Effectiveness of Dapagliflozin as Add-On to Metformin with or without Other Oral Antidiabetic Drugs in Type 2 Diabetes Mellitus: A Multicentre, Retrospective, Real-World Database Study

BACKGROUND

Real-world Indian studies evaluating effectiveness of dapagliflozin as an add-on to other oral antidiabetic drugs (OAD) in patients with type 2 diabetes mellitus (DM) are scarce.

METHODS

An electronic medical record (EMR)-based, retrospective, multicentre study was conducted to evaluate the effectiveness of dapagliflozin as add-on therapy in adult patients with inadequately controlled DM on metformin with or without other OAD. Baseline characteristics (visit 1: metformin or metformin plus OAD treatment for at least 30 days) and treatment-related outcomes (visit 2: follow-up) considered between 60 and 140 days after adding/switching dapagliflozin [glycated haemoglobin (HbA1c), body mass index (BMI), systolic blood pressure (SBP) and diastolic blood pressure (DBP)] were analysed.

RESULTS

A total of 3616 patients were screened from 478 centres. Most patients had received dapagliflozin (D) + metformin (M) + at least one other OAD [D + M + OAD, n = 2907 (80.4%), 408 followed-up with HbA1c reported], while 709 patients (19.6%, 138 followed-up with HbA1c reported) received dapagliflozin + metformin (D + M). Treatment with dapagliflozin as an add-on therapy resulted in significant change in HbA1c (-1.1 ± 1.44%; p < 0.05 for HbA1c subgroup ≥ 7.5%; -1.6 ± 1.41%; p < 0.05 for HbA1c subgroup ≥ 8%) at visit 2 compared with visit 1. Significant change in body weight (-1.4 ± 3.31 kg; p < 0.05 for HbA1c subgroup ≥ 7.5%; - 1.5 ± 3.22 kg; p < 0.05 for HbA1c subgroup ≥ 8%) was observed at visit 2. Similarly, a significant change in BMI was noted for the HbA1c subgroup ≥ 7.5% (-1.0 ± 8.38 kg/m2). However, the change in BMI in the HbA1c subgroup ≥ 8% was noted to be -1.4 ± 10.4 kg/m2, which was not statistically significant (p = 0.08). In the overall study population, significant change in the SBP (-4.5 ± 14.9 mmHg; p < 0.05 for HbA1c subgroup ≥ 7.5%; -4.5 ± 15.1 mmHg; p < 0.0001 for HbA1c subgroup ≥ 8%) was observed at visit 2 compared with visit 1. On identical lines, significant change in DBP (-1.5 ± 8.94 mmHg; p < 0.05 for HbA1c subgroup ≥ 7.5%; -1.4 ± 8.91 mmHg; p < 0.05 for HbA1c subgroup ≥ 8%) was noted.

CONCLUSIONS

Dapagliflozin showed significant improvement in glycemic parameter, BMI and BP when added to metformin, with or without other OADs in a real-world scenario.

Genomic revolution: Transforming tuberculosis diagnosis and treatment with the use of Whole Genome Sequencing - A consensus statement

Tuberculosis (TB) is a preventable, treatable, and curable disease. However, in 2020, 9∙9 million people were estimated to have developed tuberculosis, and 1.5 million people were estimated to have died from it. Whereas in India, 2.6 million were diagnosed with TB and 436,000 succumbed to TB in 2019. India (26%) is the major contributor to the global drop in TB cases. The COVID-19 pandemic has substantially reduced access to services for the diagnosis and treatment of TB, resulting in an increase in deaths and a reversal in global progress. [1] Presently, TB incidence is falling at a rate of 2% per year, obstructed mainly by the rearing pandemic of drug-resistant tuberculosis (DRTB). Particularly concerning is multi-drug resistant TB (MDRTB), defined as resistance towards isoniazid (INH) and rifampicin (RIF). [2] The World Health Organization (WHO) targeted to reduce worldwide TB incidence by 90% until 2035. (1) Early initiation of effective treatment based on susceptibility patterns of the Mycobacterium tuberculosis complex (MTBC) is considered key to successful TB control in countries with high DRTB incidence. Worldwide MDRTB treatment outcomes are poor, with cure rates less than 60% (2) due to the lack of comprehensive Drug Susceptibility Testing (DST) in most high MDRTB burden countries. This is leading to the inadequate anti-TB activity of the provided regimens (3-5), unlike regimens advised for DST assure optimal results. (6) In addition to resistances to the established regimens, the resistance to the newer DRTB drugs is increasing. On World TB Day 2022, Academy of Advanced Medical Education, Thyrocare Technologies Limited and HyastackAnalytics - IITB along with expert pulmonologist and renowned physicians from India convened for an advisory board meeting in Delhi on 20th March 2022 to discuss the role of Whole Genome Sequencing (WGS) in the diagnosis and management of TB. Objectives and specific topics relating to WGS in MDRTB were discussed, each expert shared their views, which led to a group discussion with a commitment to putting the patient first, and increasing their collective efforts, the organizations recognized that it is possible to make this goal a reality. The organizations involved in the discussion have declared their commitment to engaging in collaborative efforts to tackle DRTB detection efficiently. They advocate for strengthening access to WGS TB services, controlling and preventing TB, improving surveillance and drug resistance management, and investing in research and development. This Round Table serves as a framework to build on and ensure that the goal of ending TB is achievable with WGS services wherever needed. Post discussion, a uniform consensus was said to be arrived if more than 80% board members agreed to the statement. The present paper is the outcome of aspects presented and discussed in the advisory board meeting.

Post-COVID-19 Arterial Thrombotic Events among Three Major Permutations of COVID-19

BACKGROUND

Post-COVID-19 thrombotic events are a crucial trouble of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, affecting hundreds of thousands of people internationally. Further proof is needed at the chance of putting up COVID-19 thrombotic activities after infection with specific editions of COVID-19. In the gift state of affairs, when the maximum of human beings gets vaccinated, COVID-19 sickness is less likely. However, the remnants of preceding COVID-19 infections are nonetheless a sizeable fitness burden.

METHODS

This prospective, observational, comparative, and analytical look at a total of 3,220 COVID-19 sufferers who visited the medical institution. We covered 1,050 sufferers of α-variants; 1,275 sufferers of δ-variants; 895 sufferers of Omicron variations; from June to November 2020, March to July 2021, and January to April 2022, respectively. The affected person's records concerning demography, clinical profile, comorbidities, the severity of the disorder, clinic stay, and vaccination repute were accrued and all sufferers have been accompanied up for 6 months of duration. The sufferers who evolved post-COVID-19 thrombotic events have been approached to gather records regarding demography, comorbidities, the severity of the disease, and vaccination assay. All accumulated information has been tabulated, compiled, and analyzed to examine the post-COVID-19 thrombotic occasions among exceptional variants of COVID-19.

RESULTS

A complete of 246 (7.48%) patients [190 (14.90%) of the δ-variant, 41 (3.90%) of the α-variant, and 15 (1.68%) of Omicron version] evolved post-COVID-19 thrombotic occasions at some stage in their comply with-up period. In this observation, distinctly popular post-COVID-19 thrombotic occasions changed into coronary artery ailment (50.00%) which turned followed via cerebral vascular sickness (38.61%), abdominal vessels disease (5.69%), and peripheral artery disease (5.69%). These thrombotic occasions were not unique to any variations of SARS-CoV-2. The distinction of implying the age of patients suffering from post-COVID-19 thrombotic activities became statistically giant (p < 0.05) in comparison amongst all versions. At the time of analysis of COVID-19, 86.17% of sufferers with put-up COVID-19 thrombotic occasions had slight to excessive sickness whilst 13.82% had slight to asymptomatic disorder. The common time length to develop and publish COVID-19 thrombotic events for δ 137.18, Omicron 145.18, and α-version turned 149.85 days.

CONCLUSION

Sufferers inflamed with the δ-variant of COVID-19 are greater vulnerable to developing submit COVID-19 thrombotic events with minimum hazard within the Omicron version and intermediate risk within the α-version. The hazard of submitting COVID-19 thrombotic activities is directly proportional to the severity of the sickness.

Intermittent Use of Continuous Glucose Monitoring: A New Paradigm in Treatment of Type 2 Diabetes

OBJECTIVES

To suggest how continuous glucose monitoring (CGM) may be used intermittently in individuals with type 2 diabetes (T2D).

MATERIALS AND METHODS

The use of CGM is largely in those with type 1 diabetes (T1D), in whom it makes sense to use CGM continuously as CGM provides a valuable tool to not only adjust their insulin doses but also to match it with their diet, physical activity, and other lifestyle modifications. In the case of T2D, however, especially for those not on insulin, the use of CGM may not be needed on a continuous basis. The use of CGM on an intermittent basis is rarely discussed in the literature. This article tries to provide clinical situations where CGM can be used intermittently.

