00 : 00 / 05: 00 (Preview)

This discussion has ended. Watch the recording on Medflix app,

Newer Anti-Diabetics

Oct 27 | 1:45 PM

India is home to 77 million diabetics, second highest in the world. Given these figures, there are a slew of novel anti-diabetic drug combinations hitting the market every year. Join us as we learn about these new drugs and their efficacy in diabetes treatment with Dr. Banshi Saboo.

[Music] uh hello good evening everyone i am dr samadhna i welcome you all on behalf of netflix today we have with us dr banji sabu steep diabetologist and chairman of diabetes care and hormone clinic at amthabad he is the vice president of diabetes asia study group and the president of rssdi he is involved in a number of research projects including obesity in children epidemiological diabetes study in gujarat indian heart watch study and others he is given numerous scientific papers at national and international conferences welcome sir and we have our very own doctor made sir who is senior consultant and physician at hct hospital over to you sir good evening welcome everyone sorry to keep you waiting for dr bansi sabu is very very busy persons and hard to get and it's our real good luck that we get him he's the president of rssdi we have been posting the five day marathon we serve is the walter welty 20 club so he's very very busy persons and really we must thank him and if you go on describing his achievements probably all our time will be consumed so we cut short and we can only say that he's a clinician at part human being at part and excellent academicians and he has multiple papers in his pride of india and you ask anybody in the field of diabetology and they would say they're not dr bansi sabor he's my man so is that popular and this topic is also very good and i'm sure you are going to enjoy and learn a lot from him for one top time and because he doesn't want to go into details he said that will not be having the slides but we'll be going straight away with the uh one to one discussion so dr bansi sabu uh your very topic is the newer anti-diabetic drug so i would wish that you enlighten our audience about the newer developments in the field of diabetology and how does it uh help in the practicing clinicians to choose the truth over to your doctor so first of all uh respected dr madhyav i am thankful for your kind words the topic today is newer anti-diabetic agent and to cover it in 30 minutes it is really difficult so we will have a discussion rather than to have a slides format we know that most of those who are joining the meeting may be primary care clinician or primary care physician they would like to know more about these oral anti-diabetes we know that insulin is the oldest agent it was discovered exactly 100 years before so we are not talking about it and then metformin and sulfonylurea was the only molecule which was available to us till 1990 probably the first molecule which was glittazone and carbos egi which started in 90s or late 90s and then we started using those molecules and then things had changed completely so i'll be talking the newer oral anti-diabetic agents versus what was available to us and still they are gold standard it's not like that we are not using in our clinical practice because metformin is still considered as a gold standard molecule to start with the type 2 diabetic patients so before we start that i have to uh tell that you know there are four important clinical trials that happen in diabetes one was uk pds and which you know after uk pds we could understand that intensively controlling diabetes will reduce the complication in person with diabetes so we all clinicians started treating diabetic patients by treating diabetic patient we could understand that we can prevent the complication in diabetic patient so that was the first clinical major trial which explained us that diabetes should be treated and at that point of time it was insulin sulfonylurea and metformin was only available then you know we could understand that how we are treating that also makes difference so it is not just the glucocentric approach which is important it is ten or two please talk to us that it is the even see it is the blood pressure it is the cholesterol it is smoking situation and multiple other risk factors simultaneously to be treated in a diabetic patient but at that point of time still the molecules were the same molecules which we were using the sulfonylurea and metformin and insulin and steroid 2 trial had explained us that yes it is the multiple risk factor which reduces the complication it is not just the a1c control it is the blood pressure cholesterol are also very very important to be controlled it is not only the glucocentric drug but the blood pressure lowering agent include cholesterol lowering agents are equally important then the echo trial had come that intensively controlling diabetes someone after 10 or 15 years of diabetes may not give that much benefit so in 2008 we could understand if somebody is diabetic of 15 or 20 years and now he's uncontrolled he's already having heart disease and now you want to intensively control this guy with the insulin or whatever the newer medication which was available at that point of time actually increases the mortality so we understood that somebody is having a already heart disease and you want to treat it intensively probably it may not benefit in between the same time a story had come that a glitters on molecule at that point of time was very popular so after that the molecule which had come they have to go for a dedicated clinical trial which had to have a cardiovascular outcome trial and now we can say that newer anti-diabetic agents those who have after 2008 after the accord or after the this rosie glitters on the story we can say that glyptines the glypton one glp one which are injectable now but oral glp1 is also coming so i am putting as an oral antidiabetic agent and then sglt2 these three we can put as a newer anti-diabetic agents and before that we could consider them as older but that does not mean they are not used in our therapy we do use and you have to use in a individual patient and you have to very much induce the therapy we can't have a blanket therapy for everyone we have to be very very into last individualistic for one person who is sitting in front of you now after these molecules there was one more very important clinical trial had come which was a cardiovascular outcome data of empire glyphosate and that trial had completely changed the therapy the way we are treating now so it is empire outcome data because simultaneously