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Hypertension in Diabetes

Oct 29 | 2:00 PM

Diabetes and hypertension, when present together, are known to have a multiplicative influence on negative clinical outcomes in both microvascular and macrovascular illness. Appropriate hypertension management in diabetic individuals is crucial for preventing end-organ damage and reducing the substantial socioeconomic burden imposed by these diseases. Join us to get some insights into the management of hypertension in diabetics with Dr. Rohit Jacob.

[Music] we can begin uh so a very good evening uh to everyone i'm dr naveda from netflix and on behalf of netflix i welcome you all to today's session we have with us today uh dr robert jacka who is a consultant physician and intensivist at craft hospital and ar medical center i thank dr navita for giving me this platform to speak on this topic hypertension in diabetes i hope you can hear now okay good right so um first and foremost let me tell you that as a physician or as a medicine resident as we used to be when we take up a page in the harrison we see hypertension separately we see diabetes separately we see kidney disease separately we see heart disease separately but when a patient comes to the clinic we have hypertension diabetes kidney disease heart disease all coming together as just one cake and we have to treat them and we have to decide on what to give them depending on each of these conditions so today we are just going to discuss a cocktail of hypertension and diabetes together and also play a little bit of heart failure mi ckd and so and so forth so to start with we must know that hypertension in diabetes is a very common scenario that we see in our day to day clinical practice but this lecture is not about the pathogenesis or learning how hypertension occurs in diabetes or how diabetes influences hypertension nothing like that this is a lecture about how when a patient comes to your clinic how to deal with that patient so there are a few things that you need to know among diabetics blood pressure should be measured at every routine clinical visit second patients found to have elevated blood pressure more than 140 by 90 millimeters of mercury should have blood pressure confirmed using multiple readings patients with diabetes and hypertension first and foremost you should look for the air cvd risk score and if it states to be more than 10 percent then you should maintain the target pp as less than 130 by 80 millimeters of mercury if patients with diabetes and hypertension come with a cvt risk score of less than 10 percent then the target bp should be maintained less than 140 by 90 millimeters of mercury but in case you have pregnant patients coming to your clinic then diabetes and hypertension such patients should have a target bp of less than 135 by 85 millimeters of molecule so before we start it is important that you realize what do you mean by this ascvd risk score this is a very new term which has come into the clinical practice today wherein if a patient comes in with many co-morbidities it is important to realize what is the air cbd risk score that is atherosclerotic cardiovascular disease risk for as you see here these are certain parameters which are used in calculating the air cvt risk score first is age as you see here age must be between 20 to 79 years as it states in this picture so age is one parameter followed by gender followed by race followed by what is the current systolic and diastolic blood pressure what is the total cholesterol hdl cholesterol and ldl cholesterol values history of diabetes is there or not whether patient is a smoker or not whether patient is on hypertension treatment or not whether the patient is on a statin or not and whether he is on an aspirin or not so when you see all these parameters together and click one by one you get the 10-year ac video score which states that over or predicts that over a 10-year span of time what are the chances of the patient developing a cardiovascular disease so the main aim behind treating diabetes and hypertension or behind treating the entire disease all together is you need to reduce the cardiovascular morbidity and mortality so as you see here when a patient comes and when you see the aircvt the score first of all you should see whether the patient is in the high risk category or not in a high risk category so if a patient is in the high risk attack category then that means that a cvt risk score is more than 10 then you can look at whether what's the patient's age whether it is less than 75 or more than 75 if the patient's age is less than 75 then you will go ahead with giving a high intensity statin statins are categorized into high intensity moderate intensity and low intensity high intensity statins include atorvastatin and rosuvastatin moderate intensity also includes saturday stat and roosevelt statin the difference lies in their dosage if atorvastatin rose was statin are used in the dose of let's say 40 to 80 milligram then you can call it as high intensity rest are called as moderate intensity then there are other statins such as primrose statin simvastatin and so on and so forth so if age is less than 75 years and aircv is not at very high risk then you go for targeting hdl and ldl cholesterol ldl cholesterol less but not more than 50 in such cases you will give high intensity statin and if it is not tolerated then you go for moderate intensity statin if on statin and ltf cholesterol is found to be more than 70 then you can add something called as a pcsk9 inhibitor which is acetymide if the patient is aged more than 75 years then you can initiate a moderate or high intensity statin and continuation of high intensity statin is reasonable if the patient is having a very high risk a cvt score and you're already giving a high intensity statin then you can add a pcsk9 inhibitor so the basic