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Uncontrolled Hyperglycemia and Previous MI

Apr 11 | 3:30 PM

Diabetes is a significant, widespread, and insidious source of morbidity and mortality in people with coronary artery disease. Comprehensive management of Type 2 DM patients is crucial for early diagnosis and detection of potential CV risks. As the underlying pathophysiology of the atherosclerotic process is enhanced in individuals with type 2 diabetes, the association between hyperglycemia and increased mortality after an acute myocardial infarction is strong and unambiguous. Join us LIVE on Medflix as we discuss a case-based approach to the above with Dr. Rakesh Kumar Sahay, Professor and Head of Department of Endocrinology, Osmania Medical College & Hospital, Hyderabad.

[Music] good evening doctors on behalf of team netflix i extend a warm welcome to all of you i am dr fatima today we have the honour of having among us dr rakesh sahi who is professor and head of department of endocrinology at osmania medical college and hospital at hyderabad there is also senior consultant endocrinology and his contributions to the field of diabetes has been numerous and very very significant today we are really thrilled to be learning from you sir thank you for joining us yeah thank you thank you uh and a warm welcome to all those who have joined the program today so today we will be discussing about a interesting case of uncontrolled hypoglycemia in a patient with a previous mi so good evening once again and a warm welcome to all of you who have joined today so we are discussing about a patient with uncontrolled diabetes who has multiple cardiovascular respect i mean has a pre-existing cardiovascular disease multiple risk factors and the challenges that we face in managing such patients is what we're going to discuss today so if you look at this a 60 year old gentleman who has come with a history of he's been having frequent urination at night and he is having he has been known having diabetes for more than eight years now he's been having blood pressure for five years and lipid abnormality for more than two years and he has been on medications for all these problems he is a smoker he doesn't use other forms of tobacco but he is his lifestyle is very sedentary he has a very strong family history of diabetes and cardiovascular diseases father and elder brother have been suffering from uh from these problems he himself had an mi two years back and uh one year back and this was followed by angiography and the ptcn that was done the stenting was done to the to the lcx and om1 he has however has no other history of tuberculosis peripheral arterial disease or the history of strokes in the past and he apparently doesn't have ckd with this uh background that we've seen if we look at his and when you look at his anthropometric uh data we see that he has weight his weight is 65 kgs he's got a bmi of 29 kg per meter square his systolic his blood pressure is 136 by 86 millimeters of mercury his ecg shows a strain pattern of the left ventricular with the echo showing an every ejection fraction of 35 on ultrasonography we see grade 1 fatty liver with the normal prostate his hip hpmc was eight point two plus two percent his fasting blood sugar was 142 and postpartum and he had urine sugar a positive no previous uh no past cells or low cost in the urine and his serum creatine was 1.3 milligrams so as we see from this details that we have seen all these uh findings that we see on examination and on investigation we clearly see that this person is obese he has he has a clear evidence of cardiovascular disease in the past and he has a uncontrolled diabetes his blood pressure is in spite of all the medications that he's on his hb once he's 8.2 percent his fasting and postpartum blood glucose levels are also correspondingly high his creatine is one point three which appears to be normal so what next do you think this patient uh what would be his target hb on cb so let's see let's see what the response is from all the participants would they consider a target h1c to be less than six percent so what 25 percent uh yeah yeah twenty-five percent mean that his efficiency should be less than seven percent which i think is very appropriate uh while some of some of you have felt that we should look at more stricter control but what we need to understand here is that as we will be discussing along as we go along today we will be discussing about what should be the target appropriate target how we should individualize targets in our people with in our patients with type 2 because we have data from several studies which has shown that hypoglycemia is a major problem in people who have got who have a risk for hypoglycemia or where we are looking at aggressive therapy and hypoglycemia is a is one factor which can prosper cardiovascular diseases so looking at all that you know looking at the fact that he has a cardiovascular disease but has no other uh significant autonomic involvement and other other features which would make him prone to hypoglycemia we could look at a realistic target of less than seven percent which would be very appropriate for him a target of less than six point five or six percent would put him at a very high risk of hypoglycemia and it would trigger cardiovascular issues so let's look at his other aspect that we need to look at does he have diabetic diseases do you feel that he has got diabetic kidney disease