Consensus on "Basal insulin in the management of Type 2 Diabetes: Which, When and How?"

INTRODUCTION: Type 2 diabetes mellitus (T2DM) has attained epidemic proportions and continues to increase despite the availability of a number of oral antidiabetic medications and major advances made in insulin delivery since its discovery nearly a hundred years ago. One, amongst many other reasons responsible for the inability to achieve adequate glycaemic control in a substantial proportion of T2DM patients is the delayed initiation and inappropriate intensification of insulin treatment. Appropriate initiation and intensification of insulin is critical for the successful achievement of tight glycaemic control. OBJECTIVE: To provide simple and easily implementable guidelines to primary care physicians on basal insulin initiation and intensification, along with use of basal insulin in special situations (hepatic failure, renal failure and gestational diabetes mellitus). METHODS: Each consensus statement on basal insulin initiation, intensification and use of basal insulin in special situations was evaluated for dosing and titration based on established guidelines, data from approved pack inserts, prescribing information or summary of product characteristics for each insulin type, and published scientific literature. These evaluations were then factored into the national context based not only on the clinical experience of the expert committee representatives' but also based on the common therapeutic practices followed in India to successfully achieve optimal glucose control. RESULTS: Recommendations on initiation and intensification of basal insulin, and its use in special situations, have been developed. The key recommendations are to initiate basal insulin when 2 or 3 oral antidiabetic medications fail to achieve target glycaemic control, or in symptomatic patients with glycated haemoglobin value greater than 9%. Depending upon patient characteristics, any of the four available basal insulins [Neutral protamine Hagedorn (NPH), Glargine (IGlar), Detemir (IDet), Degludec (IDeg)] can be used. However, IDeg has a longer duration of action, comparatively lesser hypoglycaemia (both overall and nocturnal) and more flexibility in administration timing compared to IGlar) and IDet. Inability to maintain glycaemic control should lead to prompt intensification of basal insulin treatment by adding mealtime insulin, consisting of one to three injections of either rapid-acting insulin analog or regular insulin; depending upon patient characteristics, intensification can also be achieved by transition from basal insulin to twice daily premixed insulin analogs/premixed human insulin/insulin co-formulations. IDeg/IDet can be used in all grades of renal and hepatic impairment; and IDet has been approved for use in gestational diabetes mellitus. CONCLUSIONS: We hope that these consensus based recommendations shall be a useful reference tool for health care practitioners and help them in initiating and intensifying insulin therapy in T2DM patients in order to achieve optimal glycaemic control.

Merits and Demerits of Selective Isolation of Superspreaders: A Mathematical Modeling Study Based upon West Bengal (India) SARS-COV 2 Data.

CONTEXT: All COVID cases and their contacts are considered highly infectious requiring isolation, which blocks the COVID isolation beds and disrupts life in the community. AIM: To find out the effect of selective isolation and contact tracing of superspreaders as compared with the conventional ongoing protocol. SETTINGS AND DESIGN: A mathematical model was designed to look at the effect of isolation and contact tracing of only those with high viral loads (superspreaders) on COVID-19 bed occupancy and overall mortality, in comparison with conventional protocol of isolation and contact tracing of all cases. MATERIALS AND METHODS: An agent-based model, calibrated to the ongoing West Bengal COVID-19 data, was run for a total of 178 days to find out the effect of the interventions on COVID-19 bed occupancy and mortality. RESULTS: There is an impressive reduction in the occupancy of COVID isolation beds, even with the preintervention testing rate with no negative impact on mortality. CONCLUSIONS: Strict isolation of superspreaders only, maybe highly effective in reducing the burden on health care and solving the COVID isolation bed crises if the testing rate is significantly increased.

Management of asymptomatic hyperuricemia: Integrated Diabetes & Endocrine Academy (IDEA) consensus statement.

AIM: The definition and management of asymptomatic hyperuricemia has been an area of controversy for many decades. Debate persists regarding the benefit of treating all cases of asymptomatic hyperuricemia and hence, unsurprisingly there are no clear clinical practice guidelines from our country. PARTICIPANTS: Ten members consisting of eminent physicians, endocrinologists, nephrologist and a rheumatologist were selected by the Integrated Diabetes & Endocrine Academy (IDEA) for a closed meeting with the aim to come to a consensus. EVIDENCE: A literature search was performed using PubMed and Cochrane library following which published articles in indexed peer review journals were selected. CONSENSUS PROCESS: Each participant voiced their opinion after reviewing the available data and a consensus was reached after three meetings by voting. CONCLUSION: Recommendations were made on important areas such as definition, investigation and management of asymptomatic hyperuricemia.