dpp4 also had come with their cardiovascular outcome trial which out of four dpp four two of had shown that they are non-inferior and two of them had shown slightly increase in hospitalization for heart failure so allogliptin was the first trial which had come to examine and then the sexagliptin trial had come which had also shown there was some increase in hospitalization for heart failure but because and the carmel in a trial of two other glyptians which is had not shown any increase in hospitalization for heart failure but there was no benefit these were the glycemic equipoise what is the meaning of that the two uh arm has to have the similar type of glucose control in both the arm so we cannot say that it is the glucose control is actually favoring the uh that particular molecule or glucose lowering agent is the major reason for them to have a better control is the major reason for them to have a better outcome so both the arms were having similar glucose control and the molecule is specific when it was compared with other flexible control trial they could find out that whether it is really beneficial or not but these two glyphthenes were non-inferior and they were primarily designed for non-infertility they were not primarily designed for superiority so the emperor outcome trial had shown even if the patients who have established cardiovascular disease it has also made the difference as far as their cardiovascular death is concerned overall mortality is concerned or the patient total 4p mays are concerned so this is the first time after the accord we could understand that 15 years of diabetes having heart disease by intensively controlling these patients actually does not improve the outcome while here a molecule had come which is showing that these are the patients actually getting the benefit and they are not only getting the benefit they are not only cv safe it decreased cardiovascular mortality and even all-cause mortality was also then glp-1 also had come with the similar type of data but it is injectable the newer anti-diabetic agents are not only beneficial or preventing but then there is a primary prevention data outcome so whether these molecules can be used in somebody who does not have established cardiovascular disease can we use it at the time of diagnosis or at the time of starting the therapy but at present with established cardiovascular disease now it had become a therapy that should be used after metformin as a first line agent now these are sc lt2 inhibitors so we can say these are the newer anti-diabetes should we call it still newer because now they are six year old 2015 we have started like 2014's almost seven years we are using it but why is still we are calling newer because they are the newer most as far as anti-diabetic therapy is concerned we will be talking what is coming next that we will be talking later on now these newer anti-diabetic agents luckily in last six months available to our country at a very lower cost because most of indian companies have also started making them so now it is available to all of us all primary care physicians can use them they are available at the cost which is almost for other anti-diabetic agent which is costing 5 to 10 rupees or 15 rupees one tablet so that is one part of it it also told us that one thing that a good aggressive control of diabetes is very very important but still if we miss the bus at that point of time if somebody had developed the problems of ckd or somebody had developed the problem of cbd or you are ugly diagnosing them or somebody having a multiple risk factor for developing cardiovascular disease a smoker lipids are high hypertensive family history of cardiovascular disease or there is a micro album you know somebody had developed macro albumin these are the molecules which can prevent the cardiovascular disease because they are the higher risk of developing cbd they are also shown the benefit for renal outcome the renal hard end points are also important here because doubling of serum creatinine is also significantly decrease and then the scientists are you know out of the way they had gone not only for treating diabetic patients even non-diabetic patients who are having heart failure those who are having ckd they started treating these patients with these molecules they were non-diabetes and to the surprise the molecule were using in non-diabetic patients was also decreasing the ckd progression and also decreasing the benefit of this hospitalization for heart failure and cardiovascular death in patients who are even non-diabetic also so these molecules primarily discovered as an anti-diabetic agent used in a patient who are having diabetes with cardiovascular disease or other risk factors for to treat them not only as an anti-diabetic agent but also for treating these complication and then these molecules are now also useful even in non-diabetic patient with c and heart failure now our approach is completely changed yes yeah so if we say that newer that is glyphthenes and sglt2 versus the older ones sulfurism metformin and bioglycosis and agis so what is the main difference is the good part and the bad part of the newer molecule versus the older molecules so sir one biggest difference was we were having glucosamine you know we were trying to control the sugar our approach was let us have a tighter glycemic control and these molecules were very good anti-diabetic effect like sulfonylurea can reduce events you have around 1.5 or in some of the trial up to two the glyptines are also good not so powerful like this but glitter zone had shown a very good reduction in mnc so our approach was very much glucocentric and now we have a approach which is not only a glucose centric but we have to have an approach for a complication prevention so our purpose of treating diabetes even last 50 years we are treating diabetes why we are treating diabetes not for just glucose control we are controlling diabetes because we don't want our patient should go to a nephrologist a cardiologist or he should not develop a complication like that or at least we can prevent or delay the complication so our approach is completely changed but that does not mean you keep the patient as you can see 10 and you have that so glucocentric plus prevention of complication now you are saying what is the main difference between this dpp 4 and this molecule versus the sulfonylurea which we're using the one biggest difference was the hypoglycemia we will also talk there are other agents which does not cause hypoglycemia but sulfonylurea is a molecule very smart otherwise but it