RESULTS

Intermittent use of CGM defined as the "use of CGM once in 2 or 3 months or a fixed frequency," and may be useful in several situations in those with T2D. We suggest the following indications for the intermittent use of CGM in T2D-newly diagnosed patients where treatment is being started, uncontrolled diabetes where treatment is being altered, starting intensive lifestyle modification, during infections, during preoperative control, in children and adolescents with T2D, as a motivational tool to improve behavioral modification, after metabolic surgery, and in patients on steroids, apart from other indications.

CONCLUSION

Intermittent use of CGM in T2D can be useful in special situations and can also be cost saving particularly in resource-constrained regions of the world.

An Open-label, Prospective, Multicentric, Cohort Study of Nimesulide/Paracetamol Fixed Drug Combination for Acute Pain Management: Sub-group Analysis

OBJECTIVE

Nimesulide has been evaluated in numerous clinical studies in the management of a variety of acute painful conditions. However, there is limited Indian data available on the nimesulide/paracetamol fixed drug combination (FDC). Hence, an open-label prospective multicentric study was conducted to evaluate the safety and efficacy of this FDC in the management of acute painful conditions in real-world settings.

MATERIALS AND METHODS

A prospective, open-label, and multicenter study conducted at 24 centers across Indian patients with acute painful conditions due to trauma, tendinitis, myalgia, low backache, sprains, pulled muscle, soft tissue injury, dental pain, and dental procedure/surgery. Nimesulide/paracetamol FDC was prescribed by clinicians as a part of routine practice. The effectiveness was evaluated on the numerical rating scale (NRS), that is, pain intensity at rest and movement, and the physician/patient global assessment scale (GAS) among the subgroups of acute painful conditions like myalgia, dental pain, low backache, etc. Hepatic safety was also evaluated among the subgroups at the end of treatment.

RESULT

A total of 464 patients were included in the study. The reduction in NRS score at rest and movement during treatment duration across different types of pain was statistically significant (p &lt; 0.001). Pain reduction was evident as per patient and physician GAS at the end of treatment in all indications. No clinically significant difference was found in liver parameters at the end of the study. Nimesulide/paracetamol (FDC) was well tolerated across all the subgroups.

CONCLUSION

Nimesulide/paracetamol FDC was found to be well-tolerated and effective in pain management across all acute painful conditions in a real-world setting without any hepatic safety concerns.

Post-COVID Syndrome: The Stranger Ghost of Culprit COVID-19

BACKGROUND

Post-COVID syndromes are the most abundant sequel of coronavirus disease of 2019 (COVID-19) infection, which affects millions of people around the whole world. There is a significant difference observed during the acute phase as well as during the post-COVID period between patients hospitalized with (alpha, delta, or omicron) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant. In the present scenario, when most people are vaccinated, COVID-19 disease is less likely, but the remnants of previous COVID-19 infections are still a vast health burden.

MATERIALS AND METHODS

This prospective, observational, comparative, and analytical study included a total of 3,840 COVID-19-infected patients who visited the hospital. We included 1,150 patients of alpha variants, 1,845 patients of delta variants, and 815 patients of omicron variants, from June 2020 to November 2020, March 2021 to July 2021, and January 2022 to May 2022, respectively. All medical data of the study population, including hospital stay and vaccination status, were collected, and all patients were followed up for 6 months of duration. All collected data were compiled and analyzed to compare the post-COVID thrombotic and other events among different variants of COVID-19.

RESULTS

Patients infected during the delta variant are the most symptomatic at onset (higher prevalence of fever, dyspnea, cough, myalgia, headache, or gastrointestinal problems) than those infected with the alpha or omicron variant (p &lt; 0.01). A total of 2,830 patients (7.48%) [1,520 (82.38%) of delta variant, 598 (73.37%) of omicron variant, and 712 (60.34%) of omicron variant] developed post-COVID syndrome during their follow-up period out of 3,220 enrolled patients and the difference was statistically significant when compared among variants (p &lt; 0.05). In this study, the highly prevalent post-COVID syndrome was mucormycosis (11.41%), followed by new-onset diabetes (9.89%), pulmonary fiosis (7.67%), ischemic heart disease (6.46%), ain stroke (3.29%), and other thromboembolic disorders (2.37%).

CONCLUSION

COVID-19-associated onset symptoms during the delta variant were more severe and highly prevalent, while neurological symptoms (aguesia and anosmia) were more common during the alpha variant. Patients infected with the delta variant of COVID-19 are more prone to develop post-COVID-associated complications with minimal risk in the omicron variant and intermediate risk in the alpha variant. Long COVID-19 requires specific attention for management, irrespective of the SARS-CoV-2 variant.

Expert Opinion on the Diagnosis and Management of Male Hypogonadism in India

Male hypogonadism (MH) is a clinical and biochemical syndrome caused by inadequate synthesis of testosterone. Untreated MH can result in long-term effects, including metabolic, musculoskeletal, mood-related, and reproductive dysfunction. Among Indian men above 40 years of age, the prevalence of MH is 20%-29%. Among men with type 2 diabetes mellitus, 20.7% are found to have hypogonadism. However, due to suboptimal patient-physician communication, MH remains heavily underdiagnosed. For patients with confirmed hypogonadism (either primary or secondary testicular failure), testosterone replacement therapy (TRT) is recommended. Although various formulations exist, optimal TRT remains a considerable challenge as patients often need individually tailored therapeutic strategies. Other challenges include the absence of standardized guidelines on MH for the Indian population, inadequate physician education on MH diagnosis and referral to endocrinologists, and a lack of patient awareness of the long-term effects of MH in relation to comorbidities. Five nationwide advisory board meetings were convened to garner expert opinions on diagnosis, investigations, and available treatment options for MH, as well as the need for a person-centered approach. Experts' opinions have been formulated into a consensus document with the aim of improving the screening, diagnosis, and therapy of men living with hypogonadism.

An Expert Group Consensus Statement on "Approach and Management of Prediabetes in India"

The prevalence of prediabetes, a forerunner of diabetes is very high, and its conversion to diabetes is also more rapid among Asian Indians. Prediabetes also predisposes to the development of macrovascular and to a lesser extent of microvascular complications of diabetes. In a large community-based epidemiological study, the Indian Council of Medical Research-India Diabetes (ICMR-INDIAB), data reported an overall prevalence of prediabetes of 10.3%, derived from 15 Indian states. This shows that the diabetes epidemic is far from over as many of them may soon convert to diabetes. Prediabetes, however, should not be considered a path to diabetes rather it should be a window of opportunity for the prevention of diabetes. This early screening, detection, and treatment of prediabetes should be made a national priority. Several countries have introduced lifestyle programs to prevent diabetes and, when indicated, pharmacological intervention with metformin as well. This consensus statement outlines the approaches to screening and lifestyle and pharmacological management of prediabetes in Asian Indians.

Real-world Experience with Favipiravir for Treatment of COVID-19 among Indian Healthcare Professionals

INTRODUCTION

Favipiravir has shown promising results for COVID-19 globally. Though many Indian patients have received favipiravir, there is a lack of realworld data for its clinical use by the practicing physicians. Hence, a qualitative survey was conducted to understand real-world use of favipiravir in management of COVID-19.

METHODS

A cross-sectional, web-based, qualitative survey was conducted between September 2020 to October 2020, among Indian physicians from various specialties involved in COVID-19 care and using favipiravir in their practice. Physicians were provided survey link having a structured questionnaire with 32 questions. They were enquired on- 1) demographics,practice information, 2) place of favipiravir in clinical practice, 3) treatment protocol for mild to moderate COVID-19, 4) dosage and duration of favipiravir, 5) effectiveness of favipiravir, 6) tolerability of favipiravir 7) global efficacy and safety assessment of favipiravir.

RESULTS

A total of 500 physicians were contacted, of which 50 physicians completed the questionnaire. 25(50.0%) were from south zone followed by 12(24.0%) from west. . Majority physicians (47, 97.9%) stated that favipiravir was used for COVID-19 in outpatient setting. Favipiravir was considered as the current drug of choice for ' mild COVID-19 with fever(86.6%). All physicians agreed that favipiravir was being used as per the recommended dose.. A total of 75% & 62.5% physicians agreed to observed clinical improvement by around 3-5 days & 5-7 days in symptomatic mild & moderate COVID-19 respectively.

CONCLUSION

Majority of the physicians considered favipiravir to be safe and effective in treatment of mild to moderate COVID-19.

Changes in HbA1c and weight in people with Type 2 Diabetes after continuous glucose monitoring based Diabefly-Pro digital therapeutics program: Analysis of real-world data (Preprint)

BACKGROUND

Digital therapeutic platforms facilitate health care through patient-centered strategies based on multidisciplinary teams and shared decision-making. Such platforms can be used for developing a dynamic model of diabetes care delivery, which can help in improving glycemic control by promoting long-term behavior changes in people with diabetes.

