Metabolic non-communicable disease health report of India: the ICMR-INDIAB national cross-sectional study (ICMR-INDIAB-17).

BACKGROUND: Non-communicable disease (NCD) rates are rapidly increasing in India with wide regional variations. We aimed to quantify the prevalence of metabolic NCDs in India and analyse interstate and inter-regional variations. METHODS: The Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study, a cross-sectional population-based survey, assessed a representative sample of individuals aged 20 years and older drawn from urban and rural areas of 31 states, union territories, and the National Capital Territory of India. We conducted the survey in multiple phases with a stratified multistage sampling design, using three-level stratification based on geography, population size, and socioeconomic status of each state. Diabetes and prediabetes were diagnosed using the WHO criteria, hypertension using the Eighth Joint National Committee guidelines, obesity (generalised and abdominal) using the WHO Asia Pacific guidelines, and dyslipidaemia using the National Cholesterol Education Program-Adult Treatment Panel III guidelines. FINDINGS: A total of 113 043 individuals (79 506 from rural areas and 33 537 from urban areas) participated in the ICMR-INDIAB study between Oct 18, 2008 and Dec 17, 2020. The overall weighted prevalence of diabetes was 11·4% (95% CI 10·2-12·5; 10 151 of 107 119 individuals), prediabetes 15·3% (13·9-16·6; 15 496 of 107 119 individuals), hypertension 35·5% (33·8-37·3; 35 172 of 111 439 individuals), generalised obesity 28·6% (26·9-30·3; 29 861 of 110 368 individuals), abdominal obesity 39·5% (37·7-41·4; 40 121 of 108 665 individuals), and dyslipidaemia 81·2% (77·9-84·5; 14 895 of 18 492 of 25 647). All metabolic NCDs except prediabetes were more frequent in urban than rural areas. In many states with a lower human development index, the ratio of diabetes to prediabetes was less than 1. INTERPRETATION: The prevalence of diabetes and other metabolic NCDs in India is considerably higher than previously estimated. While the diabetes epidemic is stabilising in the more developed states of the country, it is still increasing in most other states. Thus, there are serious implications for the nation, warranting urgent state-specific policies and interventions to arrest the rapidly rising epidemic of metabolic NCDs in India. FUNDING: Indian Council of Medical Research and Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Macronutrient Recommendations for Remission and Prevention of Diabetes in Asian Indians Based on a Data-Driven Optimization Model: The ICMR-INDIAB National Study.

OBJECTIVE: To derive macronutrient recommendations for remission and prevention of type 2 diabetes (T2D) in Asian Indians using a data-driven optimization approach. RESEARCH DESIGN AND METHODS: Dietary, behavioral, and demographic assessments were performed on 18,090 adults participating in the nationally representative, population-based Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study. Fasting and 2-h postglucose challenge capillary blood glucose and glycosylated hemoglobin (HbA1c) were estimated. With HbA1c as the outcome, a linear regression model was first obtained for various glycemic categories: newly diagnosed diabetes (NDD), prediabetes (PD), and normal glucose tolerance (NGT). Macronutrient recommendations were formulated as a constrained quadratic programming problem (QPP) to compute optimal macronutrient compositions that would reduce the sum of the difference between the estimated HbA1c from the linear regression model and the targets for remission (6.4% for NDD and 5.6% for PD) and prevention of progression in T2D in PD and NGT groups. RESULTS: Four macronutrient recommendations (%E- Energy) emerged for 1) diabetes remission in NDD: carbohydrate, 49-54%; protein, 19-20%; and fat, 21-26%; 2) PD remission to NGT: carbohydrate, 50-56%; protein,18-20%; fat, 21-27%; 3 and 4) prevention of progression to T2D in PD and NGT: carbohydrate, 54-57% and 56-60%; protein, 16-20% and 14-17%, respectively; and fat 20-24% for PD and NGT. CONCLUSIONS: We recommend reduction in carbohydrates (%E) and an increase in protein (%E) for both T2D remission and for prevention of progression to T2D in PD and NGT groups. Our results underline the need for new dietary guidelines that recommend appropriate changes in macronutrient composition for reducing the burden due to diabetes in South Asia.

