Optimizing the treatment of newly diagnosed type 2 diabetes mellitus with combination of dipeptidyl peptidase-4 inhibitors and metformin: An expert opinion.

The expanding burden of Type 2 Diabetes Mellitus (T2DM) in today's world, with respect to incidence, prevalence, and cost incurred, is an existential risk to society. Various guidelines recommend individualization of treatment. This expert opinion aims to review the recent evidences and reach a consensus on the preferable combination therapy for use in newly diagnosed Indian T2DM patients with HbA1C >7.5%. The core committee included seventeen diabetes specialists. Three statements were developed, discussed, and rated by specialists and recommendations were noted. Specialists were requested to rate the statements using a 9-point Likert's scale with score of 1 being "Strongly Disagree" and 9 being "Strongly Agree". Statement-specific scores of all the specialists were added and mean score of ≥7.00 was considered to have achieved a consensus. Statements used to meet the consensus were: Statement 1. Majority of newly-diagnosed Indian diabetics have HbA1C >7.5%; Statement 2. Patients with HbA1C >7.5% may be initiated with dual therapy of dipeptidyl peptidase-4 inhibitors (DPP4Is) + Metformin; and Statement 3. In Indian patients with HbA1C >7.5% at diagnosis, DPP4Is + Metformin may be considered as a first-line therapy. Literature review revealed that HbA1C level at the time of diagnosis in majority of Indian T2DM patients is >7.5%. Consensus was reached that dual anti-diabetic therapy should be initiated in patients with HbA1C >7.5%. DPP4Is + Metformin is the preferred cost-effective option and may be considered as a first-line therapy in Indian T2DM patients with HbA1C >7.5% at diagnosis.

Management of Diabetes during Fasting and Feasting in India.

Fasting and feasting are integral part of many religions and cultures. As the amount of food and fluid intake are markedly altered during these phases, patients with diabetes are prone to higher risk of complications. Even though several guidelines for fasting and feasting are available; Indian specific recommendations are the need of the hour, because of the distinct dietary habits and the diet content (high carbohydrate) of Indians. To fill this void, the current guidelines have been developed by experts from India who extensively reviewed the literature, shared their practical knowledge and ultimately arrived at a consensus.

Clinical practice points for diabetes management during RAMADAN fast.

Diabetes management during Ramadan is very crucial from the patient perspective as it can present significant risk of hypoglycemia and death when proper care is not taken. Moreover, managing diabetes in fasting Ramadan patients require different mechanisms than the routine diabetes management and pose significant challenge to the health care practitioners. Here we set forth to review the available literature of various clinical trials and studies on different antidiabetic agents in the context of Ramadan. On the basis of available evidence, we suggest that gliclazide is effective and it could be safely recommended in type 2 diabetic patients fasting during Ramadan.

Microalbuminuria and left ventricular function in type 2 diabetes: a quantitative assessment by stress echocardiography in the Myocardial Doppler in Diabetes (MYDID) Study III.

BACKGROUND: Left ventricular (LV) function might be altered in type 2 diabetes (DM) and microalbuminuria (MA) may accentuate the abnormalities. We sought to investigate whether additional LV dysfunction could be unmasked using tissue Doppler (TVE)-enhanced dobutamine stress echocardiography (TVE-DSE) in patients with DM + MA. METHODS: Twenty seven DM subjects with MA, (DM + MA), 31 DM subjects without MA (DM - MA), and 13 Controls were evaluated using TVE-DSE. LV basal peak systolic (PSV), early (E') and late (A') diastolic velocities (cm/sec) at rest and peak stress were post-processed. LV filling pressure was assessed using E/E'ratio. RESULTS: PSV and E'velocity at peak stress in the respective three groups were 13.7 +/- 1.0, 10.1 +/- 1.1, 10.0 +/- 1.2 for PSV; and 10.0 +/- 1.6, 5.0 +/- 1.4, 4.8 +/- 1.4 for E' (p < 0.001 for controls vs. both groups). E/E' at rest was 7.9 +/- 0.7 in the controls, 10.8 +/- 2.4 in DM - MA, and 11.0 +/- 2.2 in DM + MA (p < 0.01 Controls vs. both the DM groups). CONCLUSIONS: Patients with DM + MA do not have additional LV regional systolic and diastolic dysfunctions compared with DM -MA, as revealed by TVE-DSE, when controlled for glycemia levels, lipids, and treatment strategies.

Impaired myocardial functional reserve in hypertension and diabetes mellitus without coronary artery disease: Searching for the possible link with congestive heart failure in the myocardial Doppler in diabetes (MYDID) study II.

BACKGROUND: Although the impact of type 2 diabetes mellitus (DM) and hypertension (HTN) on myocardial function has recently been studied using tissue Doppler echocardiography (TDE), the independent role of both conditions, and the influence of other risk factors on myocardial function has not been completely defined, particularly in absence of coronary artery disease (CAD). The aim of this study was to assess the myocardial functional reserve in patients with DM or HTN with apparently normal left ventricular (LV) systolic function. METHODS: Standard and dobutamine stress echocardiography using TDE was performed in 128 subjects: 59 had DM, 20 had HTN, 27 had both DM and HTN (HTN + DM), and 22 subjects were controls (C). Subjects with known CAD and depressed LV function were excluded. In addition, standard two-dimensional and Doppler measurements, LV regional peak systolic (PSV), early (E') and late (A') diastolic velocities, strain (S%) and strain rate (SR), were assessed at rest and peak stress. RESULTS: The LV mass did not differ, although relative wall thickness was significantly higher in subjects with HTN + DM and HTN. The PSV did not differ at rest but was lowest in subjects with HTN + DM at peak stress. The E' wave velocity was significantly lower in subjects with HTN + DM both at rest and during peak stress, as were S% and SR. CONCLUSIONS: The addition of DM to HTN has a negative effect on LV systolic and diastolic functions. A depressed myocardial functional reserve might be postulated as one of the pathophysiologic mechanisms for the excessive occurrence of congestive heart failure in patients with DM or HTN.