OBJECTIVE

This study aims to evaluate the real-world effectiveness of the Fitterfly Diabetes CGM digital therapeutics program for improving glycemic control in people with type 2 diabetes mellitus (T2DM) after the completion of 90 days in the program.

METHODS

We analyzed deidentified data of 109 participants in the Fitterfly Diabetes CGM program. This program was delivered through the Fitterfly mobile app coupled with continuous glucose monitoring (CGM) technology. This program consists of 3 phases: the first phase is observation, wherein the patient's CGM readings are observed for 7 days (week 1); the second phase is the intervention; and the third phase aims at sustaining the lifestyle modification introduced during the second phase. The primary outcome of our study was the change in the participants' hemoglobin A_1c (HbA_1c) levels after program completion. We also evaluated the changes in participant weight and BMI after the program, changes in the CGM metrics in the initial 2 weeks of the program, and the effects of participant engagement in the program on improving their clinical outcomes.

RESULTS

At the end of the 90 days of the program, the mean HbA_1c levels, weight, and BMI of the participants were significantly reduced by 1.2% (SD 1.6%), 2.05 (SD 2.84) kg, and 0.74 (SD 1.02) kg/m² from baseline values of 8.4% (SD 1.7%), 74.45 (SD 14.96) kg, and 27.44 (SD 4.69) kg/m² in week 1, respectively (P<.001). The average blood glucose levels and time above range values showed a significant mean reduction by 16.44 (SD 32.05) mg/dL and 8.7% (SD 17.1%) in week 2 from week 1 baseline values of 152.90 (SD 51.63) mg/dL and 36.7% (SD 28.4%), respectively (P<.001 for both). Time in range values significantly improved by 7.1% (SD 16.7%) from a baseline value of 57.5% (SD 25%) in week 1 (P<.001). Of all the participants, 46.9% (50/109) showed HbA_1c reduction ≥1% and 38.5% (42/109) showed weight loss ≥4%. The average number of times the mobile app was opened by each participant during the program was 108.80 (SD 127.91) times.

CONCLUSIONS

Our study shows that participants in the Fitterfly Diabetes CGM program showed a significant improvement in their glycemic control and reduction in weight and BMI. They also showed a high level of engagement with the program. Weight reduction was significantly associated with higher participant engagement with the program. Thus, this digital therapeutic program can be considered as an effective tool for improving glycemic control in people with T2DM.

Rising cost of insulin: A deterrent to compliance in patients with diabetes mellitus

BACKGROUND AND AIMS

The rapid increase in burden of type 2 diabetes mellitus (T2DM), poses a huge medico-economic challenge, especially when the cost of care is funded by out-of-pocket expenses. The aim of this review is to highlight various issues associated with rising cost of insulin, prevalence of cost-related insulin underuse, insulin related cost-saving behaviors, and viable solutions for the benefit of patients with T2DM receiving insulin.

METHODS

Electronic databases (PubMed and Google Scholar) from 2000 to 2020 were searched using the key terms uncontrolled diabetes mellitus, insulin therapy, glycemic control, direct cost, indirect cost, out-of-pocket expenses, cost-related insulin underuse, cost-saving behaviors, and biosimilar insulin in developed countries and India.

RESULTS

In majority of the patients with T2DM on monotherapy, addition of another oral antidiabetic agent is required. Despite these measures, the target glycemic goals are not achieved in majority of the patients resulting in various complications. These complications can be prevented and target glycemic goals can be achieved with early initiation of insulin therapy. However, rising cost is a major deterrent to the lifelong use of insulin. This results in non-compliance and further deterioration of glycemic control. Recently, biosimilar insulins have revolutionized the management of T2DM and look promising from the economic point of view.

CONCLUSIONS

Biosimilar insulins are likely to further enhance the compliance of patients and should be used whenever feasible in patients with DM. However, the patient, along with prescriber should be allowed to make shared, informed decisions regarding the insulin they wish to use.

Assessment of Prevalence and Associated Risk Factors of NAFLD in People Living with Diabetes in India: A Retrospective, Multicenter, Electronic Medical Records Based Study

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) has become a leading cause of liver disease worldwide. The prevalence of NAFLD varies depending on population studied and type of diagnostic tools used to screen or diagnose the patients. There is a strong relationship between metabolic syndrome components and NAFLD prevalence. This study aims to understand the prevalence of NAFLD along with the associated risk factors and their interaction with other comorbidities among people living with diabetes in Indian context.

MATERIALS AND METHODS

It is a retrospective, observational study based on data retrieved from electronic medical records (EMRs) of people living with diabetes from more than 250 individual diabetes centers located in more than 30 cities across 14 states in India. Medical records of 171,996 adults living with diabetes were included in the analysis. The assessment of prevalence of NAFLD in diabetes was done using algorithm based on alanine transaminase (ALT) and aspartate aminotransferase (AST).

RESULTS

Overall, 44.48% of people living with diabetes were found to have NAFLD. A significantly higher proportion of males (58.64%) had NAFLD compared to females (36.91%) (p&lt;0.001). Nonalcoholic fatty liver disease prevalence was &gt;50% in seven of the states. People living with diabetes along with dyslipidemia and hypertension had a significantly higher prevalence of NAFLD (p&lt;0.001). Obesity (57.1%), dyslipidemia (59.1%), and hypertriglyceridemia (42.3%) had significantly higher odds of NAFLD among people living with diabetes.

CONCLUSION

This study highlighted high-risk categories for NAFLD in diabetes, like young, obese, hypertriglyceridemia, poor glycemic control, etc. This information will help health care providers in prioritizing screening among high-risk diabetes population.

Heart Failure with Preserved Ejection Fraction: Management Guidelines (From Heart Failure Association of India, Endorsed by Association of Physicians of India)

Heart failure with preserved ejection fraction (HFpEF) accounts for 15-20% of patients with heart failure (HF) in India. Diagnosis is by clinical features supported by biomarkers and echocardiography. Lifestyle modifications, control of risk factors to optimum levels, and treatment of comorbidities are essential in the management of HFpEF. Spironolactone and sacubitril-valsartan [angiotensin receptor neprilysin inhibitor (ARNI)] are beneficial in subsets of HFpEF, especially with lower range of ejection fraction (EF). Sodium-glucose co-transporter-2 inhibitors (SGLT2i)-empagliflozin and dapagliflozin and probably sotagliflozin are the only currently available drugs which have shown benefits in HFpEF, mostly by reducing hospitalizations. The benefit of SGLT2i is evident in both diabetic and nondiabetic subsets.

Sodium-glucose Cotransporter-2 Inhibitors in Primary and Secondary Prevention of Cardiovascular and Renal Outcomes in Patients with Type 2 Diabetes Mellitus: A Meta-analysis

BACKGROUND

The available evidence was systematically reviewed to evaluate the effects of sodium-glucose cotransporter 2 (SGLT2) inhibitors (SGLT2i) on cardiovascular (CV) and renal outcomes in people with type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease (ASCVD) or multiple risk factors (MRF), with or without heart failure (HF), and per estimated glomerular filtration rate (eGFR) rate at baseline.

METHODS

We comprehensively searched three electronic databases to retrieve publications up to 30th November 2019, which were screened for inclusion. The data extracted for the outcomes according to baseline ASCVD, HF, and eGFR levels were meta-analyzed using fixed effects model.

RESULTS

Of the 735 screened citations, 15 primary and secondary publications from five CV or renal outcome trials were included. SGLT2is reduced the risk of CV death or hospitalization for HF (HHF), HHF alone, and composite renal-specific outcome, irrespective of ASCVD and HF at baseline. The three-point major adverse cardiovascular events (3P-MACE) risk was reduced by 14% (p&lt;0.001) in patients with ASCVD and by 10% (p = 0.018) in those without baseline HF compared with their counterparts. SGLT2is significantly reduced the risk of MACE (18%) in patients with mild kidney dysfunction (eGFR within the range of 60-&lt;90 mL/min/1.73 m2 and &lt;60 mL/min/1.73 m2 ).

CONCLUSION

SGLT2is are effective for both secondary and primary prevention of composite CV outcomes, and secondary prevention of MACE. The upcoming evidence may strengthen the primary prevention benefits of SGLT2is.

Study of the Efficacy of Uptitrating Teneligliptin Dose from Standard Dose (20 mg) to High Dose (40 mg) in Patients with Type II Diabetes Mellitus

AIM

To study the efficacy of uptitrating the dose of Teneligliptin from 20 to 40 mg in patients with type II diabetes mellitus.