summary of this entire chart is that you need to give statin therapy but remember the goal is not in reducing the cholesterol level the role the goal is in reducing the cardiovascular morbidity and mortality that is the basis behind ascbd dress code now moving ahead to how to target the approach towards managing blood pressure in diabetes if the patient's blood pressure is found to be more than 120 by 80 millimeters of mercury then go for lifestyle intervention if more than 140 by 90 millimeters of mercury go for lifestyle intervention plus prompt initiation of pharmacotherapy and if pp is more than 160 500 millimeters of mercury lifestyle intervention plus two drug or single pill combination therapy remember this kind of targeted approach is according to the ada and aha 220 2020 guidelines the american diabetes association and the american heart association many of us when we practice we practice in such a way that we randomly give chaloha bpa bp thai diuretic tell me certain area that is not how you manage diabetes with hypertension it's important that you give a targeted approach that too according to the guidelines now let me tell you there's one patient who had visited a nearby physician and that patient was about 65 years old that patient came with a blood pressure of about 160 by 90 and the patient had diabetes so when the bp was found to be about 160 by 90 it was seen that he was started on a calcium channel blocker and along with that he was not evaluated and told to go and then he was told to come back again after seven days seven days later when he came back his bp got controlled with 130 by 80 and he went home happily and never went for follow-up now what happened was after three to six months three months nearly that patient came to me and patient came to me with bilateral lower limb swelling so of course we all know that calcium channel blockers they are responsible for causing the side effect of lower limb swelling but the important thing to know was that even when the patient was diabetic and hypertensive together he wasn't evaluated further he was just given a medication and sent back home that is not the way how you manage this it's important that you realize and find out whether the diabetes has affected different has caused different micro and microvascular complications whether there was neuropathy nephropathy retinopathy whether there was any other involvement of deranged cholesterol levels whether there was any cardiovascular risk factor whether there was any kidney factor nothing of this sort was studied and found out and later when i found out about doing by checking the urinary albumin and creatinine level that is when i found that there's already an onset of diabetic nephropathy so the drug of choice which needs to be given after diagnosing hypertension and diabetic nephropathy together is different from only diabetes and hypertension that is how it is necessary to evaluate what is the cause and what are the complications that are occurring in a particular case first and foremost as we move ahead it's important to know what are the basic lifestyle interventions when you see the lifestyle interventions we all know that we casually when a patient comes we casually say this is all what we say we never describe and say what exactly the patient needs to do so in case of lifestyle interventions it's important to know number one you advise weight loss if a patient is obese when you advise weight loss it's important that you say that you should maintain the weight at an ideal body weight okay there are people who practice lot of keto diet and they come with another complications like abdominal pain constipation vomiting and so on and so forth so it's important that you prescribe the right regimen for the right person and also of how much fasting he should do and so on and so forth so it's important that you advise weight loss but to a limited level it's important to tell them that in a week in a week span of time you should not reduce more than 500 gram there are people who practice keto diet in such a way who reduce kilos and kilos together over a span of just one week so that is not how you practice weight loss so that is the first advice second you need to go for a dash style of eating pattern that dash stands for dietary approach to stop hypertension which is composed of high green leafy vegetables increased fruit content then low fat dairy products and so on and so forth the advantage of following a dash diet is that it contains low sodium and high potassium third point is moderation of alcohol intake when we see a an alcoholic a chronic alcoholic it's important that you tell them to stop it completely but when we um let's say when we uh see a patient who is moderately alcoholic then it's important that you give them a particular limit as to how much alcohol they need to take right so every person is allowed to drink about 20 to 40 gram alcohol per day that's about two quarters or two pints we can say only two pints more than that is always injurious to him but alcohol is not the same way how you avoid smoking you need to completely stop and avoid smoking that is an important advice to be given to all the patients next is increased physical activity it's important that you need to realize whether what kind of physical activity you need to tell them it's important that you do an aerobic exercise aerobic exercise means walking or swimming or you know cycling where you can burn lot of calories at the same time develop lot of oxygenation also so about 90 to 150 minutes of walking per week is a sufficient level of increased physical activity now moving on to the choice of anti-hypertensive drugs it's important to know that you give ac inhibitors or arbs as the first line treatment in patients with diabetes and urinary albumin to create ratio of more than 300 milligram per gram of creatinine or 30 to 299 