decreases the glucose irrespective of whatever the glucose level is there so somebody is a normal diabetic even a non-diabetic or someone have a sugar high it has a tendency to increase the insulin secretion from pancreas if there is pancreas have the insulin and it will increase the insulin secretion and which will lead to the hypoglycemia and hypoglycemia is a limiting factor for us to have a tighter glycemic control hypoglycemia is a sometime it can be dangerous also because it can go below 54 it can go even below 30 and 40 and somebody have like why accord have a higher mortality or why it was stopped prematurely because one of the reason was the patients were getting a lot of hypoglycemia they were put on premix insulin they were put on sulfonylurea in whatever the dose they wanted to use it and that was causing hypoglycemia so these newer molecules dpp4 and sglt2 they don't cause hypoglycemia but at the same time we have alpha glucoside as inhibitor and glutazone also they don't also cause the hypoglycemia so at person hypoglycemia is grenades sulfonylurea and insulin these are the three agents which can cause hypomas second the effect on weight weight gain so the second is problem is the the point which we have to understand is the weight gain if you see the american diabetic association guideline in 2019 they will be talking on three four points the glycemic efficacy the weight gain the hypoglycemia and the cost of medication but these four points were actually after this empire outcome had become secondary the first point had come what is the comorbidity if person is having heart disease or a kidney problem then first you use the molecule which are benefiting or probably preventing or delaying the complication and after this you think of these four problems also the hypoglycemia is a major issue then you think of the the weight gain which is a challenge for many of these anti-diabetes agent and then you think of the cost of the therapy also because in u.s or in uk where everything is insured the physician has to think the cost of the therapy also but we are so lucky that now in india this newer anti-diabetic at least one of these molecule hdlt2 is available to us at a very very cost effective uh you know price which is available to our country so produce some light about the glyptons which are the different types of liptis and do they differ head to head so we have almost all glyptons which are available in the world except few more glyphs might be available in japan but they are not so much studied and we have the glypton which is available to us which is available only in three countries korea japan and india generally which we are using uh in our patients you know number of patients which we are using very high the glyptic which was available to us and then telegraphed in why we started again our country is very very cost sensitive we don't want to use for our patient which is a costly therapy like 60 or 80 rupees was available to us now it is available was 6 or 10 rupees so we started using but it does not have a dedicated cardiovascular outcome data we know that 10 likely also increases the qt interval and qt interval is higher in patients with diabetes it is higher with the patient with hyperglycemia further hypoglycemia will further increase the qt interval then there are some medications which we are also commonly used like you know loans are used which can also lead to hypogly qt interval prolongation so i think we should be very conscious and cautious also while using you particularly internally in the patient with established cardiovascular disease now someone said that i had not seen the patients of dying because of this cutie interval but the person might be dying sudden contact the second is when we are writing qt i mean the generally gripping you are not following the patient same way you are not doing the baseline ecg and we are not measuring the uh every time the patient uh ecg and qt interval also so these are the things someone say that i don't have any experience of i have thousands of pictures to whom i had used and none of them is dying but that is not because you have not done the randomized control time have you checked each and every patient qt interval and have you checked that put interval what is the percentage increase in that and have you compared it with placebo or have you compared it with uh the other glyptic also so i am not going in detail of that but one should be very conscious and cautious about using you have particularly glypton when you are using in the patient with having already arrhythmia cardiomyopathy lv dysfunction patient with using other molecules like digoxin and some of these molecules so one should not use that that's number one the village left in which is also available to us and the builder glypteen is available to us twice daily now some companies had come with a once in a day in india even the originator had also come once in a day we don't know how it had come before before 15 or 20 years it was a molecule which was studied once in a day and they found slightly more hepatotoxicity in phase 2 clinical trial and that was the reason they had come with a 50 milligram twice daily now if they want to do internationally 100 milligram once in a day they have to go again back to the phase 2 trial they have to put it as a new molecule and they have to show that it is not hepatotoxic or the safety data has to be proved so all over the world it is not available as a single dose or only dose but luckily or unlucky in india it is available in a single dose without doing toxicity or safety data they are just showing the efficacy data that 100 milligram sustained release giving the similar efficacy of reduction of a1c so that's one can choose between twice daily or once daily but make sure don't use in the patient with chronic liver disease or don't use this molecule when there is already sdp or residue is high the third molecule is very popular which is again a cetagoleptin in our country which has shown because data non-inferiority data has been rude with that and it is cardiac safe which can be used in our patients who have already established cardiovascular disease but more than that the safety of leaner glyphosate is found even the best part of linagliptin it can be used the same dose can be used in the patient of ckd even up to the end still general this is the same molecule with five milligram you can use we have also allogliptin which is available only in japan and it was available in u.s market and allogliptin is also shown safety but slight increase it had shown actually