we had seen that is weird teen was 1.3 which looks normal but does a person like this who is 60 year old male with the creation 1.3 have normal kidney disease so uh 7 57 have voted for yes sir yeah so 57 have voted for yes so this is what i wanted to highlight here that many of us when you look at this creatinine value feel that this is normal he has normal renal function but that is not so that is not so if you are going to calculate the egfr the estimated gfr from the parameters that we have that is his age sex and the race from these three parameters we have got we we've got apps which are available which can be easily downloaded the uh from the national tv foundation and other apps which can tell us what the estimated gfr is and if you were to do this it shows that the estimated gfr in this patient is 63 ml per minute which is clearly not normal so he has got a stage 2 ckd or a diabetic kidney dc stage 2 which is based on the egfr estimation which can be done by using an is a smartphone and using an app which can do this calculation we have formulas for doing that also but we have a convenient app available now and most of us carry a smartphone so you can easily calculate that and we can see that is his renal function is not normal and he has got impairment and that has a significant impact on the on the cardiovascular outcomes as we will be discussing in the subsequent so what do you what would we like to do to evaluate his linear function we would like to look at his urinary and reaction ratio uranus system c egfr estimation yeah so most most of the uh participants felt that we should go ahead and do a urine and preadmin ratio which is what we should be doing because that's going to further quantify or further uh further give us information about the type of linear disease that is there and whether we need to do anything more about it what needs to be and that is that is something which is which the information we get from the urine so having looked at these aspects now let us see what his current medications are he has been on um dbp for inhibitor buildup and metformin 50 mg of beta wintergreen and 500 mg of men coming twice daily he has also been receiving five glitches he has been on rosewater in 10 20 mg then we sat on 40 mg per day and he also takes a lot of multivitamins we'll come back to this patient again we'll discuss a little few aspects about about diabetes management particularly with with reference to the cardiovascular disease and then come back to our our reference patients so as we have seen here we see that our patient has what has has cardiovascular disease he has got several other risk factors also for cardiovascular disease apart from having a cardiovascular event in the past so we are looking at controlling his sugar keeping his blood pressure under control and also reducing weight because we've seen that clearly that this person is obese so before we come back and discuss about this patient let's discuss uh look at the changing paradigms in the management of type 2 diabetes today we'll also look at what uh what are the expectations from physicians today for managing patients with type 2 diabetes and then the we will look at how we can bridge these management gaps with newer therapies and we are able to you know break the barriers and come and breathe will bridges towards uh effective management of diabetes and providing holistic management of all these risk factors so if you look at type 2 diabetes it's a progressive disease and what we see is that the major problems because of diabetes are because of the microvascular complications and the micro vascular complications when you look at the microvascular complications they start off after the onset of diabetes and so therefore we are not very much i mean we are we are looking at a good glycemic control to to bring down the risk of microvascular complications but the macroscopic the complications are the major challenge because they start off even before the onset of diabetes and that is because of clustering of other risk factors like the presence of hypertension presence of weight abnormalities presence of genetic factors which are contributing to the microvascular disease or the cardiovascular disease when you speak of micro vascular disease we are we are referring to the cardiovascular disease that is a coronary artery disease we are referring to the cellular vascular disease and so these problems start even before the onset of diabetes because of the clustering of all the other risk factors which contribute towards the development of this microvascular disease and even in the stage of early stages of even before diabetes develops this microvascular disease can manifest and it can often manifest and very very often it manifests in the face when people have got pre-diabetes that is impaired glucose tolerance or impaired fasting and it is therefore very important that we address this microvascular disease right from the onset of diabetes rather than waiting for a longer period we're waiting for for the diabetes to develop before we address that now if you look at the diabetes in india what we see is that we have several peculiarities about diabetes the presentation libraries in india itself what we see is that we tend to develop diabetes a decade earlier than in the western population and therefore we have a longer burden of of uh of the glycemic burden longer glycemic burden and because of this we are at a higher risk