milligram per gram of creatine patients being treated with ac inhibitors arbs or diuretics it's important that you monitor egfr and serum potassium levels annually and finally if a patient is having uncontrolled blood pressure it's important that you can use something called as a mineralocorticoid receptor antagonist first and foremost let me tell you that there are three ways by which diabetes can cause hypertension the first one is diabetes-induced kidney disease so whenever there is diabetes-induced kidney disease there is less raised blood pressure because there is blood pressure it's important that you give such a drug which controls not only your blood pressure but also reduces the protein urea and thus reduces the prevalence or worsening of diabetic naturopathy the second pathogenesis why how diabetes causes hypertension is extracellular volume expansion and the third one is increased arterial stiffness so these are the three main pathogenesis by which diabetes causes hypertension and so you need to choose the antihypertensive drug accordingly now coming to how to manage a patient with diabetes and hypertension coming together as you can see in this chart in this chart when a patient comes to you you see that there is an initial bp of more than 140 by 90 and less than 160 by 100. go for starting one agent right you start one agent which may be as a arb ccb or diuretic once you start one agent then you go for checking for albumin urea how do you check for albumin urea you get a urine routine test done or you can do something like urine albumin create ratio or you can do 24 hour urine protein remember when we read a textbook we only know that 24-hour urine protein more than 3 gram is nephrotic syndrome but we never know how to manage a protein urea less than 3 gram so if you see an albumin urea then you should go for starting an ace elevator or arp if there is no protein urea go for ace inhibitor arb calcium channel blocker or you can go for a diuretic this is how you manage diabetic albumin urea with hypertension after that is done you assess the bp control and adverse effects every monthly i ideally the guidelines recommends every three months but continue to assess the bp control until it's in level right so if the treatment is tolerated and the target is achieved then you can continue the therapy if it is not meeting the target then you can add a complimentary drug like is like ace with ccb or arb with ccb or ac arb with diuretic remember use ac inhibitor or arb do not use both together if you use ac inhibitor and arb together then the load on the kidney is much more and it will cause further worsening right so ac inhibitor and ccb can also be used remember that ccb also long acting dihydropyridine calcium channel blockers are the most recommended in cases of controlling hypertension in diabetes okay now if you see that still the blood pressure is not meeting target then you can go for a triple drug combination or you can add a mental or corticoid receptor antagonist this is about controlling blood pressure if it is more than 140 90 and less than 1600 if the bp is more than 1 1600 then go for starting two agents two agents such that you get if a patient has got albumin urea along with it then again go for acer bccb or diuretic or you can directly start with combination therapy once you start a combination therapy again ssb control and adverse effects and modify the drugs accordingly right so this is how you manage diabetes and hypertension together now coming to the next slide which is about managing diabetes but remember that managing diabetes is a very complex task because we need to realize as to what category of diabetes it falls in whether we are diagnosing it right whether every diabetes requires an oral hypoglycemic drug or whether you need to give insulin all these flat factors play a major role but of course an individualized therapy is also a routine approach which is practice these days now this is one of the most favorite charts of mine which is recently updated in up to date and this is in such a way that um new drugs have come into the market and how the entire management of diabetes has got modified to understand uh what drug should be used when let's see many of us have read in the textbook that there is type 1 diabetes there's type 2 diabetes there's autoimmune diabetes there's gestational diabetes there is maturity onset diabetes of the young and so on and so forth but when to diagnose how and how to diagnose when remains a big question in our minds so let's put a practical approach a patient comes to you with raised sugar levels into your clinic the first thing you will do is check for hba1c levels and check for the fasting and the post meal blood sugar every diabetes or every raised blood sugar does not fall into type 1 or type 2 okay there may be other possibilities also if a patient comes who is having lean body weight age is less than 50 years or if patients patient is having extreme body weight loss or patient is having ketone urea or bmi less than 25 and so on and so forth then it is important that you suspect an autoimmune cause okay if the patient is having a pre-existing autoimmune disease maybe like sle or celiac disease and so on and so forth then also you should suspect an autoimmune cause or autoimmune diabetes now let's say all of these are not there then you will look for whether the patient falls in type 1 category or type 2 category differentiating between type 1 and type 2 is the most tedious task ever because there is no strict rule which falls in the picture if age is less it is type 1 if age is more it's type 2 wrong there are many patients who have young age and still fall into type 2 category if patient presence with ketoacidosis it is type 1 if no keto estrosis is type 2 again wrong because many patients of type 2 also have diabetic ketosis and type 1 also do not have