METHOD

A retrospective, comparative analysis was undertaken in 853 type II diabetes mellitus patients (499 males and 354 females) who had follow-up records for more than 6 months. These patients were uncontrolled after use of atleast three oral antidiabetic drugs (OADs) and Teneligliptin 20 mg was added as the fourth drug. Patients who remained uncontrolled with the addition of 20 mg of Teneligliptin at the end of 3 months and were switched to receive 40 mg of Teneligliptin daily were included in this study. Results were analyzed at 3 and 6 months to ascertain efficacy of high-dose (40 mg) Teneligliptin. All other OADs remained the same in both groups. In all patients, the fasting blood glucose, postprandial blood glucose, and hemoglobin A1c (HbA1C) were evaluated and compared.

RESULT

A total of 853 patients whose dose of Teneligliptin was increased from 20 to 40 mg were included in the study. At the end of 3 months after using Teneligliptin 40 mg, mean reduction in HbA1C was 0.5% (p-value 0.154). Similarly, mean reduction in fasting blood sugar (FBS) and postprandial blood sugar (PPBS) was 6.5 and 3.6 mg/dL, respectively (p-value 0.234 and 0.143). At the end of 6 months after using Teneligliptin 40 mg HbA1C showed no change but mean FBS and PPBS showed a modest reduction of 14.6 and 14 mg/dL, respectively (p-value &lt; 0.001).

CONCLUSION

The results of our study show that there was no statistically significant improvement in glycemic parameters when dose of Teneligliptin was increased from 20 to 40 mg at 3 months. But at 6 months, the FBS and PPBS showed a modest reduction of 14.6 and 14 mg/dL, respectively (p-value &lt; 0.001) but the HbA1C showed no change.

Monkeypox: What do we know so far? A short narrative review of literature

Monkeypox was a zoonotic infection, first detected in parts of northern Africa in the 1970s. Monkeypoxvirus, the causative agent of monkeypox, is a species of genus Orthopoxvirus and is closely related to long-eradicated smallpox caused by variola virus. Outbreaks in the West (in USA, UK, and Ireland) along with periodic re-emergence of the disease in parts of Africa have generated concern among global health bodies due to the existent deficiency of guidelines for management of the disease. Genetic variations and altered mechanisms favoring better survival of the virus have made early identification of the disease during screening difficult, particularly in resource-limited settings like rural areas of Africa. Through evidences gathered from experimental studies conducted after these outbreaks, the virus is known to be transmitted from several animal reservoirs along with human-to-human contact of blood, body fluids, or aerosol. Early diagnosis through immunoassays and polymerase chain reaction (PCR) tests, although not very specific, allows early treatment and subsequently better patient survival and recovery. Presence of lymphadenopathy along with fever, sore throat, and a vesiculopustular rash is diagnostic. The virus affects the gastrointestinal, hematological, ocular, and respiratory systems, in like manner producing afflictions of the specific system. Treatment, through experimental data, has been preferred to be symptomatic, with the aim to prevent superinfections. Antivirals like cidofovir and tecovirimat have been studied upon and used in clinical trials with favorable outcomes. Antiviral immunoglobulins have also been used with success in certain patients for postexposure prophylaxis.

Clearing the Myths around non-nutritive/noncaloric Sweeteners: An Efficacy and Safety Evaluation

Non-nutritive sweeteners (NNSs) are used to substitute sugar in the diet and are approved by the regulatory bodies in many countries, including the Food and Agriculture Organization (FAO)/the World Health Organization (WHO). Non-nutritive sweeteners are here to stay, as it is an effective strategy to reduce sugar and caloric intake which is a public health priority today. It is a tool to increase dietary compliance in the management of obesity and diabetes and is a partner for fitness seekers. However, the debate on its safety and efficacy continues, including several myths associated with its usage. This review has evaluated the scientific literature in-depth and concludes that NNSs are safe to use within an acceptable daily intake (ADI). Non-nutritive sweeteners are beneficial for their intended use, including weight management and diabetes control when consumed as a part of a dietary management program. The current data do not provide sufficient evidence that NNSs can affect the gut microbiome, and more research, particularly at relevant doses, is required. We also need more randomized control trials (RCTs) among the Indian population on the impact of sugar reduction with NNSs and its health benefits to strengthen the evidence for its use in medical nutrition management and preventive health, helping the individual make an informed choice.

Noninvasive Measurement of Aortic Pressure and Evaluation of Arterial Stiffness in Patients with Hypertension: An Observational Study

AIM

Arterial stiffness, a major marker of vascular impedance, has been identified as a predictor of adverse cardiac outcomes. The present study determined the relationship between blood pressure (BP) and arterial stiffness measured noninvasively using a periscope in hypertensive patients. It has also evaluated the usefulness of indices of arterial stiffness in cardiovascular (CV) risk stratification and the necessity to implement these aortic pressure parameters in clinical practice.

METHODS

The prospective, observational study involved patients with hypertension between the age of 18 and 80 years. The demographic and anthropometric measurements of all the participants were recorded and various central and peripheral (brachial) arterial pressure parameters were measured using a periscope. The clinical variables were compared separately for different CV risk grades and arterial stiffness index (ASI) using Kruskal-Wallis test for non-normal data and chi-square test for count data. The correlation of different parameters with CV risk grade and ASI were evaluated using Spearmen's correlation method. The agreement of different ASI indices with CV risk grades was assessed using Kappa method.

RESULTS

The study recruited a total of 3,032 patients with hypertension. Classification of the subjects for CV risk grades had demonstrated that major proportion of the patients (n = 713) had moderate and severe CV risks (n = 708). The classification of hypertensive patients for arterial stiffness had shown that 1,037 subjects had severe arterial stiffness. Classification of arterial stiffness based on BP levels had demonstrated that 623 patients with severe arterial stiffness and 315 with borderline arterial stiffness had stage II hypertension, and 480 patients with normal BP had no arterial stiffness. Brachial ASI had a strong correlation with systolic BP (SBP). A very good agreement with K value 0.871 was noted for Kappa agreement of arterial stiffness indices with CV risk.

CONCLUSION

The present study corroborates the use of central BP parameters as indicators of arterial stiffness in hypertensive subjects. Noninvasive measurement of these indices has wider implications in personalized risk assessment of CV risk in subjects with hypertension.

Asian Best Practices for Care of Diabetes in Elderly (ABCDE)

The elderly population with diabetes is diverse with the majority experiencing a decline in physical and mental capabilities, impacting the entire diabetes management process. Therefore, a need for geriatric-specific guidelines, especially for the Asian population, was identified and subsequently developed by an expert panel across government and private institutions from several Asian countries. The panel considered clinical evidence (landmark trials, position papers, expert opinions), recommendations from several important societies along with their decades of clinical experience and expertise, while meticulously devising thorough geriatric-specific tailored management strategies. The creation of the ABCDE best practices document underscores and explores the gaps and challenges and determines optimal methods for diabetes management of the elderly population in the Asian region.

Executive summary of evidence and consensus-based clinical practice guideline for management of obesity and overweight in postpartum women: An AIIMS-DST initiative

INTRODUCTION

Postpartum obesity is a public health concern. There is a need to counsel women about their postpartum weight management, accounting for various barriers they face. Limited literature in the Indian context underscored the need to develop the clinical practice guideline to be used by healthcare providers in Indian healthcare settings.

METHODS

The guideline was formulated by following the standardised methodology proposed by the National Health and Medical Research Council. Various steps such as identification of the patient population, assembly of the guideline development groups, identification of the key clinical questions, guideline development methods, grading the quality of evidence and recommendations and guideline translation were carried out to develop and validate the clinical practice recommendations.

RESULTS

The evidence and consensus-based clinical practice guideline has been developed, providing recommendations for key topics of interest for first-line treatment of obesity (lifestyle-related management). Recommendations focus on screening and initiating discussion with overweight and obese postpartum women as well as those who had normal pre-pregnancy body mass index but have retained excessive weight in the postpartum period. Recommendations highlight the evaluation and management of dietary, physical activity and breastfeeding behaviour. Recommendations also account for behavioural modification techniques to improve adherence to the prescribed weight management advice. Duration and frequency of follow-ups as well as the advice to be disseminated have also been discussed in the recommendations.

CONCLUSION

The guideline provides clinical practice points that can be used by healthcare providers, postpartum women and policymakers for opportunistic screening and management of postpartum obesity.

Executive summary of evidence and consensus-based Clinical Practice Guidelines for management of obesity and overweight in midlife women: An AIIMS-DST initiative

BACKGROUND AND AIMS

Weight gain is an independent risk factor for decline in cardiometabolic and overall health-related quality of life in midlife women. The AIIMS-DST initiative aims to develop and validate stepwise recommendations specific for weight management in midlife women.

METHODS

The key clinical questions specific to weight management in midlife women were finalised with the help of a multidisciplinary team of experts in the guideline development group (GDG). Phase I included a systematic and/or narrative review to gather evidence, grading of evidence and expert opinion was sought to develop clinical practice recommendations for each clinical question. Phase II focused on validation of clinical practice recommendations using the peer-review, Delphi method and GRADE approach.

