sliding skill usually there is not so much practice nowadays because even major societies discourage it so what to do about that what you do is that you go with the insulin that is the glucose load in acute condition you see that how much is the insulin say it is 11. again your patient is having 300. so what you do you give it 14 unit or 16 units and then after you wait for that and you take three readings we pay all the readings and then you adjust the insulin prices so that you can be having the equipment okay uh we have another question uh what is the role of yoga in deep breathing in prevention of diabetes yes it is a very good question and there are a lot of data is accumulating about the life has tagged more diffusion particularly the relaxation therapy it is known to reduce the insulin resistance it has been proved beyond out in the human studies and it is also known to reduce the hyperglycemic events it has also known to reduce the oha requirement there is a good role of yoga and relaxation therapy you must offer your patient and how much your patient will benefit how intensely how compliant he is that you have pain as far as the universal guidelines on use of yoga and the meditation therapy it is not yet in the standard scientific literature okay we also have a question asking the role of neem and bitter god extracts in diabetes which this is tracts neem and bitter gourd extracts [Music] i am part of the tkdl which is the traditional knowledge digital library i have found lot of thing but it is not a standardized therapy i don't know exactly how much is the role but i find enough evidence retaining their different uh literatures that people have been told many adequately controlled with that but in personal experience i have got very limited knowledge on this uh one person is asking to comment on diabetes in pregnancy okay diabetes in pregnancy is a different ballgame you have to understand two key concepts first one is that he is in gdm or it is ve diabetes with fragments because goals are different the therapy is different the first and foremost therapy in that that you go with the insulin which is the most physiological otherwise now the safety of metformin is proven even sulfonylureas are used with the good results so that is there so you have to understand the pregnancy diabetes if it is gdm it is primary you should go with the insulin as much as possible if it is the diabetes otherwise you can go with the overall hypoglycemic presence the key is that you should prevent hypoglycemia which is determined so that is the thing you cannot allow hyperglycemia you cannot allow hypoglycemia but treating gdm is a tough thing you have to keep observing many times as many times as possible and then after keeping them the first and golden one is the insulin second one is the metronome and some hypoglycemic agents as per you okay another question from dr niharika why don't we prefer insulin over oha in long-standing diabetic patients long-standing if you really understand the insulin has got 100 it has got the challenges the challenges are that the it has to be injected it has it has to be preserved in the adequate temperature it has to be offered uh with the local complications while the wages are far easier to administer give they are cheap there are hardly any additional issues such as preservation and like that and on the top in national policies also in national emergency drug we have got two uh drugs which are sulfonylureas and nhs which is again a socialistic type of structure we also prefer that okay uh so we'll take a last question uh whether diabetes is curable or just manageable with drugs [Music] but as the beta cell implantation is coming up i foresee the cure is also coming as the beta cell can be implanted within the abdominal cavity they will start with the insulin of a individual and definitely i foresee that there is a cure but today it is controlled all right so thank you so much for that insightful presentation uh a recording of this session will along with the summary will be available in three to four business days uh thank you so much sir for this session

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dr. Lt Col Ojha

Dr. Lt Col Ojha

Professor, Internal Medicine | K J Somaiya Medical College, Mumbai

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dr. Lt Col Ojha

Dr. Lt Col Ojha

Professor, Internal Medicine | K J Somaiya Me...

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