diabetic ketosis and so on and so forth so it's important that you find out how whether a patient belongs to type 1 or type 2 a routine way which clinicians practice nowadays is that any patient that comes let's say above 50 years of age you start on oral hypoglycemic drugs when you start on ohas you will notice that the sugar is getting controlled or not getting control if the sugar is getting controlled then you categorize this less type 2 if sugar is not getting control then you can start an insulin therapy and give a trial and if on insulin therapy is getting control then you can call it as type 1. so this is one of the very crude practice way which is followed for diagnosing between type 1 and type 2 diabetes irrespective of the same both of them require the treatment of insulin and type 2 requires a initial approach with oral hypoglycemic drugs now let's say you are suspecting an autoimmune cost then how do you approach diabetes if a patient comes with diabetes and it falls into all these risk factors then you go for checking fasting c peptide level eyelid cell auto antibody levels and gad65 these are the three main tests which you need to do another way which i forgot to tell you of how to diagnose type 1 dn which is a sure short method is checking the fasting c peptide level if c peptide level is less than 0.2 then you can say that it belongs to a type 1 category apart from this when you come to the autoimmune there is eyelid cell auto antibody and there is gad 65 antibody there is tyrosine phosphatase antibodies and so on and so forth but when you check the antibody levels it's important that you realize if a patient is on insulin therapy for more than two weeks then antibody test will come positive okay so it's important that patients should not be on any therapy of insulin and then you check for 20 body levels and then you will come to know whether patient belongs to the autoimmune category or not remember that if one antibody is positive there are high chances that the remaining antibodies also turn positive so indirectly it is more of a sensitive test than a specific test understood so now let's move ahead to the overall approach of diabetes if you can see the chart here i hope you can zoom in if you zoom in and see first line therapy is metformin and comprehensive lifestyle method if a patient is having hba1c less than six or patient is falling to the impaired glucose tolerance category this is an important way by which you can do just follow lifestyle intervention if the patient is going towards diabetes then start with metformin and lifestyle interventions now let's say patient is having or patient is belonging to a high risk category where there is ckd ascbd heart failure and so on and so forth then you will consider to check for the hba1c level individually target hba1c level after the metformin use now you will go for checking the ascvd risk as i said earlier let's say the patient is belonging to a very high risk category patient is having you know let's say coronary artery disease or age is more than 55 years or uh kidney problems and so on and so forth then the new practice which is followed today is combining metformin with the glp one receptor economist or using an sglp2 inhibitor the commonly used ones today are empaglifosin dapaglifocin and kineglyphosis even glp-1 agonists are used commonly today now after starting them you will look for the hba1c if hba1c level is still above target then you go for a combination drug or let's say for example you combined metformin with glp1 then you can move towards metformin plus sglt2 or you can combine all the three together or you can use pcd categories this isolate and tunes dpp4 inhibitors or you can start with basal insulin or you can go for sulfonylureas this is one way of categorizing or how to approach diabetes now let's say patient is having heart failure remember sglt2 inhibitors are one of the best drugs for controlling diabetes because using hdlt2 not only controls the sugar levels but it also has a cardiovascular benefit it also has a kidney benefit and so on and so forth so if a patient is having heart failure with reduced ejection fraction sglt2 inhibitors are have been proven to show maximum benefit okay now let's say a patient is having ckd then also sglt2 inhibitors plays a supreme role along with metformin so you combine sdlt2 inhibitors with metformin or you can use glp1 analogues with metformin and so on and so forth remember that it is important that you know that metformin should not be used if creatine level is more than two right that means the patient is moving more towards an end-stage renal disease when the patient moves towards an end-stage renal disease avoid using metformin but in the early stages of diabetic nephropathy it is a very good drug to be used to manage diabetes along with hypertension right so as you go ahead if you see that patient does not belong to um you know the high risk category then you can target the hba1c levels individually and you can start directly with dpp4 glp one analog sglt2 inhibitors or thiazolium tunes and so on and so forth and similarly you can exchange and use as you can see here in the orange box if dpp4 inhibitor you're using and hba1c is above target combine tpp four with the remain one of the remaining three similarly if you're using glp one you can combine it with one of the remaining three similarly with this glt-2 and similarly with isolated and tunes so this is how you go from managing towards diabetes in spite of all this if you see that sugars are uncontrolled then go for starting towards insulin therapy another way which you can do is going for a quadruple therapy where you combine glp one sglt to metformin along with sulfonyl uterus so combining all these four can also help in reducing the sugar levels despite all of this again if it doesn't get controlled you can go for a foreign insulin