it was the first leptin had examined trial had shown some increase in hospitalization for heart failure some signal had come actually and saxagliptin had given clear data that there is increase in hospitalization for heart failure we have luckily all these six molecules which are available so you can choose accordingly but the best part of the glyptonin is their side effect profile of glypton is very safe i mean you can safely give somebody a glypt in without worrying of that he is going to call you middle of the night i mean just to write it even the elderly population also it is very safe so from uh young patient to elderly obese to non-obese even it is not causing it is weight neutral and lipid friendly so all the way you can write to all types of patients i can say glyptons for all i mean any diabetic patient you can use the best part is they are the sugar in i mean the insulin increase they also increase the insulin secretion from the pancreas but it is glucose sensitive so somebody of getting hypoglycemia because of glyptons are very very less side effect profile is very less it can be used in elderly patients and during covet time even it is found to be safe during patients with kovid even somebody who is started with first time detected in hospital in hospital first time detected diabetes but not in icu even safely you can start these patients also on riptide so glyptons are very safe and we are using almost like nowadays and even metformin intolerant patients i would like to use glyptic first therapy rather than going for any other thing so sglt2 they are very good but the one of the biggest disadvantages that it actually excrete extra glucose in the unit so one problem is this extra glucose which is coming in the urine can lead to genitomicotic infection more common with the female but male patient also complain and we have to explain the patient about the urine hygiene how they should do it how they should clean the local part that's very important the second is if somebody is having existing urinary tract infection then it is relative contraindication somebody have a severe or infection already then it is definitely contraindicated but history of severe uti which is even upper urinary tract infection is also there then one should be more conscious i mean cautious of using this molecule and in female patients or elderly patients with male or female patient with prostatitis particularly or with prostate hypertrophy i normally get urine routine micro more frequently when i'm using sglt2 we should ask in a leading question also that do you get any problem as far as infection is concerned some patients may complain some may not complain and we must explain the hygiene how to they should keep this infection part as less as possible one word for the glitta zone then the glitter zone is a insulin sensitizer it's very good molecule the disadvantage is weight gain but the advantage is we indians are thin fat indians we are highly insulin resistant and this molecule really improves insulin sensitivity because nowadays we started doing c peptide not for the purpose of uh for clinical management of the patient but to understand that how much hyper insulin is there and by adding the glitter zone you can see that how c peptide levels comes down or it becomes normal also so it's a fantastic molecule but the weight gain is a major challenge now that weight gain challenge is actually by adding the patient on hdlt2 actually it goes away because that weight gain and the fluid retention will not be there but still one more problem those patients who have lv dysfunction it can precipitate hard too then the problem of the elderly female it can also lead to bone fracture so you should not be using this molecule particularly in post menopausal female where it can increase the risk of bone fracture then pioglitazone also have a one very peculiar problem of increasing macular edema so if somebody have retinopathy and you make sure that there is no macular edema otherwise it should be stopped so that is also one of the problem then there was a a article which came in negam which was talking that pioglitazone increases the bladder cancer and then follow-up of these patients also had shown that actually it decreases other type of cancer so in bladder cancer is not very a major challenge for indian patients because we have less incidence of bladder cancer but yes if somebody have unexplained uh hematuria or we should be because nowadays with hdlt2 you might be getting your patients more frequently urinating micro and if you get the there is a rbc try to understand why is the reason for rbc and if it is there then at least you stop biographing that is what at present the black box warning is there in u.s market they are using less but in indian market we are still very comfortable to use this parameter the last part is even with the newer anti-diabetic agents which we are talking i would like to talk about alpha glucosidase agi is very popular in our country and why they are more popular is because we are eating carbohydrate carbohydrate carbs our diet is 65 to 70 percent is carbs and if i take gujarat then i think probably we are most of us are vegetarians and our diet contains more carbs than even any part of country so we eat rice and we eat roti both you know we are eating in equal amounts so that is the reason we are having very carb rich diet and carb rich diet will lead to post wheel glucose peak is very very high so sometimes we achieve a control of 7.5 or even 7 but still the post mean glucose is 200 or 200 plus and that requires a good control by adding alpha glucosidase inhibitor where i don't think these even newer anti-diabetic agents will also have real so after nutrition counseling if you have a patient with post prandtl glucose is not coming down and it is always remain more than 200 i think egi is a good choice but one disadvantage of gastric problem or it is not gi friendly so that's a problem otherwise they are good right so when i'm comparing newer drag and all the drug i always see that all drug have some role to play it is like that you have multiple you know things in your hand so sometimes you need sword and sometimes you need even a simple thing also so i mean you have multiple things like now i am using only on mobile actually i was thinking that i should join with the laptop or desktop so you know it is working only on mobile phone so you need everything for every you know so it has to be very much invisalign you have a patient to whom you have to give only metformin or you have a patient to whom you have to give only agility