RESULTS

-The guidelines provide clinical practice points to address challenges encountered by midlife women in their attempts to manage obesity via lifestyle modification techniques. The initiation of discussion would help the healthcare provider to identify the weight management needs of the women, educate women on different modalities of weight management, and empower them to incorporate corrective lifestyle behaviours. Before initiating the management, a comprehensive assessment of clinical and lifestylerelated parameters should be completed. A personalised behavioural lifestyle modification program addressing the midlife specific barriers for optimal metabolic, musculoskeletal, and mental health should be planned. A consistent follow-up is required for maintenance of corrective eating and activity habits by addressing midlife specific barriers for sustenance of healthy weight.

CONCLUSION

These recommendations will be useful in opportunistic screening and management of obesity in midlife women across healthcare settings.

Rheumatic Heart Disease in India in 2020: Advances in Diagnostic and Therapeutic Options

Rheumatic Fever (RF)/ Rheumatic Heart Disease (RHD) is the result of autoimmune response triggered by group A Beta-haemolytic streptococcal pharyngitis leading to immune-inflammatory injury to cardiac valves. It is practically disappeared in developed countries. However, it continues to be a major cause of disease burden among children, adolescents, and young adults in low-income countries and even in high-income countries with socioeconomic inequalities. For decades, many cases of Acute Rheumatic Fever (ARF) and RHD were missed and were denied the secondary prophylaxis, as a result these patients used to end up with complications and untimely death. Advanced understanding of the echocardiography can prevent both under diagnosis and over diagnosis and thus help in management strategy. Another new advancement in recent past is the mitral valve repair, which is technically demanding, and the results are acceptable in experienced cardiac surgical units. Whenever feasible, valve repair should be preferred over valve replacement since it precludes the need for anticoagulation and future risks of prosthesis dysfunction.

Biapenem

Biapenem is a novel parenteral broad spectrum carbapenem primarily used for the treatment of complicated infections like sepsis, lower respiratory infections, urinary tract infections, intra-abdominal and genitourinary infections etc. in Japan, Thailand and China since two decades, has been recently approved in India. Biapenem shows good bactericidal activity against Gram-positive bacteria including streptococcus pneumoniae, pyogenes and methicillin-susceptible staphylococcus aureus (MSSA). It also shows antibacterial activities against Gram-negative bacteria including resistant Pseudomonas aeruginosa and Acinetobacter baumannii. Evidence from international studies confirmed that biapenem can be used as effectively and safely as meropenem or imipenem/ cilastatin in the treatment of various infectious diseases. This article summarizes the milestones, unique structure, mechanism of action, pharmacokinetics, special pharmacological properties and spectrum of in vitro activity of biapenem. The results of comparative clinical trials on Biapenem are also described, as is the patient safety and tolerability observed during these studies.

Executive summary of evidence and consensus-based clinical practice guidelines for management of obesity and overweight in midlife women: An AIIMS-DST initiative

Weight gain is an independent risk factor for decline in cardiometabolic and overall health-related quality of life in midlife women. The AIIMS-DST initiative aims to develop and validate stepwise recommendations specific for weight management in midlife women. The key clinical questions specific to weight management in midlife women were finalized with the help of a multidisciplinary team of experts in the guideline development group. Phase I including a systematic and/or narrative review, grading of evidence, and expert opinion was sought to develop clinical practice recommendations for each clinical question. Phase II focused on validation of clinical practice recommendations using the peer-review, Delphi method, and GRADE approach. The guidelines provide clinical practice points to address challenges encountered by midlife women in their attempts to manage obesity via lifestyle modification techniques. The initiation of discussion would help the health-care provider to identify the weight management needs of the women, educate women on different modalities of weight management, and empower them to incorporate corrective lifestyle behaviors. Before initiating the management, a comprehensive assessment of clinical and lifestyle-related parameters should be completed. A personalized behavioral lifestyle modification program addressing the midlife-specific barriers for optimal metabolic, musculoskeletal, and mental health should be planned. A consistent follow-up is required for maintenance of corrective eating and activity habits by addressing midlife-specific barriers for sustenance of healthy weight. These recommendations will be useful in opportunistic screening and management of obesity in midlife women across health-care settings.

Effects of Metabolic Surgery on Diabetic Kidney Disease and Diabetic Retinopathy Among Obese Asian Indians with Type 2 Diabetes

INTRODUCTION

To evaluate the effect of metabolic surgery on microvascular changes associated with diabetic retinopathy (DR) and diabetic kidney disease (DKD) in obese Asian Indians with type 2 diabetes (T2DM), one year after metabolic surgery.

METHODS

This is a follow up study in 21 obese Asian Indians with T2DM who underwent metabolic surgery (MS). Diabetic microvascular complications were assessed before and one-year post surgery using urinary albumin, protein creatinine ratio, eGFR, retinal colour photography and Optical coherence tomography (OCT).

RESULTS

Microalbuminuria (54±26 vs 28±16 vs 21±6 µg/mg, p&lt;0.001) and protein creatinine ratio (0.4±0.1 vs 0.2±0.03 vs 0.1±0.02, p&lt;0.05) reduced significantly 6 months and one year after Metabolic surgery (MS) respectively compared to baseline values. Estimated Glomerular Filtration (eGFR) rate and creatinine was stable and there was no decline in renal function one year after MS. DR was present in eight individuals at baseline. After metabolic surgery, 12 % of individuals achieved regression of DR and 12% individuals showed a one step regression from severe to moderate non proliferative DR while 12 % individuals progressed from moderate to severe non proliferative DR. Of the 14 (53.8%) individuals who had micro or macroalbuminuria at baseline, 43% individuals reverted back to normoalbuminuria. There was also a reduction in the usage of anti- hypertensive medications after MS.

CONCLUSION

In obese Asian Indians with T2DM, metabolic surgery reduced urinary microalbuminuria and protein creatinine ratios at one-year post MS. MS resulted in stable D. Retionpathy status one-year post surgery. MS may help to improve in stabilisation of the microvascular complications in obese patients with T2DM.

Quantifying Remission Probability in Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) is a chronic progressive disorder and is associated with significant morbidity and mortality. The concept of T2DM remission and the reversal of diabetic parameters to normal levels has been gaining momentum over the past years. T2DM remission is increasingly being recognized by various global guidelines. Multiple models have been developed and validated for quantifying the extent of remission achieved. Based on favorable clinical evidence, T2DM remission can be considered as the therapeutic goal in diabetes management and, in select cases, as an alternative to expensive treatment options, which can be burdensome as T2DM progresses. This narrative review discusses the available strategies, such as lifestyle interventions, physical activity, bariatric surgery, medical nutrition therapy, and non-insulin glucose-lowering medications, for achieving T2DM remission. Although the concept of T2DM remission has emerged as a real-world option, effective implementation in routine clinical practice may not be feasible until long-term studies prove the efficacy of different approaches in this regard.

Hypertension in Young Adults in India: Perspectives and Therapeutic Options amongst Clinician's in a Cross Sectional Observational Study

BACKGROUND

The prevalence of hypertension in the young adult population is rising in India. Increased arterial stiffness due to RAAS activation and increased sympathetic overactivity due to stress have been implicated as primary factors for the same. This study was aimed to understand the Indian clinician's perspective on approach to management of hypertension in young adults.

METHODS

A cross sectional observational survey using a structured questionnaire was conducted online with 2287clinicians (cardiologists, diabetologists, consultant physicians and family physicians).

RESULTS

The prevalence of hypertension was 10-30% as per opinion of 64.8% clinicians. The top three risk factors for hypertension in young were perceived to be smoking, mental stress and obesity. Around 57.4% respondents opined that both increased heart rate and systolic blood pressure were markers of sympathetic overactivity. More than 60% respondents across specialities preferred ARBs to treat hypertension in young adults. Amongst the ARBs, telmisartan was the preferred ARB by &gt;80% respondents. Metoprolol was the preferred beta blocker by almost 64% respondents. The objective of selection of beta-blocker by majority of clinicians due to sympathetic overactivity. Telmisartan and Metoprolol single pill combination achieved the BP goal in 40-60% of patients as reported by 41.3% of the physicians. The combination therapy was well tolerated in young hypertensive patients.

CONCLUSIONS

Initiation of an early and appropriate antihypertensive treatment in young population may lower the burden of cardiovascular disease in this population. ARBs and beta -blockers were the preferred class of anti-hypertensive drugs in the cohort of young hypertensive patients .