of complications what we also see is that we tend to develop diabetes at a lower bmi that is as and and at that pmi also at a lower bmi also as compared to other populations we tend to have developed we when we tend to have more of abdominal obesity and this abdominal fat which is deposited around the viscera the visceral fat is metabolically very active and leads to the development of diabetes leads to development of cardiovascular disease and leads to several other problems non-alcoholic fatty liver diseases are one of the manifestations so people with diabetes tend to have poor glycemic control in our country we see as you can see the the in the center of the of the slide you can see the the number of people who are at good metabolic control versus those who are at poor control we see that almost two thirds of the people are at poor control and therefore they are at very high risk of cardiovascular complications now we have very good evidence from various uh various epidemiological studies which have shown that the poorer the glycemic control the greater is the risk of development of complications meet the micro vascular disease beat the microscopic disease whatever complication you speak of the it is clearly related to the degree of testing control the word and particularly when you look at the cardiovascular disease that's the reason that's the one which is of special interest today and also it is a special interest because the fact that it contributes uh to most of the modernity because of diabetes and also most of the modernity people almost 70 of people with diabetes die because of cardiovascular diseases and so therefore it is very important that we address this issue and we understand the fact that the relative risk of cardiovascular disease is much higher in indians as compared to other populations and when you look at the average prevalence of cardiovascular disease in a population of in the population of us it was in the indian population in non-diabetics it was 11 and if you look at the diabetes it is the prevalence rates of cardiovascular diseases 21 showing that we are at a much higher risk of cardio strategies and when you look at the life expectation in people with diabetes we see that there is a a reduction in the life expectation almost six years when even without any uh cardio strategies but when cardiovascular disease sets in then the reduction life expectation goes down about 12 12 years and so therefore it's very important that we we address this issue early try to see that we prevent the cardiovascular disease and if it develops then we try to try to treat it effectively so as to prevent recurrent treatments and as you can see from this data which is again from the uk pedia study the ukpd study was was probably one of the largest studies which looked at people with diabetes right at the onset of type 2 diabetes and they followed them up for 20 years or so and what was seen was that with one percent reduction in which you don't see there's a clear reduction in all the micro vascular complications and a reduction in the announced one significant reduction in the cardiovascular disease as you can see from this slide that even a one percent reduction where the intensively treated group had a hb1c of seven percent and that's where we all say that you know seven percent is a target because in the uk study the target uh achieved by the by the glycine target that was achieved and achieved by most of the patients in the intensive control arm was seven percent and what we find there was with that reduction in one percent in the in the hb1c there was a clear 37 percent reduction in all the microscopic complications and the major benefit was seen in terms of reduction amputation rates and deaths from from from vascular from peripheral vascular disease and that was clearly reduced by 40 which was not very significant statistically and then we had the the follow-up of this these patients were the uk video study a long-term follow-up of those patients showed that the initial intensive control didn't provide a benefit in reducing the the microvascular disease also the cardiovascular disease also came down in those patients and therefore the concern that was there but but since it didn't come down initially the concern which people had was whether we should be targeting a lower hp and c level uh target whether we should look at target of 6.5 or 6 and from from that with that in mind the advanced accord and the video studies were designed and they looked at people with diabetes for more than 10 years duration of almost eight to ten years duration of diabetes were poorly controlled and they gave them aggressive control and tried to reach a target of six point five percent or six percent in their experience and what they found was that in in contrast to what they were expecting there was a reduction there was an increase in the morbidity mortality amongst the group that were intensified and that actually gave us a better understanding of the fact that all this problem that happened i mean the increase in mortality that happened in that study was mainly because it was mainly linked to the hypoglycemia that was that was uh happening more often in those patients were very aggressively being managed with the objective of bringing down the hb1c2 to less than six percent and what we would see clearly is that these studies brought out the fact that that that while we are managing diabetes there are