to for one more word for agility too in 2019 european society of cardiology had come out with a guideline that if somebody have a established cardiovascular disease you should use hdlt2 even before metformin so all guidelines in the world is talking that metformin should be the first anti-diabetic agent to start with the patient but when we are coming with a patient with a established cardiovascular disease who is drug knives you are seeing a patient first time in patient sugar had come 200 but unluckily patient is having cardiovascular disease i think before starting metformin you start the patient on hdlt to inhibitor that is what european society of cardiology is saying and it is endorsed by european association of study of diabetes and we all believe that because the benefit of this molecule is so high then we should use this molecule as a first add-on or as a first line therapy also in patients with established cardiovascular diseases excellent we have covered practically everything there are few questions and comments in the comment sections one of the uh member wanted to know about the eu glycemic diabetic ketosis with the use of sclt2 so hdlt2 inhibitor working with extra glucose going out from the body so someone can have a diabetic ketoacidosis because glucose getting down and down but the the system is not getting sufficient amount of the glucose inside the system and fat will have uh this ketone body will be formed but some amount of this eu glycemic ketosis some ketone bodies are actually wise in heart failure because they are giving a alternate uh energy which they are going to get from the ketone and probably that is also a mechanism for them to have a benefit of hospitalization for heart failure is decrease but when the ketone bodies are high enough and it can lead to a eu glycemic diabetic ketosis we see in a patient with severe insulin deficient diabetes some of these patients who are sid or patient of lada or misdiagnosis type 2 actually they are insulin deficient we try to control them with the hdlt2 we are decreasing the dose of insulin and ultimately they develop diabetic ketosis but the glucose level for these patients may be absolutely normal so before some time you used to understand that somebody have a 350 sugar then can have the acetone in the body but here you can have a patient with 150 or even 120 still you're the patient may have acetone of 60. so eu glycemic diabetic ketosis isn't a a complication a known complication with patient but these are the normally patient who are insulin deficient they should not be started with sglt2 inhibitor as a therapy of choice right for the postgraduate students who might be attending the eu glycemic ketoacidosis can also occur in pregnancy with diabetes and also in people who are alcoholic this just a question that sometimes they ask and very importantly whenever the patient is known as glt when if he has diarrhea vomiting or dehydration we have to keep in mind that he could be having an acidosis and get the acetone and we should stop hdltd for the time being in fact that was the citizens when the kovitz started coming initially that we should be very careful in using sglt2 with kovit right and so otherwise also in acute problems we should stop it is better to stop for a few days before you know then one of the member wanted to know about repeating about the molecules which can cause hypoglycemia potential so so sulfonylurean glynides so sulfonylurea mean glyphizite glybenclamide glimepride and gliclazite these are the four glenites we have repuglianite and even netting glennid is also available in our country so these are the oral antidiabetic agents we can call they can oral hypoglycemic agent we started calling everyone but hypoglycemic agents which can lead to hypoglycemia other than that insulin definitely can lead to hypoglycemia it could be basal it could be premix or co-formulation they can also lead to hypoglycemia but if patient is already on sulfonylurea and on insulin and you add any other anti-diabetic occasion correct it can precipitate so you know the person was on seven html c with sulfonate and you want to add this patient on hdlt2 it will precipitate the hypoglycemia hypoglycemia might be because of sulfonylurea but precipitating factor was hdlt2 so if i am adding sglt2 i have to either remove or i have to you know decrease the dose of the molecule also that's very good that's a very very important take on message that when the patient is on drugs which normally don't cause hypoglycemia can still cause hypoglycemia of their another drug simultaneously receiving sulfonylureas or insulin so that's very very important point i think we must keep that in mind and particularly patients who are on fasting or they then also we have to be very careful in using this drug so whatever take on the periodic fasting that many of the communities whether chains or ramadan and all what are your drugs of choice amongst the newer drugs so sir first and foremost thing in india you know people do fasting without asking the doctor and that should not be advisable i mean we should tell them you can do the fasting but plan the fast thing first thing should be plan even for one day 10 day or 30 days whatever the fast which you do and you please go and meet your doctor how to start when to start whether you are fit for fasting or not what type of fasting which you are going to do whether you are one time you are going to like intermittent fasting not eating after five or six o'clock so what type of fasting which is important if somebody is on these anti anti-hyperglycemic agent which will not cause hypoglycemia i may not worry of that much but if i am using insulin or if i am using the patient on a sulfonylurea type of drug then the things are to be completely changed because otherwise it can lead to severe hypoglycemia and they may require even hospitalization also right and we know that most of the drugs have a long half-life so there is no point in asking the previous day just one day before starting the fasting that what should i change so that's very very important again that we have got to have a planned fasting or changing the dose of medications not only the anti-diabetic blood he might be on anti-hypertensive medicines also and so many other medicines so it's very very important that whenever the diabetic patients undergoes any plant fasting for a prolonged period he or she should consult his doctor it's very very important and amongst the sglt2 is there a preference for one of the like whether it is an empaglyphozine had shown that you know most of hdlt2 they are