A Practitioner's Toolkit for Polycystic Ovary Syndrome Counselling.

Polycystic ovary syndrome (PCOS), a frequently occurring health issue, has a significant effect on the cosmetic, metabolic, psychosocial and fertility aspects of women. A multidisciplinary team approach based on the core pillars of screening, assessment and counselling to detect, prevent and treat physiological and psychological issues in PCOS is very essential. Women are treated medically, but the psychosocial part is often forsaken. Hence, counselling forms an integral part of PCOS management that enables enhanced clinical outcomes and patient satisfaction. Digital tools and PCOS support groups have built an opportunity for physicians to create awareness, help timely diagnosis and overcome PCOS symptoms. The absence of clear guidelines to tackle the often less discussed aspects of PCOS warrants the need for consensus on PCOS counselling. This review summarizes the biopsychosocial health, clinical assessment and treatment strategies of PCOS and associated co-morbidities. The review article will discuss the clinician's role in patient education with the special focus on counselling of females with PCOS regardless of age group.

Atherosclerosis and Associated Cardiovascular Risk Factors in Nonalcoholic Fatty Liver Disease and Metabolic Syndrome.

OBJECTIVES: Nonalcoholic fatty liver disease (NAFLD) is a well-known contributor for the development of cardiovascular disease (CVD). Nonalcoholic fatty liver disease is considered as the liver component of metabolic syndrome (MetS). This study aimed to assess the influence of NAFLD and MetS on markers of subclinical atherosclerosis, including carotid intima-media thickness (CIMT), ankle-brachial pressure index (ABI), and to investigate the impact of NAFLD and MetS on left ventricular (LV) diastolic and systolic function. STUDY DESIGN: A case-control study. MATERIALS AND METHODS: In this case-control study, 120 cases and 90 healthy controls in the age group ranging from ≥18 to ≤65 years were included. Metabolic syndrome was assessed using International Diabetes Federation (IDF) criteria. Height, weight, waist circumference, body mass index (BMI), and blood pressure were measured. Liver ultrasonographic scanning was used for assessing fatty liver. To assess atherosclerosis, CIMT and ABI were used. RESULTS: The prevalence of NAFLD was 66.7%. As compared with control subjects, patients with NAFLD had a significantly greater (p = 0.02) mean CIMT while in patients with MetS, it was not significant. Left ventricular diastolic and systolic function were significantly impaired (p = 0.03, p = 0.04, respectively) in NAFLD while only LV diastolic function was significantly (p = 0.04) impaired in MetS. There was a strong positive correlation between CIMT and triglyceride (TG) (r = 0.46, p = 0.0001), total cholesterol (TC) (r = 0.47, p = 0.0001), low density lipoprotein cholesterol (LDL-C) (r = 0.46, p = 0.0001), very low density lipoprotein cholesterol (VLDL-C) (r = 0.259, p = 0.001), BMI (r = 0.21, p = 0.003), and age (r = 0.22, p = 0.002). CONCLUSIONS: Carotid intima-media thickness, ABI, and LV diastolic function were affected in patients with NAFLD and MetS.

Achievement of guideline recommended diabetes treatment targets and health habits in people with self-reported diabetes in India (ICMR-INDIAB-13): a national cross-sectional study.

