Clinical practice recommendations for the detection and management of hyperglycemia in pregnancy from South Asia, Africa and Mexico during COVID-19 pandemic.

The human coronavirus disease 2019 (COVID-19) pandemic has affected overall healthcare delivery, including prenatal, antenatal and postnatal care. Hyperglycemia in pregnancy (HIP) is the most common medical condition encountered during pregnancy. There is little guidance for primary care physicians for providing delivery of optimal perinatal care while minimizing the risk of COVID-19 infection in pregnant women. This review aims to describe pragmatic modifications in the screening, detection and management of HIP during the COVID- 19 pandemic. In this review, articles published up to June 2021 were searched on multiple databases, including PubMed, Medline, EMBASE and ScienceDirect. Direct online searches were conducted to identify national and international guidelines. Search criteria included terms to extract articles describing HIP with and/or without COVID-19 between 1st March 2020 and 15th June 2021. Fasting plasma glucose, glycosylated hemoglobin (HbA1c) and random plasma glucose could be alternative screening strategies for gestational diabetes mellitus screening (at 24-28 weeks of gestation), instead of the traditional 2 h oral glucose tolerance test. The use of telemedicine for the management of HIP is recommended. Hospital visits should be scheduled to coincide with obstetric and ultrasound visits. COVID-19 infected pregnant women with HIP need enhanced maternal and fetal vigilance, optimal diabetes care and psychological support in addition to supportive measures. This article presents pragmatic options and approaches for primary care physicians, diabetes care providers and obstetricians for GDM screening, diagnosis and management during the pandemic, to be used in conjunction with routine antenatal care.

Euthymia in Diabetes: Clinical Evidence and Practice-Based Opinion from an International Expert Group.

AIM: To develop an evidence-based expert group opinion on various types of euthymia associated with diabetes mellitus (DM) and its management. BACKGROUND: Diabetes mellitus is a metabolic syndrome characterized by diverse biomedical and psychosocial features. Emotional health disturbances may lead to psychological and psychiatric dysfunction and may negatively influence glycemic control. Patients with DM may experience diabetes distress (DD) associated with burden of self-care, interpersonal issues, and emotional worries regarding the ability to cope with the illness. Euthymia or a state of positive mental health and psychological well-being should be considered a key outcome of diabetes care. Therefore, to achieve optimal outcomes, the consideration and measurement of psychological and psychiatric aspects along with glycemic levels are very important. A group of multidisciplinary clinical experts came together in an international meeting held in India to develop a workable concept for euthymia in diabetes care. A multidisciplinary approach was suggested to enhance the clinical outcomes and facilitate patient-centered care. During the meeting emphasis was given to the concept of a euthymia model in diabetes care. This model focuses on enhancement of self-care skills in diabetic patients and preventative health awareness among diabetes care providers. Euthymia also encompasses patient-provider communication to aid enhancement of coping skills. RESULTS: After due discussions and extensive deliberations, the expert group provided several recommendations on implementing the concept of euthymia in DM care. CONCLUSIONS: Introduction of the concept of euthymia in routine clinical practice is important to improve the quality of life and coping skills in patients with DM. A timely clinical assessment of psychological and psychiatric aspects along with patient-reported outcomes of diabetes contributes to overall health and well-being of affected individuals. FUNDING: Sanofi India.

Glucocrinology of Modern Sulfonylureas: Clinical Evidence and Practice-Based Opinion from an International Expert Group.

AIM: The primary objective of this document is to develop practice-based expert group opinion on certain important but less discussed endocrine and metabolic effects of modern sulfonylureas (SUs) and their usage in the management of diabetes mellitus (DM). BACKGROUND: Modern SUs may be considered a panacea in DM care with their beneficial extra-pancreatic, pleiotropic, and cardiovascular effects. Safe glycemic control with SUs could be achieved with appropriate patient selection, drug and dosage selection, and patient empowerment. Additionally, sulfonylureas also exhibit certain endocrine and metabolic effects, which could be considered beneficial in the management of DM. In this regard, a group of international clinical experts discussed the less known beneficial aspects of SUs and safe and smart prescription of modern SUs in DM care. RESULTS: The concept of glucocrinology or the relationship of glycemia with the endocrine system was emphasized during the meetings. Clinical experts arrived at a consensus for the usage of modern SUs in the presence of other endocrine dysfunction and the impact of these drugs on endocrine health. The beneficial pleiotropic and cardiovascular effects of modern SUs were also discussed. The key discussion points were considered to develop clinical expert opinions for the use of modern SUs in persons with DM. Clinical expert opinions were developed for indications, pleiotropic benefits, cardiovascular outcomes, adherence, and safe use of modern SUs. CONCLUSIONS: Appropriate clinical judgement coupled with a patient-centered approach is crucial to achieve the best outcome in persons with DM. Owing to their safety, efficacy, extra-pancreatic benefits including effects on endocrine and metabolic aspects, and low cost of therapy, modern SUs could be considered as drugs/agents of choice for the treatment of diabetes. FUNDING: Sanofi India.