people who are young people who have got a very short duration of diabetes do not have other commodities but whereas those people who have got pre-existing cardiovascular disease have got other cardiovascular or other factors which are contributing to moderate significant morbidity have a bloomness for developing hypoglycemia or have autonomic neuropathy which makes them again for developing uh developing uh autonomic i mean hypoglycemia unawareness also in such individuals we need to be less strict in our targets and could keep them even at hmmc eight percent uh also so that that has been the major uh change which has happened in all the guidelines from the last say we could say in the last one decade this has been the major change that we've been seeing in the in the guidelines speaking about individualization now what we also know is that despite all the newer therapies that are available we are speaking of so many newer therapies we speak more so much titration being possible uh more of monitoring but in spite of all this we find that many of our patients still remain and poor placement control and there's a lot of challenges that leads to realist and this is what we need to look at and this has also prompted us to bring about a revolution in diabetes management looking not only as as they are not only looking at the hb1c goal which is certainly a very important aspect but looking beyond that towards treating the treating target rather than going by stepwise approach and looking at the multiple other commodities that are present and and seeing that they are also satisfactorily addressed and another important issue is that that has been brought to light is the fact that we should be using consider using combination therapies rather than using monotherapy in the management of several years and having looked at that let me just quickly uh run you through certain aspects about about cardiovascular disease which are very important the presence of renal dysfunction is very important because that is a multiplier of the cardioid space we could say that people who have got renewal dysfunction tend to have five to six times higher risk of cardiovascular disease and that is that is the reason why we need to we should be looking for renewal dysfunction uh and assessing the linear function by not just looking at clearing but parameters which can help us in early detection and also another important factor about function is that it increases the risk for for individuals to be to be developing hypoglycemia whether it is mild or moderate or severe hypoglycemia some of the individuals also develop severe hypoglycemia and this is all related and as we have shown that hypoglycemia can trigger very various cardiovascular universes of cardiovascular disease now uh the other important factor that i would like to highlight quickly just touch upon is the presence of obesity waste is again an important risk factor for the development of cardiovascular disease and as you can see whether we're looking at uh uh whether we're looking at metabolically healthy or unhealthy obviously we see that these individuals tend to have a higher tend to have higher risk for development cardiovascular disease and the mechanisms are clearly seen here that individuals who have have a vestibule are at a higher risk for developing cardiovascular diseases and it is also there are some proponents of uh who who say that you know there is a there is an entity called metabolically healthy obesity where individuals who are obese do not have diabetes do not have hypotension or do not have other risk factors for your studies but in even in such individuals what we see is that obesity itself is a is a significant enough risk factor for the development of various problems in so this is something which has to be addressed effectively and weight reduction is an important role in the management of diabetes now let us look at how the has happened over the years in terms of uh the management algorithm as you can see this is the ada esd algorithm which was proposed in 2006 and went on till 2000 um and and and this was the one which was proposed in 2012 actually the earliest one the first algorithm came out in 2006 and this was a major revision which happened in 2012 where a cafeteria approach for the management of diabetes was proposed where what was proposed was that metformin should be the first line therapy for management of diabetes and then after meant forming when metformin alone is hard enough to keep so these are all the i mean additions that can be done to a person in which your person is already injured so that was the that was the approach where where each and one h and the plus and minus points of each of these forms of therapy was was discussed in that and and and the providers or the physicians were at liberty to choose which one of the agents they would prefer based on the factors uh 18 onwards you know with the availability of the cardiovascular outcome trials from the two major cluster drugs that is glp1 analog clp1 receptor analogues and the sglt2 inhibitors there's a major shift in the paradigm or rather paradigm shift in the management of diabetes and today we have what we are saying speaking is that we would try our patients with diabetes to see whether they have got atherosclerotic cardiovascular disease or renal dysfunction or heart failure and if they have any of these then then it necessitates that these patients these individuals should