Efficacy and safety of combination of empagliflozin and metformin with combination of sitagliptin and metformin during Ramadan: an observational study

BACKGROUND

Management of diabetes during fasting is a clinical challenge. Sodium glucose co-transporter -2 inhibitors (SGLT2i) are considered safe with a low risk of hypoglycemia. However, studies on SGLT2i are scarce. This study was designed to compare the efficacy, safety, and tolerability of empagliflozin with metformin during Ramadan in comparison with sitagliptin and metformin.

METHODS

It was a prospective, observational study, conducted at 11 different sites all across Pakistan on an outpatient basis during Ramadan (May 2021-June 2021). including 132 patients, 88 who received metformin and sitagliptin, and 44 patients who received metformin and empagliflozin.

RESULTS

Patients of the SGLT-2i group experienced similar symptomatic hypoglycemic episodes (15.9%) as the sitagliptin group. There was an improvement in blood sugar levels after the use of SGLT-2i (RBS 181 ± 64 before Ramadan vs 162 ± 53 after Ramadan). HbA1c also improved after the use of SGLT-2i before and after Ramadan (7.2 ± 0.8 vs 6.9 ± 0.9 for Metformin + Empagliflozin and 7.8 ± 1.5 vs 7.6 ± 1.6 for Metformin and sitagliptin). Weight and BMI improved after the use of SGLT-2i (BMI 36.5 ± 4.8 before Ramadan and 33.7 ± 2.4 after Ramadan). There were no reported cases of urinary tract infection in the empagliflozin group.

CONCLUSION

SGLT-2 inhibitors combined with metformin for patients with diabetes during Ramadan fasting is as effective, safe and well tolerated as DPP4 combined with metformin.

Expert Opinion: Use of sodium glucose co-transporter type-2 inhibitors in South Asian population -The Pakistan perspective

Sodium-glucose co-transporter type 2 inhibitors (SGLT 2- i)are increasingly being used in the management of type 2 diabetes mellitus (T2DM). With the novel insulinindependent glycosuric action, these agents help to attain glycaemic goals by lowering HbA1c and fasting blood glucose. In addition, these agents improve metabolic control in diabetes and ameliorate comorbidities like obesity and hyper tension. Beneficial effec ts on cardiovascular outcomes have been a key attraction for physicians. These agents are used alone or in combination with oral antidiabetic agents and insulin to attain glycaemic and metabolic targets. A major disadvantagewith these agents is the increased risk for genital andurinary infections. When used in appropriate settings, there is no additional increased risk of hypoglycaemia or volume depletion with these agents. Available evidence suggests good efficacy and safety of these agents in diabetes management. The easy and convenient oncedaily dosing should be customized according to patient needs and glycaemic profiles.

Safe and pragmatic use of sodium-glucose co-transporter 2 inhibitors in type 2 diabetes mellitus: South Asian Federation of Endocrine Societies consensus statement

Diabetes prevalence shows a continuous increasing trend in South Asia. Although well-established treatment modalities exist for type 2 diabetes mellitus (T2DM) management, they are limited by their side effect profile. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) with their novel insulin-independent renal action provide improved glycemic control, supplemented by reduction in weight and blood pressure, and cardiovascular safety. Based on the clinical outcomes with SGLT2i in patients with T2DM, treatment strategies that make a "good clinical sense" are desirable. Considering the peculiar lifestyle, body types, dietary patterns (long duration religious fasts), and the hot climate of the South Asian population, a unanimous decision was taken to design specific, customized guidelines for T2DM treatment strategies in these regions. The panel met for a discussion three times so as to get a consensus for the guidelines, and only unanimous consensus was included. After careful consideration of the quality and strength of the available evidence, the executive summary of this consensus statement was developed based on the American Association of Clinical Endocrinologists/American College of Endocrinology protocol.

The obese pregnancy

Weight gain in pregnancy is physiological but if a woman is overweight prior to pregnancy, this will put both women and foetus at risk of adverse complications. Obesity can affect women at all the stages of pregnancy. Obese women can be a cause of reduced fertility as compared to a normal weight woman, and a typical example is of the Polycystic ovarian syndrome (PCOS). The incidence of Gestational Diabetes Mellitus ,hypertension and preeclamsia is 2-3 folds higher in obesity particularly with a BMI of> 30kg/m2. The chances of thromboembolism, miscarriage, Caesarian - section and stillbirth are increased as well. Perinatal mortality, increased chances of genetic disorders of the foetus and macrosomia are all increased with obesity. To avoid all these complications health education regarding healthy life style and diet with regular moderate intensity exercise is the cornerstone of the management.