BACKGROUND: There is little information on comprehensive diabetes care comprising glycaemic, lipid, and blood pressure control in India; therefore, we aimed to assess the achievement of treatment targets among adults with self-reported diabetes. METHODS: The Indian Council of Medical Research (ICMR)-India Diabetes (INDIAB) study is a cross-sectional, population-based survey of adults aged 20 years or older in all 30 states and union territories of India. We used a stratified multistage sampling design, sampling states in a phased manner, and selected villages in rural areas and census enumeration blocks in urban areas. We used a three-level stratification method on the basis of geography, population size, and socioeconomic status for each state. For the outcome assessment, good glycaemic control was defined as HbA1c of less than 7·0% (A), blood pressure control was defined as less than 140/90 mm Hg (B), and the LDL cholesterol target was defined as less than 100 mg/dL (C). ABC control was defined as the proportion of individuals meeting glycaemic, blood pressure, and LDL cholesterol targets together. We also performed multiple logistic regression to assess the factors influencing achievement of diabetes treatment targets. FINDINGS: Between Oct 18, 2008, and Dec 17, 2020, 113 043 individuals (33 537 from urban areas and 79 506 from rural areas) participated in the ICMR-INDIAB study. For this analysis, 5789 adults (2633 in urban areas and 3156 in rural areas) with self-reported diabetes were included in the study population. The median age was 56·1 years (IQR 55·7-56·5). Overall, 1748 (weighted proportion 36·3%, 95% CI 34·7-37·9) of 4834 people with diabetes achieved good glycaemic control, 2819 (weighted proportion 48·8%, 47·2-50·3) of 5698 achieved blood pressure control, and 2043 (weighted proportion 41·5%, 39·9-43·1) of 4886 achieved good LDL cholesterol control. Only 419 (weighted proportion 7·7%) of 5297 individuals with self-reported diabetes achieved all three ABC targets, with significant heterogeneity between regions and states. Higher education, male sex, rural residence, and shorter duration of diabetes (<10 years) were associated with better achievement of combined ABC targets. Only 951 (weighted proportion 16·7%) of the study population and 227 (weighted proportion 36·9%) of those on insulin reported using self-monitoring of blood glucose. INTERPRETATION: Achievement of treatment targets and adoption of healthy behaviours remains suboptimal in India. Our results can help governments to adopt policies that prioritise improvement of diabetes care delivery and surveillance in India. FUNDING: Indian Council of Medical Research and Department of Health Research, Ministry of Health and Family Welfare.

Prescribing Patterns and Response to Antihyperglycemic Agents Among Novel Clusters of Type 2 Diabetes in Asian Indians.

Aim: To assess the prescribing patterns and response to different classes of antihyperglycemic agents in novel clusters of type 2 diabetes (T2D) described in India. Materials and Methods: We attempted to replicate the earlier described clusters of T2D, in 32,867 individuals with new-onset T2D (within 2 years of diagnosis) registered between October 2013 and December 2020 at 15 diabetes clinics located across India, by means of k-means clustering utilizing 6 clinically relevant variables. Individuals who had follow-up glycated hemoglobin (HbA1c) up to 2 years were included for the drug response analysis (n = 13,247). Results: Among the 32,867 participants included in the study, 20,779 (63.2%) were males. The average age at diagnosis was 45 years and mean HbA1c at baseline was 8.9%. The same four clusters described in India earlier were replicated. Forty percent of the study participants belonged to the mild age-related diabetes cluster, followed by insulin-resistant obese diabetes (27%), severe insulin-deficient diabetes (21%), and combined insulin-resistant and insulin-deficient diabetes (12%) clusters. The most frequently used antihyperglycemic agents were sulfonylureas, metformin, and dipeptidyl peptidase-4 inhibitors apart from insulin. While there were significant differences in HbA1c reduction between drugs across clusters, these were largely driven by differences in the baseline (pretreatment) HbA1c. Conclusions: In this new cohort, we were able to reliably replicate the four subtypes of T2D earlier described in Asian Indians. Prescribing patterns show limited usage of newer antihyperglycemic agents across all clusters. Randomized clinical trials are required to establish differential drug responses between clusters.

Variations in glycated haemoglobin with age among individuals with normal glucose tolerance: Implications for diagnosis and treatment-Results from the ICMR-INDIAB population-based study (INDIAB-12).