almost same like the empire outcome had shown a significant benefit in compared to other agility too but when it had come with emperor and and upper heart failure the dapper heart failure had shown the dapper is more beneficial in compared to the emperor so now it we could understand that most of these sglt2 they are giving the similar type of benefit but that does not mean i can extrapolate the same benefit for remo also because that does not have any clinical trial but at present i can say this more or less these all three sclt2 inhibitors are working similarly and their benefits are also more or less same see so i may not go for a this preference only i should use only this molecule if i am using a patient on an apoglyclogen he's having heart failure i will continue i will not go with that i have an empire outcome data is better so i should change it what are your drugs of choice if the person is diabetic and obese or he wants to lose weight that was one of the questions glp one analog will be definitely so now we will be talking about the future near future we are going to have a oral glp one which is sigma glutathione is coming to our market maybe january and we will have that molecule with us and it's a glp1 analog only problem is the cost the second is the gastric problem or the second and third person is the injectable so one of the problem will go away after oral sema glutathione because now it is available in oral form but still the cost of the therapies itself is a major challenge and glp have a typical effect of that gastric fullness is there and many of our patients they are not ready to accept that fact that they consider it's a side effect rather it is the effect of the molecule so we have to explain the patient that you know this is effect this is not the side you uh please try to understand that this is the effect of the molecule and by this effect only you are going to lose the weight i do have any idea or experience about non-allopathic drugs being used to control the diabetes that is one of the questions asked by one of the members sir there are 200 halves which have been tried by icmr in a different stages and many clinical trials have happened in india if any molecule has to become as an anti-diabetic agent the hb1c reduction should be more than 0.5 we know that even placebo can have a effect up to 0.3 so that is the reason none of these herbs is been identified even icmr had tried to combine different molecules also i i mean these different hubs to give the therapy like as an anti-diabetic agent but none of these molecules could reduce uh in a hb1c of more than 0.5 and this is the short trial of 12 weeks even better than that even the sarro glitters are and bromocriptine and hydroxychloroquine could reduce the hpvc of more than 0.5 and that is the reason in india they have to be approved in agent even you and me as a clinician may not be using it more often as an anti-diabetic agent but none of these herbs is being clinically proved that they can reduce the events of more than 0.5 i'm glad that you already covered sarah blaser because that was one of the questions asked about something about sarah clitazore as you said that it is a double dpr gamma and alpha and so it works but its main effect is on the triglycerides and nafld and it's insulin sensitizer so it has to have some benefit on this right right and one of the members wanted to know about the nepa glyphosate in an urad crystals excretion so any idea about it is a ureco-cyric agent and that is also beneficial so it decreases the uric acid and that is the reason for these molecules can be used as an urecosoric agent but not primarily because we have our carb rich country you know so we have many of our patients who have high uric acid and i will be you know when you use the hlt2 and if you follow these patients you will find that uric acid is also decreasing uric acid is also indirect marker of inflammation it is also a marker where the more cardiac problems can occur i mean i have people are sometimes there i don't want to take the protein because my uric acid is six but primarily having uric acid high because of high calf because of his sedentary lifestyle and because of inflammation so if we make the persons more healthier by giving a better diabetes control and particularly like sclt2 inhibitor which will also decrease the uric acid inflammation will go away as uric acid will be absolutely fine i mean i don't think the protein will increase right so you have practically covered everything in the time and i know you are very hurry and already programs lined up behind do i summarize that in treatment of diabetes glucose is not the only parameter we need to see their other com morbid conditions and whether what is the status of the heart and the kidney and the retina and we also have to combine as many drugs as required for the control of different parameters but as of now we don't have multiple combinations so what is the last thing that how many drugs you can combine at a time so once he had to leave i suppose he just is busy with another program i can just sum up that in treatment of diabetes the newer as well as all older molecules also have their place important thing is that we have to be very aggressive in the initial five years when we try to bring down hp1c to less than seven as far as possible and we have to be very rational when the patients is more than 15-20 years of diabetes and when he has got many other comorbid conditions may be retinopathy or cardiac involvement then our target of hb1c control may be relaxed to 7.5 to 8 but very importantly whenever the patient's hb1c is more than nine or he's symptomatic the first drug of choice has to be offered is insulin so insulin still remains the drug of choice but because the patient doesn't want insulin it's a brick that we have to start with the molecules we can start with more than one molecule at a time that's the new take that initially we used to think that we have to start with the lifestyle modifications and diet and all and then met four minutes after three months but now we don't need to wait when the initial hb1c is more than seven point five or eight we start better with the combinations of metformin plus either glyptons or the normal sclt2 individual so that's what we start and that's what we practice uh in the clinic also and he has covered everything and we thank all the participants who remain in the large number till the last minute and we'll be bringing many such uh experts on our dies thank you good night and over to you oh thank you so much sir for a wonderful discussion