be on on either a glp one a therapy or on a glp inhibitor therapy or and and this is what has to be looked at and if the person does not have any of these factors then we look at other factors which are decided mainly by the convenience issues and by issues of not causing weight gain not causing hypoglycemia and these are the major changes that have happened in the last few years i mean i would say that this came out in 2018 and subsequently subsequently there was the european society of cardiology which was very progressive and they have they have they have proposed their own algorithm where they say that people with diabetes who have got cardiovascular disease should be managed for their uh for the skin uh i mean should be managed for the cardiovascular disease you should be managed for the diabetes with the use of agents like sglp and glp1ra right from the onset of diabetes i mean right as a first line therapy rather than waiting for metformin to fail to keep them at target so that is how the the paradigm shift has occurred again in terms of deciding what should be the first 93 versus what should be an add-on so what we are seeing is that today we have we have realized that there are several compelling needs for uh for to be addressed in individuals with diabetes and to see whether they are uh so that we are moving from a approach which is beyond the glycemic control looking at beyond glycemic control looking at the risk of heart failure and the risk of atherosclerotic cardiovascular disease looking at the risk of risk of renal impairment in patients and also seeing that while we are trying to achieve uh a good placement control you're trying to do that without causing hypoglycemia without uh preventing weight gain and also providing a good personalized care to the patient this is how we think that the the paradigm shift is a burn occurred having looked at these uh issues now i would quickly look at two of the classes of drugs which i've already spoken about the glp one rs or the glp one receptor which work by providing a supra physiological levels of of the glp1 analogues which act on the on the glp receptors and it is through these they produce a a good reduction in c without increasing the risk of hypoglycemia and at the same time they also provide the same they benefits have been shown to have a very significant beneficial effect on the weight of the image so these are some of the benefits that we've seen and the other important aspect that has happened over the years is the availability of these uh agents of this particularly similar trade as a as a oral agent for the management of diabetes and if you look at the glp one are outcome trials we see that there's a clear benefit shown in the leader trial which showed that there was a a clear benefit in terms of uh in terms of reduction of the three-point base and uh now if you look at the the weight reduction that has happened in various studies we see that clearly that the a good way is a a good improvement has has been seen in terms of uh of the weight reduction and the major issue with these agents is that initially there's a gastrointestinal adverse events that is presence i mean development of nausea and and and and this taste for food happens in the first few days and this settles down and what if we did a few days the patient is able to go on comfortably with the use of these agents and if you look at the pioneer program and also the the large number of trials reaching the glycemic targets at the same time with without causing hypoglycemia and providing a signal and weight benefit and providing cardiovascular benefits also this has been what i will show in these trials now if you look at the cardiovascular outcomes with syma glutathione they were they were seen in the in the in the pioneer program which was not really designed for growing the superiority of this agent so so therefore and some of them can be used even with egff are going down quite significantly to the stage five category also while with the s320 meters we are preferring to use them uh um up to a pgfr of of say 30 ml emotional situations and uh if you look at the mechanism by which the uh glacial p2 inhibitors are working that they are bringing about a loss of glucose in the urine and thereby providing the glycemic benefit and also they also uh help in weight reduction they are needing to improve improvement in the hyperinsulinism improvement in improvement in the metabolic switch uh metabolic switch between weight loss and and and the metabolic aspects so through all these benefits the hdl meters provide a significant cardiovascular benefit and this was seen in different studies and this is this is a study which is looked at the glycemic effective effectiveness of protein in people who are on different uh then uh what we see is that uh if you look at the major cardiovascular outcome trials with the sj20 meters and the gpu and array we clearly see that there was a clear cardiovascular benefit if you look at them empire [Music] a wide spectrum of patients with different risk factors and there also you could see that the four point base was significantly uh benefited by the use of now if you look at the empiric trial there was a clear 32 percent reduction in uh with the use of empirical closing as compared to standard care in terms of reduction in the oil cost there was a production the cv modernity also to the tune of 38 with the use of and so clearly what we see is that