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.

Fatty acid composition of erythrocyte phospholipids is related to insulin levels, secretion and resistance in obese type 2 diabetics on Metformin.

BACKGROUND: Relationships between fatty acids in erythrocyte phospholipids and insulin parameters have been described in healthy and overweight individuals, but not in obese diabetics. We assessed whether erythrocyte phospholipid fatty acids are related to insulin parameters in obese type 2 diabetics on Metformin. METHODS: In 23 diabetics, the fractions of the different fatty acids in erythrocyte phospholipids were correlated with insulin levels, secretion, sensitivity, resistance and insulinemic response following a standardised breakfast. RESULTS: Fasting insulin levels and insulin resistance correlated positively with the fraction of alpha-linolenic and dihomo-gamma-linolenic acid and with the ratios of stearic to palmitic and dihomo-gamma-linolenic to linoleic acid and negatively with the fraction of palmitic acid in erythrocyte phospholipids. Insulin secretion correlated negatively with the fraction of palmitic acid. For this parameter, a positive correlation was also found with the sum of uneven fatty acids. Insulinemic response following a meal was negatively associated with the fraction of oleic acid in erythrocyte phospholipids. Insulin sensitivity did not correlate with erythrocyte fatty acids. CONCLUSIONS: The relationships found differ from those described in healthy and overweight individuals and may be characteristic for type 2 diabetics. They concur with the recommendations that saturated fat intake should be reduced and monounsaturated increased.

Medication use and disease management of type 2 diabetes in Belgium.

OBJECTIVE: The aim of this study was (International Diabetes Federation. Diabetes Atlas Second Edition Executive Summary. Brussels: International Diabetes Federation; 2003) to describe the current status of medication use and disease management of type 2 diabetic patients in Flanders (Belgium), (World Health Organization. Prevention of diabetes mellitus. Technical report series no. 844. Geneva: World Health Organization; 1994) to identify the aspects of type 2 diabetes care a community pharmacist could provide additional educational services for, and (American Diabetes Association. Diabetes Care 2006;29:S4-42) to propose these services as a pharmacist intervention. METHOD: We recruited 338 patients in 77 community pharmacies in Flanders (Belgium). Each patient completed a questionnaire collecting personal data, information on duration of diabetes, medication, diabetes symptoms and self-management. At inclusion, patients measured their fasting plasma glucose (FPG) on three consecutive days. Prescription drugs (antidiabetic and other) purchased by each patient during the 12 months prior to inclusion in the study were reviewed from anonymized computerized pharmacy records. MAIN OUTCOME MEASURES: Degree of self-management, glycaemic control and medication use. RESULTS: The mean FPG of the sample was 150.7+/-43.0 mg/dl. Controlled glycaemia (FPG between 90 and 130 mg/dl (5.0-7.2 mmol/l)) was achieved in only 34.9% of the patients. Mainstay of hypoglycemic treatment consisted of metformin monotherapy (29.6%) and metformin combined with sulfonylurea (29.0%). Regarding co-medication, 76.9% of the patients used antihypertensive drugs whereas only 33.1% and 39.9% were on aspirin and statin therapy, respectively. ADA recommendations for annual eye and foot examination were not followed in 38.8% (eye) and 39.2% (feet) of the patients. CONCLUSION: The current management of type 2 diabetic Flemish patients falls short of recommended treatment goals. Community pharmacists may play a role in enhancing the awareness of glycaemic control and in stimulating self-management in diabetic patients by motivating patients towards correct medication use, better medication adherence, healthy lifestyle and smoking cessation.

Quantitative measurement of ketone bodies in urine using reflectometry.

BACKGROUND: Recently, automated urine test strip readers became available that can report quantitative data. We explored the possibility of measuring all ketone bodies (acetone, acetoacetate, 3-hydroxybutyrate) in urine with these test strips. Monitoring urinary ketone concentrations could offer the advantages of measuring higher values (due to the low renal thresholds) and being less sensitive to fluctuations. METHODS: We evaluated URISYS 2400 (Roche) quantitative reflectance data for the ketone reflectance field and compared it with biochemical data from urine samples. Using an easy sample pre-treatment with 3-hydroxybutyrate dehydrogenase, we were able to assay 3-hydroxybutyrate as well, which normally does not react on urine test strips. RESULTS: Within- and between-run reproducibility of the reflectance signal for high- and low-concentration urine pools was 11.0-3.6% and 11.0-5.8% for aceto-acetate, 8.2-9.2% and 10.4-16.1% for acetone, and 5.1-3.0% and 5.6-3.5% for 3-hydroxybutyrate, respectively. The lower limit of detection for acetoacetate was 0.13 mmol/L (CV=3.6%). Fair agreement was obtained between test strip data for ketones andcolorimetrically determined acetoacetate values (r=0.90). CONCLUSIONS: In urine test strip analysis, quantitative ketone reflectance data allow a simple and fast analysis, offering affordable screening for the detection of ketone body production in diabetes, especially in emergency settings.