therapy now going for an insulin therapy has also also got various tips and tricks remember that there are two ways of actually there are many ways of practicing insulin therapy the few common ways which are practiced today are using a rapid acting insulin three times a day along with a basal insulin during the night hours another one is using intermediate acting insulin for twice a day morning and night and then using a basal insulin also so these are two common ways which are used in today's practice so this is how you manage diabetes and hypertension together one important thing i would like to conclude by saying is that the two filecraft medicine are reason and observation observation is the clue to guide the physician in his thinking so remember do not see one disease and go for treating it instead form a holistic approach a collective approach see the patient completely and then go towards diagnosing recently i saw one patient who is about nine months pregnant and she came with high sugar levels right so when she came with high sugar levels uh she was already taking insulin and she had been taking insulin since last nine months in such a way that she is taking mixtape that is the combination that is isofine insulin she was taking 32 units in the morning 30 units in the afternoon and again 30 units at nighttime despite all this she is taking basal lantis of 42 units at bedtime and in spite of all this her sugars are uncontrolled and this is how the patient came to me so when the patient came to me i saw that the fasting sugar was uncontrolled it was always above 120 and the post-transient sugars were always controlled so it always gave me a big confusion as to what to do in such a situation and she always came and told me that you know my sugar is not getting controlled it's not getting controlled and she was very much stressed out and she was nine months pregnant so even i was not sure as to how to approach such a case that is when i called up my professor so when i called up my professor my professor told me she's already on land this is already on mixed up you have seen that postgraduate sugars are already controlled so only the fasting levels remain uncontrolled so do not go for controlling it because the more you go towards controlling it the more patient develops anxiety the more counter regulatory hormones act more the sugars will rise so that is how the physiological mechanism works instead what you do let the sugars be as it is continue the way you're giving insulin therapy and let it be as it is and sugars remain controlled even though fasting remains high then also despite all of this after one month when we checked the hbnc level it was found to be less than 6 which is a very good target so managing diabetes is always an art it's always something which cannot be completely known or completely studied it's about knowing few facts few things and combining it using your own level of ideas and thoughts and moving towards practicing it so this is a summary of how to manage diabetes hypertension and its complications thank you thank you so much dr rhodes for that amazing presentation of pick-up questions uh so but a really uh very very nice talk with a lot of real life examples uh that were given so uh case-based uh study so we have here um uh what's the reference to download these charts so the charts that were used during the presentation uh if they would like to use it where could they use them from yeah so these chats are few taken from ada website view from aha website and few are taken from up to date up to date is an app which is commonly used by many medicals so it gives lot of very good charts and the latest updates so the best part about using up to date is that it is very newly updated any new thing that comes in the market or any new practice then that is put into the picture and that is how it is shown so it is very useful so these are the common references which i've used all right thank you so we have um another question is hp a1c a gold standard test see hb a1c is as we know that detects uh sugar levels or you can come to know how the three month level is but remember that hba1c is something which comes into the criteria of how to manage or how to monitor diabetes right but that is not the only way out because you need to monitor the fasting post meal and in fact the what the guidelines recommend is doing fasting post meal that too after breakfast after lunch after dinner and then deciding what level of insulin or what level of drug you should give but for an overall estimate of how the sugar levels are it is possible that you can use hba1c as an estimate thank you uh we have one request uh dr dinesh i'm gonna take diabetes plus hypertension blood pressure is also controlled but i am on mixed are 30 to 30 two times plus glick lizard 60 milligram metformin combination two times and when the winter glyph in metformin two times fifty five hundred but uh pp2bs is slightly controlled maybe but fasting is not controlled 3m sugar is control mostly in the less than 150 right so what should be i do yeah okay see now 3m sugar maybe around 100 to 150 but then when the morning it is more than the 152 up to 200. okay yeah so uh first and foremost thing is that uh you're you're already taking insulin so you can continue that a good idea would be changing glycoside okay if you change glycoside to glimepride you can benefit with that use the advantage of that is that glimmer pride has got an adverse effect of causing hypoglycemia so that will be useful for you by using glimmer pride with metformin during just before bedtime that will control your fasting sugars in the morning so that is a trial which you can try and find out whether your fasting sugars are getting controlled okay i have to uh avoid glycoside i have to stop and use clement you stop like yeah you stop glycoside and start with glimmer plus med