choosing glucose lowering regimes now in the is is hbo has to look at first looking at presence of established cardiovascular disease or renal disease and accordingly stratifying our patients to receive therapies which are which would give them benefit in terms of these three problems now we have very elegant data from uh from the correct trial which is clearly shown that that the the cardiovascular benefit which you'll now have from the cuisine is independent of the glycemic as you can see the same reduction in the cardiovascular event so seen even with even in the subgroup that that was uh having a good lifespan that is the classified status was already at less than seven and when when empowered was added it still did provide the benefit in terms of the cardiovascular protection which happened even at even even when the glycemic status was normal so in saying that independent of the glycemic efficacy of the drug there is a clear benefit on various cardiovascular endpoints and even with hospitalization part where there was a significant benefit from the use of temper and as you can see emphasis consistently reduced the rates of cv risk of sea modernity across various presentations of cbd and as you can see in the cv continuum when you look at the empiric trial we're looking at people who are already having cardiovascular disease that is accounting only for one third of the patients and remaining two thousand patients are still uh i did not have the could not be enrolled in the in the empire trial but we have something called a prize study empire study which was a real life study which complemented the the the information that we obtained from the empire trial and putting these two together we can say that the molecule works across the entire spectrum of of uh people with diabetes with or without rainy diseases so clearly what we see is that the entire study uh supplemented the information that we got from the empiric study and went on to show all the key points that is that there was a significant reduction in the in the all-cause modern team and there was this improvement in the various parameters so clearly what we see is that there there was a benefit which was going beyond the cardiovascular aspects alone and even there was a analysis of the subgroup of patients who had data on their egfr's and other real outcomes it was clearly seen that there was a improvement between the outcomes also with the use of information so clearly we have got a lot of researchers speaking about hdl t2 inhibition and glp1 are a therapy in the management of diabetes and towards this end even what have the guidelines done if we look at the european society cardiology guideline they came out with the guideline in 2008 where they really said that they have understood the importance of these classroom drugs which are available the either be the hd20 meters or the it is clearly shown that these can be used as given as monotherapy in patients with diabetes with other with pre-existing cardiovascular diseases and also pre-existing heart failure so in all these individuals they have they have highlighted the need for using these agents as the first entrepreneur then waiting for metropolis and taking taking the uh i mean and and if you look at the american association clinical and technology guidelines also uh for the management of hyperlinks we clearly see that they have spoken about driving patients into well they they have a hvac i mean the entry-level agency decides what form therapy that they should get if they have a hmmc level entry level efficiency of more it is clearly said that they should be they would benefit from double combination i mean double therapeutical therapy rather than a single monotherapy and those who have got an experience more than 9.5 percent may benefit from a triple therapy uh triple combination therapy or even the use of insulin and when we look at the ada esd algorithm which was earlier proposed which always spoke about metformin as being the first line and then looking at these aspects but in the current ada standard okay that was published in 2012 uh january uh there was a clearly a change in stance by the ada where they really highlighted the fact that in people with with the established atherosclerotic cardiovascular disease or rainy disease or i mean or risk for heart failure such individuals should be such individuals should be should be benefiting from the use of hdl32 meters or glp1r right from the onset of these diabetes and then waiting for metformin to fail to provide the lesson so uh in fact what they have also suggested is that if your patient is on on on any of the uh or not on any of these valves then you could even substitute those drugs and start the drugs which are providing going to provide the cardiovascular and then they have also spoken about the fact that we need to look at the the risk of hypoglycemia the risk from weight gain and the economy of the person so as to decide what type of therapy would be best and if you look at now having looked at the entire spectrum of this now let's come back to our patient who was who whom we had initially presented and we said so that he was having uncontrolled diabetes with the previous history of mi and he was on different therapies i mean he was on vidcom he was on [Music] needs to stop either injectable or oral and the other option was the use of hdl so the patient except ramen chose to use the sgp 20 meters was not very keen on using