AIM: To report on glycated haemoglobin (HbA1c) values among individuals with normal glucose tolerance (NGT) at different age groups, using data acquired from a large national survey in India. MATERIALS AND METHODS: Data on glycaemic parameters at different age groups were obtained from the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study, in adults aged ≥ 20 years representing all parts of India. Age-wise distribution of HbA1c was assessed among individuals with NGT (n = 14,222) confirmed by an oral glucose tolerance test using the World Health Organization (WHO) criteria. Results were validated in another large epidemiological study (n = 1077) conducted in Chennai, India. RESULTS: Among NGT individuals, HbA1c increased gradually with age from 5.16 ± 0.71% (33 mmol/mol) in the age group of 20-29 years to 5.49 ± 0.69% (37 mmol/mol) in those aged 70 + years. In the validation study, conducted in another study population, HbA1c was 5.35 ± 0.43% (35 mmol/mol) in age group of 20-29 years and 5.74 ± 0.50% (39 mmol/mol) in those aged 70 and above. In the INDIAB study, for every decadal increase in age, there is a 0.08% increase in HbA1c and this increase was more significant in females (females: 0.10% vs. males: 0.06%) and in urban (urban: 0.10% vs. rural: 0.08%) population. CONCLUSIONS: HbA1c levels increase steadily with age. This suggests that age-specific cutoffs be used while utilizing HbA1c to diagnose diabetes and prediabetes, so as to minimize the risk of overdiagnosis and unnecessary initiation of treatment in elderly people who could have physiological increase in HbA1c levels.

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.

Clinical Evidence of Evogliptin plus Metformin in Management of Type 2 Diabetes mellitus.

Achieving adequate glycemic control in type 2 diabetes mellitus (T2DM) remains a difficult but achievable goal. Oral agents (OADs) are important option for management of T2DM. Most T2DM patients require more than one medication for adequate glycemic control. Metformin based combination therapy is recommended when monotherapy is insufficient. Evogliptin is a recently developed dipeptidyl peptidase-4 (DPP-4) inhibitor, which can to be combined with metformin for treating T2DM. Combination therapy of Evogliptin and Metformin lowers blood glucose via augmentation of insulin secretion, suppression of glucagon secretion, and insulin sensitization. Co-administration of Evogliptin and Metformin showed no clinically relevant pharmacokinetic differences compared to the administration of each drug alone. Combination therapy of Evogliptin and Metformin also provides significantly better glycemic control compared to the respective monotherapies. Efficacy and safety of Evogliptin and Metformin had been demonstrated in several multicentre randomized clinical trials conducted in various countries like South Korea, Russia and India. Consequently, fixed dose combination (FDC) of Evogliptin and Metformin is approved in South Korea and India. Complexity of the treatment regimen and polypharmacy are well-known factors of poor medication adherence and FDCs have the potential to improve adherence by reducing the pill burden. Adoption of this combination therapy in clinical practice for management of T2DMs will provide a greater degree of HbA1c reduction than that observed with the use of either drug as monotherapy, and is unlikely to cause significant hypoglycemia. Combination therapy of Evogliptin and Metformin is a promising strategy in the treatment of T2DM.

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.

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.

Challenges in Women with Diabetes During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has created significant challenges for healthcare systems across the world. The disease seems to infect men and women in equal numbers, though trends suggest that men have greater morbidity. This has been attributed to differences in immunological response, expression of angiotensin-converting enzyme 2 (ACE2), prevalence of comorbidities, and health-related behaviours, such as smoking. However, this cannot be taken to mean that women are somehow protected. Advanced age, smoking, diabetes, hypertension, cardiovascular disease and chronic obstructive pulmonary disease have emerged as the leading contributors to increased morbidity and mortality from the disease. Women with diabetes form a vulnerable group as they often receive suboptimal diabetes care and support, even though they have a high burden of comorbidities and complications. While there are challenges in healthcare delivery during the pandemic, cardiometabolic care cannot be compromised, which calls for exploring new avenues of healthcare delivery, such as telemedicine. Pregnant women with diabetes should continue to receive quality care for optimal outcomes, and the psychological health of women also needs special consideration. The management of hyperglycaemia during COVID-19 infection is important to reduce morbidity and mortality from the infection. The gendered impact of outbreaks and quarantine goes beyond biomedical and psychological aspects, and the socioeconomic impact of the pandemic is likely to affect the long-term care of women with diabetes, which creates an urgent need to create effective policies and interventions to promote optimal care in this vulnerable group.