Management of Hyperglycemia in COVID-19 and Post-COVID-19 Syndrome - Proposed Guidelines for India

SARS-CoV-2 virus spread rapidly all over the globe in 2020 and the second wave has taken our nation, India by storm. The pandemic has posed unique challenges in people with metabolic disorders, including diabetes, hypertension, obesity, pulmonary, cardiovascular, kidney and non-alcoholic fatty liver disease. Uncontrolled diabetes, in conjunction with endocrine, inflammatory and metabolic effects of the infection itself has made management of hyperglycemia in COVID-19 infection particularly challenging. Furthermore, the post-COVID-19 syndrome has also emerged as a sequela in COVID-19 survivors, increasing the risk of death, complications and adding further burden on the health care system. With more than a year of experience, we have gained substantial insight; and now provide practical recommendations on the management of hyperglycemia in COVID-19 as well as post COVID-19 syndrome.

Roadmap for the Management of Acute Undifferentiated Febrile Illness: An Expert Discussion and Review of Available Guidelines

Acute undifferentiated febrile illnesses (AUFIs) are associated with specific characterizations like fever of less than two weeks' duration with no organ-specific symptoms at onset. These range from mild and self-limiting disease to progressive, life-threatening illness. Acute undifferentiated febrile illnesses are classified into malaria and non-malarial illnesses on the basis of microscopy or malariadiagnostic tests. Various challenges, such as comorbidities, geriatrics, pregnancy, and immune-compromised profile of the patient, impede the treatment regimen. Identifying the root cause of undifferentiated fever becomes critical and involves correct diagnostic tests along with empirical treatment initiation. Doxycycline, being a broad-spectrum antibiotic, confers activity against many Gram-positive, Gram-negative, and "atypical" bacteria. Apart from antimicrobial activity, Doxycycline demonstrates the potential to inhibit dengue virus replication and exhibits anti-inflammatory activity by down-regulating proinflammatory cytokine levels. As coronavirus disease 2019 (COVID-19) spreads, the clinical management of associated cytokine storm remains unanswered. Considering the probable beneficial effect of doxycycline, it has been recommended by the national and international experts for the empirical management of COVID-19.

QTc prolongation Safety and Effectiveness of Teneligliptin in Indian patients with type 2 Diabetes Mellitus: A real world study (QSET 2)

AIMS

To evaluate the safety with respect to QTc prolongation and effectiveness of Teneligliptin in Indian Type 2 Diabetes Mellitus (T2DM) patients.

METHODS

Retrospective data of T2DM patients on teneligliptin 20 mg or 40 mg once daily as a monotherapy or add-on therapy and having ECG records (before and after teneligliptin initiation) was collected. Safety was evaluated by change in QTc interval and effectiveness was evaluated by changes in fasting plasma glucose (FPG), postprandial plasma glucose (PPG), and haemoglobin A1C (HbA1c) from baseline to 12-weeks.

RESULTS

There was no significant change in mean QTc interval from baseline [418.68 milli seconds (ms) to 419 ms; mean change +0.33 ms; P = 0.1023] to follow up visit (mean duration 91 days). There was a significant reduction from baseline to 12 weeks in FPG [173.1 mg/dl (9.61 mmol/L) to 128.4 mg/dl (7.12 mmol/L), mean change - 44.64 mg/dl (2.47 mmol/L), P ≤ 0.001], PPG [242.5 mg/dl (13.46 mmol/L) to 176.5 mg/dl (9.79 mmol/L), mean change - 65.93 mg/dl (3.66 mmol/L), P ≤ 0.001], and HbA1c [8.2% (66 mmol/mol) to 7.2% (55 mmol/mol), mean change - 1.00% (10.9 mmol/mol), P ≤ 0.001].

CONCLUSION

Teneligliptin did not cause QTc interval prolongation and was significantly effective in improving glycemic control.

Beneficial Primary Outcomes of Metabolic Surgery with Changes in Telomere Length and Mitochondrial DNA in Obese Asian Indians with Dysglycemia

INTRODUCTION

Although metabolic surgery has been shown to offer beneficial primary outcome results in obese individuals / obese Type 2 diabetes mellitus (T2DM) patients, there is paucity of information on the underlying mechanisms. In the recent years, estimations of non-invasive molecular parameters viz., telomere length and mtDNA copy number (mtDNAcn) assume significance as robust biomarkers. However, there is lack of evidence about this especially, in the Indian context. To assess the changes in the telomere length and mtDNAcn levels after metabolic surgery in obese Asian Indians with dysglycemia along with routine measurements of anthropometry, glycemic/lipidimic parameters and inflammatory markers.

METHODS

This study is a prospective one-year follow-up study of 16 obese individuals with dysglycemia who underwent metabolic surgery at a tertiary diabetes centre in South India. Telomere length, mtDNAcn, serum adiponectin, glycated haemoglobin and high- sensitivity C-reactive protein (hs-CRP) levels were analysed before surgery and at 6 and 12 months after surgery.

RESULTS

There was a significant reduction in weight (p&lt;0.001), BMI (p&lt;0.001), waist circumference (p&lt;0.001), fasting and postprandial glucose (p&lt;0.05), HbA1c (p&lt;0.001), triglycerides (p&lt;0.05), hs CRP (p&lt;0.05) and increase in serum adiponectin (p&lt;0.05) at 6 and 12 months post-surgery compared to the preoperative status. There was a significant reduction in mtDNAcn (p&lt;0.001) and a significant increase in telomere length (p&lt;0.001) at 6 and 12 months post metabolic surgery.

CONCLUSION

We report an increase in telomere length and decrease in circulatory mtDNA copy number levels at 6 and 12 months post metabolic surgery in obese individuals with T2DM in India.

Diabetes in Pre-independence India: Rediscovering a Forgotten Era

Around 300- 400 AD, ancient Indian physicians described a condition akin to diabetes mellitus which was called "Madhumeha". Sushrutha and Charaka, are also credited with describing two types of diabetes which would roughly correspond to type 1 diabetes and type 2 diabetes. However, little is known about the history of diabetes in India between the first and 19th century AD. A thorough search of literature revealed a large number of publications on diabetes from India in the 1800s and early 1900s, mostly from Calcutta and the Madras Presidency, suggesting that the prevalence of diabetes was high in these two places. Building on the observations made by a number of English physicians, Chunilal Bose in 1907 suggested the link between diabetes and lifestyle in India. Amazingly, India did not have to wait long after the discovery of insulin by Banting and Best at Toronto in 1921, to get its own supply. Around this time, Dr. J.P. Bose, eminent physician and diabetologist from Calcutta made remarkable contributions to the study of diabetes in India. He was also the first to describe the dramatic effects of insulin administration to children with type 1 diabetes in India. All these facts have remained largely forgotten which prompted the authors to delve deep into the history of diabetes in pre-independence India. This has led to the unearthing of several pearls of knowledge which are presented in this article as a fitting tribute to the 100th year of Insulin Discovery.

Effectiveness of Nimesulide in Acute Fever Management in Adults: Retrospective Electronic Medical Records Database Study Outcome in Outpatient Department

BACKGROUND

Various clinical trials have established anti-inflammatory and antipyretic properties of Nimesulide in a controlled setting, however, the fever management in real-world settings is quite different.

OBJECTIVE

To assess the effectiveness of Nimesulide in acute fever management in real-world clinical practice.

METHODOLOGY

A retrospective, multicenter study was conducted on electronic medical records (EMR) of 302 patients visiting out-patient departments at three centers between Jan 2016 and Jan 2020 and were prescribed Nimesulide for acute fever. The effectiveness of Nimesulide was analyzed as a change in fever from baseline to follow-up visit within 14 days and tolerability as the number of side effects captured post-Nimesulide ingestion.

RESULTS

The provisional diagnosis at the baseline visit reported major complaints like fever, fever with abdominal pain, body-ache, cough and myalgia. The mean baseline body temperature was 103.2±1.5°F with a mean duration of 4.4±2.8 days significantly (p 0.0001) decreased to 99.7±1.8°F on the administration of Nimesulide. The liver and the renal profiles were found to be normal on records, and the side effects such as nausea and dyspepsia were reported only in 2% of patients.

CONCLUSION

Nimesulide was found to be well-tolerated and effective as an antipyretic for acute fever management in adults during short-term use in real-world clinical practice.

An Assessment of Knowledge, Attitude, and Practices of Physicians in the Management of Hyperuricemia in India: A Questionnaire-Based Study

BACKGROUND

Hyperuricemia is found to be associated with the development and progression of gout, chronic kidney disease, cardiovascular diseases and several others. However, consistent recommendation in the management of hyperuricemia among physicians in India is absent. This study was done to assess the knowledge, attitude, practice (KAP) and barriers in the management of hyperuricemia among physicians in India.

METHODS

A cross-sectional study using a telephonically-administered questionnaire was distributed to 350 physicians treating hyperuricemia patients with co-morbidities like hypertension, diabetes mellitus, metabolic syndrome etc. The questionnaire included 25 questions on qualitative and quantitative aspects. Descriptive statistics were used for demographic characteristics. Inferential statistics (binary logistic regression) was used to identify the relationship between knowledge scores across different physician factors.