the um using the glp and arrays and then the other therapies except for the stopping zone and then what we see is that he had a benefit in his glycemic control and over the three months of treatment we could see that his adjuvancy came down from eight point two to seven point one percent and he also lost three kg and his blood pressure was also at 132 by 84 and he had modest reductions in his systolic industrial blood pressure and he also lost three kgs of weight his frequency at night had come down and he was comfortably sleeping and he had a comfortable sleep without having a disturbed sleep at night so i would like to conclude by saying that we have over the years moved from a glucocentric to a cardio metabolic and holistic patient patient care where we are looking at certainly looking at the providing good blessing control but we are trying to do this without with a careful consideration of the risks of cardiovascular disease a careful concentration about the risk of heart failure and also the risk of renal impairment and we are seeing that we not increase the increased problems because of hypoglycemia or and we are discussing with our patients individualizing our targets so as to why get good patient compliance in terms of uh in terms of reaching the brackets that we look with that i would like to thank you all for the patient hearing i'll be happy to take any questions thank you sir you have beautifully covered every aspect of the topic we'll just give a moment to our audience to drop in their queries so dr ali says excellent thank you all dr vishnu pratap says great sir dr mahadev visay says excellent in-depth discussion covering all aspects of diabetes management thank you so much dr sahai thank you so we have a question from dr simchana sir in case of advanced renal failure where egfr is not favorable to use stl to inhibitors then how do we proceed to control the glycemic range of the patient yeah so we have the option of using insulin which can be used at any any level of egfr the other aspect is that the sga the gfp one receptacle or even in stage five it can be used so that is the other option that we have in addition to the incident okay thank you sava our next question is with dr sanket patient with 8.66 hp a1c on metformin and right uh should we add on what are your views sir yeah a person who is having experience of eight point six percent clearly requires a addition of therapy and the options again we need to look at all these options that are available if he is right if he has got a good i mean indication for and he has got a compelling indication like having a cvd and security risk factors strong risk factors for these conditions or have this factor of heart failure then he should be started on hcl2 uh otherwise he can be on financial also a combination of sglp and dpp for may be suitable in this patient because he has a he has to uh you know he has his hvac which is one point five percent more than the target that we know we're looking at a target of seven percent and his hbo nc is eight point five percent so clearly we require not one but two agents and we can use a combined therapy with a zero two uh dpp for combination we have one of them which is available is a is a combination of of lenovo and and uh so that's a good combination that can be used and around 1.5 percent reduction is what we receive okay thank you sir uh dr sahab says thank you so much doctor yes i'm just looking okay dr g asks uh sir during treatment of the type 2 diabetes uh why metformin causes lactic acidosis yeah so metformin uh more than metformin phen forming which was a because i mean which was a molecule which is in same category was known to cause lactic resources particularly in patients who had green insufficiency there because of the fact that whenever there is a whenever there is a anoxia situation of hypoxia tissue hypoxia then lactic acidosis is induced when patients are on on one of these cluster drugs so with metformin lactic acidosis has been very rarely reported and particularly in patients with who have where it has been used in appropriately that is in patients who have got significant renal insufficiency or in patients without advanced lung disease which with hypoxia or impatience or what say a significant liver dysfunction in all these situations we would avoid using for these reasons okay thank you sir uh dr ashwini patel says great session from dr ashuni uh we have a question from dr sanya when can we use glimetrite alonzo would it be safe yeah so blimey parent alone is becoming less and less popular in terms of use because of the fact that it can uh in when it can induce hypoglycemia and some so now the this indication where it would be used alone is in a patient was intolerant to metformin and you are looking at using a drug which um brings about an effective reduction in see there i think uh right stands out particularly and also in which there could be patients who have got say past history of pancreatitis because of which they are not able to use any of the ingredient based therapies like uh like inhibitors or glp he cannot use that and if he is whatever intolerance to i mean he has got recurrent uti with the use of uh with the use of hdlt meters so greenbride stands out as it as a good choice in that situation so there could be many individuals who could have all these problems uh and and in such individuals we are unable to use uh drugs like the ones which have discussed about