form in combination like glycomic gp 0.5 yeah what just start with fast uh bedtime during night hours and if it's yeah only one time because it causes severe hypoglycemia so that will be useful for you during uh to control your fasting sugar so it's better to give glycomic no sorry metformin plus glimmer pride during just before bed bedtime and just stopped like okay or any other medication required don't keep adding medication i think if you just modify this a little bit it will help you if with this also it doesn't work a good idea would be uh to start dapaglifosa that is also a good idea dapa sodium thank you so much um you can take the next request we have dr dinkar see let me tell you metformin is useful if there is early stages of diabetic nephropathy but it is not recommended if threat is more than two because when you use it in create more than two if you calculate the e g f r and c it follows below the stage four and stage five category so using the kidney function at an advantage for metformin will be failed because metformin won't work if the kidney function is not adequately nice so that is why end stage renal disease metformin is not recommended then what will be the choice see the choice of truck as i said apart from metformin you can go for some specific yeah apart from metformin you can go for something like sdlt2 inhibitors glp1 analogues and so on and so forth so that is very useful in case of any kind of nephropathy okay thank you sir thank you so much dr sushant i see you're back i'm gonna accept your request sir actually i would like i like to ask you one question about type 1 diabetes i just heard you saying that there are some kind of autoimmune disease where the risk of developing type 1 diabetes increases so i would like to know more about it what are the various kind of autoimmune diseases where the patient can develop type 1 diabetes if not monitored for a long time okay uh first and foremost uh there's a slight correction that autoimmune diseases may may cause type 1 diabetes is not the right thing what i meant is autoimmune diseases can cause diabetes which is commonly mistaken as type 1 okay like autoimmune diabetes like latent autoimmune diabetes which is called as a 1.5 diabetes okay one is latent autoimmune diabetes then um all common diseases like celiac disease or any tropical spruce or what we call as autoimmune hemolytic anemia or autoimmune thyroid problems in such cases there are there is possibility that you it may cause autoimmune diabetes so the best way to find out what may be the cause or how to diagnose it is going for a fasting c peptide eyelid cell auto antibody and gad 65 at antibody levels so when you check these you can identify what is the role because let me tell you autoimmune diabetes and type 1 diabetes both can be effectively managed with insulin and less with oral hypoglycemic drugs okay so that is the significance of recognizing it early but there are few diseases like if you see modi maturity onset diabetes of the young they present with type 2 and type 1 together so it is difficult to actually find out what is or how do we approach such a case but it's important that you whatever we can find out and rule out at the initial stage itself will always be beneficial so whenever you see autoimmune diseases like celiac or sle or autoimmune hemolytic anemia autoimmune thyroid problems and so on and so forth any kind of autoimmune disorder screen for the sugar levels and if it is raised green for the antibody levels okay thank you my uh curie is dissolved thank you very much thank you let's take up a few questions so we have a question here uh what would you suggest in gestational uncontrolled sugars okay now in case of gestational uncontrolled sugars we have very limited options number one is using metformin use metformin to the maximum dose possible like you can prescribe metformin at a dose of even two thousand two thousand two hundred milligram per day okay you can go for metformin and combined with insulin as i said earlier insulin you can go for two uh one you can use multiple rapid acting insulin with the basal insulin or or what we call as a bolus basal bonus regimen another one is using intermediate acting insulin along with the basal insulin and so on and so forth so different kind of insulin combination therapies are available and along with that you can combine with med form this is the usual practice which is followed even after this if it is not controlled then only way is using an insulin infusion pump so that's the basic thank you i hope that answers your question dr patel uh we have dr mehta who's asked uh sir please tell us how to titrate insulin according to blood sugar levels fasting and postprandial okay so uh see let me tell you there is no particular fixed rule as to you know how you can titrate levels there used to be a time when every patient was started on short acting insulin put on sliding scale like everyone is told like 151 to 200 sugar 201 to 250 though 251 to 300. this is how it used to be practiced and if you see that still sugar levels are not controlled you increase the scale a little bit so this was the earlier practice right but now how it is practiced is more like you give short acting insulin throughout the day okay now let's say a patient comes with sugar levels let's say fasting is about 130 post meal is about 180 okay and let's say you want to use insulin therapy so you will go let's say with short acting insulin like activate so best way to do is if you have free breakfast free lunch free dinner you practice with a short acting actor bit or what we call as the rapid acting list pro or aspect insulin okay so when you give these insulin you give in such a way like if pre meal the sugar levels are about 90 then don't give anything if sugar levels are about more than 200 you can give four or six units whatever according to what you feed