BEING ATTENDED BY

Dr. Anbu Anbu & 1807 others

SPEAKERS

dr. Banshi Saboo

Dr. Banshi Saboo

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

+ Details
dr. Rohan Desai

Dr. Rohan Desai

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

+ Details
dr. Mahadev Desai

Dr. Mahadev Desai

Senior Consultant Physician | Ahmedabad

+ Details
dr. Samadnya D

Dr. Samadnya D

Dentist, MBA in Hospital and Healthcare Management. “Be like a Stem Cell, differentiate yourself from others”

+ Details
dr. Banshi Saboo

Dr. Banshi Saboo

Chief Diabetologist & Chairman of Diabetes Ca...

+ Details
dr. Rohan Desai

Dr. Rohan Desai

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

+ Details
dr. Mahadev Desai

Dr. Mahadev Desai

Senior Consultant Physician | Ahmedabad

+ Details
dr. Samadnya D

Dr. Samadnya D

Dentist, MBA in Hospital and Healthcare Manag...

+ Details

About Medflix

Medflix is a new platform by PlexusMD, India's most active and trusted doctor community. On Medflix, you can discover live surgeries, discussions, conferences and courses from some of the top doctors and institutions across the world. Join clubs in your areas of interest and access hundreds of amazing live discussions everyday.