and neutral right okay thank you sir um just one more uh surf patient serum creatinine is more than 1.5 should we stop the metformin still could we continue it yeah so the current understanding about metformin is that we could continue it till the age of 30 ml so we have the calculators you can look at the egfr calculation if we are i mean in the in the zone of 30 to 45 million per minute we would try to restrict the use to about 1500 mg per day not beyond not going beyond 1500 mg per day with a easier part falling below 30 then you would like to stop me okay i hope this answers your question dr ali we have a question from dr ashok so what would be your impression be about gliclazide yeah so glycoside is again a very uh good cellphone area which is the modern century as you can put it to along with like uh with humichlite and it has uh some good properties in the sense that it doesn't i mean causes less of hypoglycemia as compared to the older cell phone doesn't cause ischemic reconditioning because as used to happen with the so from that perspective glycoside is a good molecule and it has been uh we have data from the advanced study and also data from the stream to study which support uh the beneficial effects of i hope that answers your question dr ashok we have a question from dr mahadev desai for ckd and cvd high risk any specific preference of stl2 inhibitor yeah so um the specific preference would be based on the evidence that is available so if you look at the evidence available as a good evidence from the incorrect trial and then we have data from the uh from the credence triangle which which so these are three evidence based uh html emitters so we would prefer using one of these as compared to any of the newer ones for which we do not have as much evidence thank you doctor thank you dr sahai desai uh we also have another question from dr britton jayakumar is it inevitable to have insulin requirements if on long-term use of glimepiride well long-term use of blemish i mean the earlier concept was that uh that there is that the sulfonylureas lead to exhaustion beta cells and therefore sooner or later you require insulin uh once your once you started a personal issues but that has been refuted by different studies where we have seen that even after several years of use of molecules like sulfur india you find that patients still have a significantly good energy secretion so it is not inevitable that everybody requires insulin but what we see is that you look at natural history of diabetes itself by the time diabetes is diagnosed it is 50 percent of the beta cell function is is lost and over a period of a few more years you find that there's a there's a gradual decline in the beta cell function and and because of this people require insulin to be added yes thank you for answering the question we have a lot of positive comments thank you thank you sir for the session great session so i think we have covered all the sessions we have a request for you to do a webinar in diabetes management a lot of positive comments from our audience uh formula of character calculating egfr uh age and sex wise yeah so we have uh these formula available we could go so with that we have the calculation available for the egfr now uh we have to make it more simple we have these apps available you can download the app and you just need to put in these two or three parameters and you have the egypt calculated for you okay thank you sir one last question sir uh recurrent uti prostitus are these contraindications for sta2 inhibitors yeah they are we could say a relative content indication for hd meters because um these are these can be treated between many effects they can be treated with what we have normal okay thank you sir last so could we take one more question i hope i'm not taking too much of your time [Music] yes sir uh dr digi asks what would be the best painkiller for bone dislocation in type 2 diabetes patients so uh yeah i would i would thank the drive for bringing this uh aspect because uh what we would like to highlight here is that you know uh one of the important causes for uh for ckd inflation with diabetes is is the use of painkillers nsaids so it is preferable to avoid the nsaids because they can respect the real damage renal dysfunction so the safest of them would be would be parasimol and if the pain is more severe i mean like a dislocation and all that you're speaking of there in that situation using uh using the the agents like the ones which are you cannot train and other agents would be better you will not feel uh untrusted these agents are much more better and then using okay so just one one more uh thoughts on lena glypton as monotherapy in hp1c less than eight percent yeah so uh if you look at lena 15 it has a efficacy of bringing down the experience to the tune of about 0.8 to 1 so it can be used in these situations but you know it complements very well with metformin unless the person has product contraindication to mentally using a combination of dna is a better choice but if the person has some some form of intolerance then you may have to use therapy with agent you dr sahai uh these cover all the questions in the comments section we are truly grateful for your time so we indeed had an enlightening session we would be thrilled to have you over again on netflix thank you thank you it's been my pleasure to be here yes sir thank you so much

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