RESULTS

A total of 350 responses were obtained with a response rate of 100%. Majority of the physicians (90%) were male and 10% were female with median age of 45.5 ± 12.2 years. Mean scores for knowledge and attitude were 7.4 ± 2.35 and 12.1 ± 1.6, respectively. 66.1% (230) of physicians had adequate knowledge score, while the remaining 33.9% (118) had inadequate score. Irrespective of comorbidity status, no change in the attitude of physicians towards management of hyperuricemia was found.

CONCLUSION

This study demonstrated that the majority of physicians demonstrated adequate level of knowledge, positive/favourable attitude and reported optimal treatment practices for the management of hyperuricemia while exhibiting a few perceived barriers. Nevertheless, facilitating widespread physician awareness about the benefits of optimal management of hyperuricemia is warranted.

SGLT2-inhibition and Vascular Euphoria a Reconciliation of Vascular Health and Disease Homeostasis

The concept of SGLT2-inhibition, once regarded as a non-physiological approach to glycemia control, now finds a foundational relevance in risk-modification for cardiovascular, kidney, and metabolic outcomes, spanning beyond type-2 diabetes. Major studies have proven meaningful improvements in various clinical outcomes, with different SGLT2-i agents. Apart from glycosuria, SGLT2-inhibition is associated with several patho-physiological effects, which may contribute to the clinical benefits seen with these agents. This narrative review is an attempt to appraise the different patho-physiological effects mediated by SGLT2-inhibition, based on contemporary evidence. The review classifies these effects in the acronym of EUPHORIA, and grades the possible relevance of each effect, in improving clinical outcomes.

New and Unique Clusters of Type 2 Diabetes Identified in Indians

Type 2 diabetes (T2D), the most common form of diabetes, is recognized as being a heterogenous disorder, and presents a universal threat to health. In T2D, the pathophysiology and phenotype differ significantly by ethnicity, particularly among Asian Indians, who are known to have the 'Asian Indian phenotype', which makes them more susceptible to develop T2D than white Caucasians. The recent subclassification of T2D into different subtypes or clusters, which behave differently with respect to clinical presentation and risk of developing complications is a remarkable development. Five unique "clusters" of individuals with diabetes were described in the Scandinavian population [Severe Autoimmune Diabetes (SAID), Severe Insulin Deficient Diabetes (SIDD), Severe Insulin Resistant Diabetes (SIRD), Mild Obesity-related Diabetes (MOD) and Mild Age-Related Diabetes (MARD)]. For the first time in India, identification of clusters of diabetes was done on 19,084 individuals with T2D, using 8 clinically relevant variables (age at diagnosis, BMI, waist circumference, HbA1c, triglycerides, HDL cholesterol and fasting and stimulated C-peptide). Four replicable clusters were identified [SIDD, MARD, IROD (Insulin Resistant Obese Diabetes) and CIRDD (Combined Insulin Resistant and Deficient Diabetes)], two of which were unique to the Indian population (IROD and CIRDD). Clustering of T2D helps i) to accurately subclassify diabetes into different subtypes, ii) plan therapies based on the pathophysiology, iii) predict prognosis and prevent diabetic complications and iv) helps in our approach to precision diabetes. Further studies would help us to refine the usefulness of these clusters of T2D particularly in the Indian population, with respect to selection of appropriate therapies and hopefully in the prevention of complications of diabetes.

Real Time Flash Glucose Monitoring: Now a Reality in India

Tight glycemic control has been recognised as the cornerstone of modern diabetes management. Until recently, glycated hemoglobin (HbA1c) was the only reliable tool for measuring glycemic control, but it is not an ideal metric as it is retrospective, unable to pick up hypo- and hyperglycemic excursions and prone to interference by conditions such as anemia and hemoglobinopathies. The advent of continuous glucose monitoring systems is a giant leap in diabetes management as it enables visualisation of glucose trends over periods of time, helping in identification of hypo- and hypoglycemic events and enabling appropriate treatment decisions to be made. The recent launch of the real-time patient CGM in India is a further step in the right direction as it will empower patients to take control of their diabetes by providing them information on their glucose levels and trends in real time.

Role of favipiravir in the treatment of COVID-19

The coronavirus disease-2019 (COVID-19) outbreak all over the world has led the researchers to strive to develop drugs or vaccines to prevent or halt the progression of this ailment. To hasten the treatment process, repurposed drugs are being evaluated. Favipiravir is one such oral drug that was approved for new and reemerging pandemic influenza in Japan in 2014 and has shown potent in vitro activity against severe acute respiratory syndrome coronavirus-2. It has a wide therapeutic safety margin indicated by a wide CC50/EC50 ratio for a high dose. From the clinical studies in COVID-19, it has shown rapid viral clearance as compared to lopinavir/ritonavir (LPV/RTV) and superior recovery rate than umifenovir. Overall, favipiravir has shown promising results in clinical studies in China, Russia, and Japan, and more trials are underway in multiple countries, including USA, UK, and India. Recently, treatment guidelines from many countries and some states from India have included favipiravir in the treatment protocol. This review provides insights into the evidence-based evolving role of favipiravir in the management of COVID-19 infection with emphasis on benefits of initiating an early antiviral therapy with special focus on favipiravir, its pharmacodynamic, pharmacokinetic, in vitro, clinical data, and inclusion in the treatment protocols of COVID-19.

Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective

Diabetes and obesity are both increasing at a fast pace and giving rise to a new epidemic called diabesity. Lifestyle interventions including diet play a major role in the treatment of diabetes, obesity and diabesity. There are many guidelines on dietary management of diabetes or obesity globally and also from South Asia. However, there are no global or South Asian guidelines on the non-pharmacological management of diabesity. South Asia differs from the rest of the world as South Asians have different phenotype, cooking practices, food resources and exposure, medical nutrition therapy (MNT) practices, and availability of trained specialists. Therefore, South Asia needs its own guidelines for non-pharmacological management of diabesity in adults. The aim of the Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective is to recommend therapeutic and preventive MNT in the South-Asians with diabesity.

Cardiometabolic vigilance in COVID-19 and resource husbandry in resource-challenged times: Clinical practice- based expert opinion

BACKGROUND AND AIMS

The ongoing pandemic of coronavirus disease 2019 (COVID-19) is rapidly evolving, thereby posing a profound challenge to the global healthcare system. Cardiometabolic disorders are associated with poor clinical outcomes in persons with COVID-19. Healthcare challenges during the COVID-19 pandemic are linked to resource constraints including shortage of Personal Protective Equipment's (PPE), laboratory tests and medication. In this context, a group of clinical experts discussed the endocrine and cardiology vigilance required in times of COVID-19. Further, the group proposed certain resource husbandry recommendations to be followed during the pandemic to overcome the constraints.

METHOD

The clinical experts discussed and provided their inputs virtually. The expert panel included clinical experts comprising endocrinologists, Consultant Physicians and cardiologists from India. The panel thoroughly reviewed existing literature on the subject and proposed expert opinion.

RESULTS

The expert panel put forward clinical practice-based opinion for the management of cardiometabolic conditions including diabetes mellitus and hypertension. As these conditions are associated with poor clinical outcomes, the expert panel recommends that these persons be extra-cautious and take necessary precautions during the ongoing pandemic. Further, experts also provided appropriate, affordable, available and accessible solution to the resource constraint situations in times of COVID-19 pandemic.

CONCLUSION

The clinical expert opinion put forward in this article will serve as a reference for clinicians treating diabetes and cardiovascular disease during the COVID-19 pandemic.

Insulinization in T2DM with Basal Analogues During COVID-19 Pandemic: Expert Opinion from an Indian Panel

The ongoing global pandemic of the coronavirus disease 2019 (COVID-19) has placed a severe strain on the management of chronic conditions like diabetes. Optimal glycemic control is always important, but more so in the existing environment of COVID-19. In this context, timely insulinization to achieve optimal glycemic control assumes major significance. However, given the challenges associated with the pandemic like restrictions of movement and access to healthcare resources, a simple and easy way to initiate and optimize insulin therapy in people with uncontrolled diabetes is required. With this premise, a group of clinical experts comprising diabetologists and endocrinologists from India discussed the challenges and potential solutions for insulin initiation, titration, and optimization in type 2 diabetes mellitus (T2DM) during the COVID-19 pandemic and how basal insulin can be a good option in this situation owing to its unique set of advantages like lower risk of hypoglycemia, ease of training, need for less monitoring, better adherence, flexibility of using oral antidiabetic drugs, and improved quality of life compared to other insulin regimens. The panel agreed that the existing challenges should not be a reason to delay insulin initiation in people with uncontrolled T2DM and provided recommendations, which included potential solutions for initiating insulin in the absence or restriction of in-person consultations; the dose of insulin at initiation; the type of insulin preferred for simplified regimen and best practices for optimal titration to achieve glycemic targets during the pandemic. Practical and easily implementable tips for patients and involvement of stakeholders (caregivers and healthcare providers) to facilitate insulin acceptance were also outlined by the expert panel. Simplified and convenient insulin regimens like basal insulin analogues are advised during and following the pandemic in order to achieve glycemic control in people with uncontrolled T2DM.