right record it and keep record the entire scale and keep for the entire day continue like that for two to three days right and then you will see what is the total units of insulin required per day let's say rapid acting list pro and aspart you're requiring requiring something like um 20 units per day okay let's say you're requiring 20 units then when you're discharging the patient or sending the patient back home you will discharge on intermediate acting insulin where out of those 20 units two thirds will be given in the morning one third will be given in the evening so let's say 14 units in the morning six units at bedtime and discharge vacation seven days monitor ask the patient to check fasting and post me or seven days later tell him to come again check the values of fasting and post me and modify the insulin treatment accordingly so this is the common practice which is followed nowadays thank you i hope that answers your question uh then we have another question if eight months ago the fps and ppbs are normal um but now the hb a1c is 9.3 how do we justify such okay let me tell you hba1c is not a sure short thing okay it is not something which is like um completely specific towards diabetes sugar levels do not fluctuate with your fasting and post meat sugar levels fluctuate throughout the day that is why some clinicians today practice something called as a continuous glucose monitoring where they place a patch on your on your arm and it monitors the sugar levels throughout the day and whenever you check fasting it will be low whenever check post meal it will be low rest of the time it will be high so that is how it happens and then again hba1c remains high so that is a common cause okay so the best way to do is go for a continuous glucose monitoring see whenever the sugar levels are rising and see what are the cost for sugar levels let's see today i'm monitoring the entire day today entire day my sugar levels are normal tomorrow i had one portion of chicken and i saw that my sugar level raised to 250 so try to avoid chicken next day try without chicken sugar levels are normal so that is how you do the dietary modification with continuous glucose monitoring so this is an effective answer for why you're saying that fasting post meal may be normal and hvac may be released i hope that answers the question um let me just check if yeah so dr ashok i'm gonna take you up on stage sir i want to ask you regarding the c peptide level whether it should be fasting or postponed in c peptide and what it yeah so the thing is uh ideally what is recommended is post glucagon c peptide level that is how the entire guideline mentions okay but the routinely practice is fasting c peptide level and less than 0.2 if it states then there is a chance that it could be type 1 diabetes so that is how it is routinely done hey what is the exact interpretation of c peptide suppose c peptide is in a normal range not less than 0.2 in a very early stage of modi then we said consider it as a type 1 or type 2 suppose 3 is there ok so let me tell you that c peptide level is like a sensitive marker it is not a very specific marker ok so when you do c peptide there is nothing which states that something is ruled out if you see modi moddy presents some some categories of modi present as type 2 in the initial stages and some present as type 1 in the late stages so it is very difficult to say which belongs to which category so that is why just to screen out whether there is a possibility of type one you can do a c peptide level and check but if c peptide levels are normal then there is a possibility that you can initiate the therapy with oral hypoglycemic drug and try and see whether sugars are getting controlled or not so this is one particular way which is practiced okay so we have dr sonic who's asked how to treat diabetics with ckd patients especially when they are on thrice weekly dialysis with hyperglycemia during dialysis okay see let me tell you hypoglycemia during dialysis is a very common phenomenon okay so in such patients what i would recommend is go for an insulin therapy and insulin therapy and you can go for an oral hypoglycemic drugs but in such a way that it is beneficial for the kidney also a better way would be going for insulin and second it would be using sglt2 inhibitors which are really good drugs to use in case of chronic kidney disease [Music] when i have gone for the hdlts the people are perspiration intolerance polyurea all those things are suffering so when i'm start is cl2s i'm getting this what will be the cause and less than g30 gfr sclts can be used or not so ideally what happens is sglt2 inhibitors as we know it acts through the sodium glucose core transporter so if egfr is less than 30 sdlt2 inhibitors there is nothing like which states that recommended and not recommended it just states that it can be used in case of diabetic nephropathy but if suppose patient is not tolerating hdlt2 then what you can do is shifting completely towards an insulin regimen okay and using sulfonylureas along with it so this is an ideal combination which can be done insulin infusion insulin therapy also you can use something called as intermediate acting with long-acting insulin now in long-acting insulin there is large and there's the gluten i have seen patients where patients are allergic to collagen but then when i give the gluten it's a big advantage the sugar levels are not in control it's more than epp37 now sulfonylus [Music] what will be the choice of next so uh so next way is going for an insulin pump therapy or next let me tell you it is important that in such a case you check for an eyelid cell auto antibody level okay when you check in such a case there is possibility of autoimmune diabetes and when autoimmune diabetes comes together then you need to manage it in a very different alt way altogether which even i am not aware mostly in