Place of sulfonylureas in the management of type 2 diabetes mellitus in South Asia: A consensus statement

Since their introduction in clinical practice in the 1950's, Sulfonylureas (SUs) have remained the main-stay of pharmacotherapy in the management of type 2 diabetes. Despite their well-established benefits, their place in therapy is inappropriately being overshadowed by newer therapies. Many of the clinical issues associated with the use of SUs are agent-specific, and do not pertain to the class as such. Modern SUs (glimepiride, gliclazide MR) are backed by a large body of evidence, experience, and most importantly, outcome data, which supports their role in managing patients with diabetes. Person-centred care, i.e., careful choice of SU, appropriate dosage, timing of administration, and adequate patient counseling, will ensure that deserving patients are not deprived of the advantages of this well-established class of anti-diabetic agents. Considering their efficacy, safety, pleiotropic benefits, and low cost of therapy, SUs should be considered as recommended therapy for the treatment of diabetes in South Asia. This initiative by SAFES aims to encourage rational, safe and smart prescription of SUs, and includes appropriate medication counseling.

Frequency of hepatitis C infection in diabetic patients

BACKGROUND

Diabetic patients are at an increased risk of acquiring Hepatitis C virus (HCV) infection owing to the nature of the disease and its inherent complications or frequent parentral exposure. On the other hand HCV infection may itself contribute to the development of Diabetes Mellitus. The epidemiological evidence of this association has not been studied in Pakistan at a population level and its exact biological mechanisms are not obvious. Objective of this study was to study the frequency of HCV infection among adult diabetic patients attending the Hospital.

METHODS

The study comprised of 100 Diabetic patients visiting the out patient clinics or admitted in the medical wards of a Teaching Hospital, in Peshawar. Diabetes was confirmed according to the new diagnostic criteria based on 2 fasting or 2 random plasma glucose levels of more than 126 milligram per deciliter (mg/dL) and 200 mg/dL respectively. The presence of HCV infection was confirmed by Enzyme Linked Immuno-Sorbent Assay (ELISA) method. A concise history of the patient, examination and laboratory findings were recorded on a Performa.

RESULTS

Out of the hundred diabetics, 36% were found to be anti HCV positive and all of them had type II diabetes. There was no gender difference in the seropositive cases. Serum Glutamic-Pyruvic Transaminase (SGPT) level was raised in 75% of the positive cases as compared to the 25% of the seronegative patients. The seropositive cases had a comparatively higher blood sugar level.

CONCLUSION

HCV infection occurs more often in type II diabetics and further investigations should be done in diabetic patients with raised SGPT for the presence of chronic HCV infection.

Glycemic control status in patients with type-2 diabetes

OBJECTIVE

To assess the status of glycaemic control in patients with type-2 diabetes mellitus (DM) in NWFP, Pakistan.

DESIGN

Observational study.

PLACE AND DURATION OF STUDY

Medical Out-patient Department (OPD), Lady Reading Hospital, Peshawar and a private clinic of physician from January 2003 to December 2003.

PATIENTS AND METHODS

Two hundred and ten patients with type-2 diabetes were included in the study. The glycemic control of these patients was determined by estimation of blood glucose (fasting and random) and glycosylated hemoglobin (HbA1c). The patients were grouped in three categories, the 1st one having good glycaemic control, the 2nd having fair (acceptable) glycaemic control and the 3rd group having poor diabetic control with their HbA1c values being 6%-7%, 7.1%-8.2% and >8.2% respectively. Statistical analysis of the results was made by application of Pearson's chi-square test and student's t-test.

RESULTS

Around half, 51.43%, of the patients had poor control of diabetes, with mean HbA1c of 10.183 +/- 1.73 SD (standard deviation) and were placed in category 3. Good control of diabetes accounted for 31.43% of our patients having mean HbA1c of 6.64 +/- 0.27 SD and were placed in category-1. The rest, 17.14%, were placed in fair control category having mean HbA1c value of 7.68 +/- 0.44 SD.

CONCLUSION

Majority of our patients with type-2 diabetes are having poor control of their glycaemic status.