Pre-Basal Insulin Analog Era: Paving the Way for Modern Day Basal Insulins

Prior to the discovery of insulins, diabetes was managed predominantly by dietary interventions. Discovery of insulin and its first human trial highlighted the need for higher purity insulin thereby steering the subsequent journey of insulin development. Considering the limitations of the early preparations like short duration of action and need for several injections per day, attempts at protracting the duration of insulin action were made. This led to the development of intermediate-acting Neutral Protamine Hagedorn (NPH) and the Lente family of insulins. This review provides insights into the discovery of insulins and the shortcomings of early protracted release preparations, which in turn, gave impetus to the search for a 'true' basal insulin, which could mimic the endogenous human basal insulin secretion.

Cardiorenal Syndrome in Type 2 Diabetes Mellitus - Rational Use of Sodium-glucose Cotransporter-2 Inhibitors

Cardiorenal syndrome (CRS) in people with type 2 diabetes mellitus (T2DM) illustrates the bidirectional link between the heart and the kidneys, with acute or chronic dysfunction of one organ adversely impacting the function of the other. Of the five subtypes identified, type 1 and 2 CRS occur because of the adverse impact of cardiac conditions on the kidneys. Type 3 and 4 occur when renal conditions affect the heart, and in type 5, systemic conditions impact the heart and kidneys concurrently. The cardiovascular and renoprotective benefits evidenced with sodium-glucose cotransporter-2 (SGLT2) inhibitors make them a potential choice in the management of CRS. Cardiovascular protection is mediated by a reduction in cardiac workload, blood pressure, and body weight; with improvement in lipid profile, uric acid levels, and adaptive ketogenesis process. Renoprotection is facilitated by reduction in albuminuria and hypoxic stress, and restoration of tubuloglomerular feedback. The favourable effect on cardiovascular complications and death, as well as renal complications and progression to end-stage kidney disease, has been confirmed in clinical trials. Guidelines endorse first-line use of SGLT2 inhibitors after metformin in patients with T2DM with high cardiovascular risk, chronic kidney disease or both. Since most trials with SGLT2 inhibitors excluded subjects with acute illness, patients with CRS subtypes 1 and 3 have not been studied adequately, making SGLT2 initiation in clinical practice challenging. Ongoing trials may provide evidence for SGLT2 inhibitor use in CRS. This review aims to enhance understanding of CRS and provide guidance for judicious use of SGLT2 inhibitors in T2DM.

API-ISG Consensus Guidelines for Management of Gastrooesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common problem in the community. The Indian Society of Gastroenterology and Association of Physicians of India have developed this evidence-based practice guideline for management of GERD in adults. A modified Delphi process was used to develop this consensus containing 43 statements, which were generated by electronic voting iteration as well as face-to-face meeting, and review of the supporting literature primarily from India. These statements include 4 on epidemiology, 9 on clinical presentation, 11 on investigations, 18 on treatment (including medical, endoscopic, and surgical modalities), and one on complications of GERD. The statement was regarded as accepted when the proportion of those who voted either to accept completely or with minor reservation was 80% or higher. The prevalence of GERD in large population-based studies in India is approximately 10% and is probably increasing due to lifestyle changes and increase in obesity. The diagnosis of GERD in the community should be mainly based on presence of classical symptoms like heartburn and sour regurgitation, and empiric treatment with a proton pump inhibitor (PPI) or H2 receptor antagonist should be given. All PPIs in equipotent doses are similar in their efficacy in the management of symptoms. Patients in whom symptoms do not respond adequately to PPI are regarded as having PPIrefractory GERD. Invasive investigations should be limited to patients with alarm symptoms and those with refractory GERD.

Teneligliptin Real-World Effectiveness Assessment in Patients with Type 2 Diabetes Mellitus in India: A Retrospective Analysis (TREAT-INDIA 2)

INTRODUCTION

Teneligliptin is an antidiabetic medication that has been approved for the management of type 2 diabetes mellitus (T2DM) in Japan, South Korea and India. It is one of the most commonly prescribed antihyperglycaemic agents. The aim of this study was to assess the effectiveness of teneligliptin in improving glycemic control amongst Indian patients with T2DM in a real-world setting.

METHODS

This was a retrospective observational study in which a predesigned structured proforma was used to collect information from hospital records of 18 medical centres across India. All participating centres were established primary care hospitals with adequate record keeping, a pre-determined condition in the study design. Data were collected during the period of January 2019 to June 2019. Data extracted from patient records, including glycaemic parameters, concomitant drugs, drug dosage and duration, were collated. The effectiveness of teneligliptin was assessed by analyzing the mean change in glycosylated haemoglobin (HbA1c), fasting plasma glucose (FPG) and post-prandial plasma glucose (PPG) at 12 weeks after initiation of teneligliptin.

RESULTS

Data from 10,623 patients were available for analysis. The mean age of the enrolled patients was 51.86 ± 11.76 years. At 12 weeks after initiation of teneligliptin as monotherapy or add-on to other medications (combination therapy), the patients showed a signficant decrease from baseline in mean HbA1c, FPG and PPG. Mean HbA1c dropped from 8.66 ± 1.15% at baseline to 7.67 ± 1.28% at 12 weeks (71 ± 12.6 to 60 ± 14 mmol/mol), with a difference of - 0.99% (95% confidence interval [CI] 0.96-1.02) or - 10.8 (95% CI 10.5-11.1) mmol/mol (p < 0.0001). The mean reductions in FPG and PPG were 43.12 mg/dL (2.39 mmol/L) and 87.73 mg/dL (4.87 mmol/L) (both p < 0.0001) respectively. HbA1c (%) reductions with teneligliptin when used as add-on to metformin, add-on to metformin + sulfonylurea combination and add-on to metformin + sulfonylurea + alpha glucosidase inhibitor combination were 0.76% (8.3 mmol/mol), 1.24% (13.6 mmol/mol) and 1.04% (11.4 mmol/mol), respectively. Teneligliptin also significantly reduced HbA1c (1.13% or 12.4 mmol/mol, p < 0.0001) in patients with impaired renal function, without worsening the estimated glomerular filtration rate. Teneligliptin consistently reduced HbA1c across all three age categories tested-by 1% (10.9 mmol/mol) in patients aged < 60 years, by 1.15% (12.6 mmol/mol) in patients aged 60-75 years and by 0.88% (9.6 mmol/mol) in patients aged > 75 years.

CONCLUSION

Teneligliptin significantly improved glycaemic parameters in Indian patients with T2DM when prescribed either as monotherapy or as an add-on to one or more other commonly prescribed antihyperglycaemic agents.

Hypoglycemia at the time of Covid-19 pandemic

BACKGROUND

Hypoglycemia is the limiting factor in the glycemic management of diabetes, which need to be addressed critically to avoid complications. Lockdown because of new coronavirus strain (COVID-19) pandemic has further complicated the issue of hypoglycemia due to limitations in access to food, outpatient clinics, pathological services and medicines.

AIM

To assess the factors associated with the risk of hypoglycemia during April-May 2020 lockdown in people with type 2 diabetes mellitus.

METHODOLOGY

We analyzed the data retrospectively from 146 patients of type 2 diabetes mellitus (T2DM) reporting to the emergency department (ED) during lockdown period with symptoms suggestive of hypoglycemia.

RESULTS

The majority of patients were male (90/146) with a mean age of 59.88 ± 10.09 years and a mean random blood glucose level of 57.67 ± 9.00 mg/dL. Two-third of patients (70.83%) had level 1 hypoglycemia, while level 2 hypoglycemia was reported in 29.16% of patients. A combination of Metformin and Sulfonylureas (SU) was most commonly associated with the risk of hypoglycemia (65.75%) followed by insulin (33.56%). Subjects who received insulin reported a lower blood glucose value (50.75 ± 8.20 mg/dL) as compared to those receiving a combination of metformin and SU (60.95 ± 7.10 mg/dl). 330.56% of patients who had received prophylaxis hydroxychloroquine (HCQ) 400 mg twice a day along with the routine anti-hyperglycemic agents without their dose adjustment reported hypoglycemia. Patients with hypertension, micro-vascular, macro-vascular complications, and coexistent with each other had a higher propensity to the risk of hypoglycemia (46.58%, 33.56%, 23.29%, and 32.88%) respectively.

CONCLUSION

The COVID-19 lockdown has shown to influence the risk of hypoglycemia in patients with T2DM, especially those receiving SU, insulin, HCQ especially in patients with associated co-morbidities. Patient education, support, and telemedicine plays a pivotal role to prevent hypoglycemia.