endocrine lodges deals with such cases where they go for an insulin pump where they provide an insulin pump to the patient and with that pump continuously insulin is discharged into the body so it's important that you evaluate and see what may be the cause behind it um [Music] we have dr saxana uh i'm accepting your request please come up on stage hi this is regarding one of my patients which i am dealing with say about 45 year old obese diabetic since long now the problem which i have been facing with this patient is sugars have never been on control she has been on various combinations of sulfonylureas dbp4 when i put this patient on a clt2 she develops a urinary tract infection and the problem is that if i start the patient on insulin as sugar goes up i have tried glargine i have tried the glue deck but now this is a situation where i am stuck so right now i am giving a long acting combination of glycolyzide along with the dpt4 uh cetagleptin and i am giving a combination of vaguely was and rapidly night now that is the only option which i could see right now but still her sugars are high yes if i use pie glitter zone she does a little bit better sugar comes into the range of around 200 but she starts developing federal redeemer right okay uh sir in such a case know what i recommend is go for continuous glucose monitoring and find out which part of the day sugars are rising and you see what diet she's following let me tell you at times we follow we give so many drugs but patient is not following the diet properly so that may be a primary cause so even if we give so many drugs and if diet is not followed properly then there's no point okay so a better way would be go for a continuous glucose monitoring continuous glucose monitoring is such a way that you place a patch here and the reading comes on your screen yes i was thinking and if any other medication because i was thinking in terms of bromocritic and the hcq and all those stuff ah sir let me tell you uh what is usually practiced and what we rarely practice is it's a big controversy kind of thing okay using a rare practice it's much better to use a unique of the common rather than going for an ear okay so i think if your continuous glucose monitoring fails then you should think of all these things but i think i would suggest that it would be better to go for a continuous glucose monitoring because initially i was thinking maybe she's on some sort of steroids so i got those levels checked normal i have been discussing this on quite a few because that is one case which is stuck and she has been to quite a few endocrinologists of the city and still things are safe okay okay so then there is one more one more suggestion one more thing which uh i usually do in such a case is that if i give deglutec or lantis let's say i'm giving 40 units then i split it i split 20 units in the morning and i split 20 units in the night okay so when i do that the basal thing acts double the dose throughout the day so that also gives a slight benefit another thing which i usually do is i avoid using glycolysis and i use glimmer pride a lot because the side effect of chlamypride can be put to our advantage when sugars are uncontrolled so that is one thing which you can do and another thing is by using glimmer pride the only thing which you need to do is monitor 3m sugars if it falls low then avoid gloomy bright giving during the night hours but you can safely give it during the daytime so this is another practice which you can try thank you thank you so much there's a question could you give us some a safe beta blocker with uh diabetes mellitus one answer to this is carvalho that's it there's no and no more answer to this you can give bisoprolol and you can give menoprolol but carvedilol is gold standard and there is nothing better than that carbohydrate start with 3.125 milligram per day and that is a very good drug for giving in patients with diabetes with hypertension with a recent mi or with a recent heart failure and so on and so forth thank you that was a very short answer and the to the point answer uh so we have another question here uh please comment on long acting insulin long acting insulin right so uh basically what is practice i'll tell you one is called as glargin another one is called as diglootec okay deglutec has started coming into the picture in recent years okay because it gives a very good control and as i said earlier also that many patients are allergic to glaring and they are proved beneficial to the gluten basal insulin is my favorite to give because when i give a basal insulin every short acting insulin gets like a booster okay because short acting insulin control sugars only for four to five hours and when there is a basal booster then short acting insulin tries to pounce and control the sugar levels so long acting insulin is one of the best things to give start always with around eight to ten units at bedtime so that it works throughout the day the routine practice is where long-acting insulins are given during bedtime but if suppose sugars are uncontrolled then you can split the dose into morning and night which many people do not do but that is a good way of controlling sugars too so long-acting insulins are really good to use for sugar control thank you for that um i think we've gone through most of the questions thank you so much uh doctor to come up on our platform we had a wonderful session with you and we hope to see you again on our platform on a regular basis

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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. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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dr. Rohit Jacob

Dr. Rohit Jacob

Consultant Physician & Intensivist at Craft H...

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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