Metabolic Diseases and Associated Complications in Patients with Psoriasis.

BACKGROUND: Psoriasis patients are at increased risk of developing metabolic diseases. Proinflammatory cytokines such as IFN-γ, IL-17, IL-23, and TNF-α,IGF that are increased in psoriasis play an important role in the development of diabetes mellitus(DM), hypertension, dyslipidemia, obesity, insulin resistance and their complications. AIMS: To study prevalence of insulin resistance (IR) using HOMA-IR index in psoriasis patients and its association with severity of psoriasis. To study prevalence of metabolic diseases, macro and microvascular complications of these diseases in psoriasis. MATERIALS AND METHODS: A hospital based case control study was conducted involving 102 psoriasis patients and 102 age and sex matched controls. All patients were analysed for the presence of metabolic diseases and their complications. RESULTS: Mean age of cases was 38.41±16.37 years. Majority of cases(58.8%) as well as controls (55.9%) were males. Prevalence of hypertension, prediabetes, DM, raised TG, low HDL, MetS and IR was 46.1%, 28.4%, 27.5%, 42.2%, 31.4%, 31.4% and 48% respectively in cases as compared to 26.5%, 13.7%, 11.8%, 24.3%, 16.7%, 10.8% and 26.5% respectively in controls. However there was no significant difference in obesity (29.4% vs 21.6%, p=0.2024) and LDL among the cases and controls(14.7 %vs 10.8%,p= 0.4). Prevalence of all the metabolic disorders except LDL was significantly higher in cases as compared to that in controls. Prominent complications noted were retinopathy, neuropathy and CVD. With increased psoriasis severity insulin resistance increased. CONCLUSION: There is a positive correlation of psoriasis with IR and it is associated with increased risk of metabolic diseases and their complications.

Assessment of Glycemic status, Insulin Resistance and Hypogonadism in HIV Infected Male Patients.

OBJECTIVES: The aim of the present study was to assess the glycemic status measured as Fasting Plasma Glucose (FPG) and glycosylated haemoglobin (A1C); prevalence of Insulin Resistance (IR), hypogonadism and to study their correlation with CD4 (CD4 lymphocyte) counts in HIV infected patients receiving ART. Correlation between percentage android fat and IR was also studied. METHODS AND MATERIALS: 84 HIV male patients as diagnosed by ELISA test aged 18 to 70 years were included in this case control study. Software IBM SPSS 20.1 and Microsoft Excel 2013 was used for analysis of data. The numerical data was compared using two tailed student t-test. Log transformation was used for the conversion of qualitative data (% android fat) to quantitative data so that it can be correlated to HOMA-IR. The level of significance was considered 0.05. RESULTS: Out of total 84 patients, 19 had FPG ≥ 100. 11(13%) had Impaired Fasting Glucose (IFG) and 8 (9.5%) had Diabetes Mellitus (DM). 20 patients had A1C > 5.6. Nine (10.7%) patients had Impaired Glucose Tolerance (IGT) and 11 (13.1%) patients had DM on the basis of A1C. 11 (13.1%) patients had DM based on either FPG or A1C criteria. Patients with higher percentage android fat had significantly higher IR. 33 (39%) patients had hypogonadism, six patients (7.1%) had primary hypogonadism; 24 (28.6%) had secondary hypogonadism and 3 (3.6 %) had compensatory hypogonadism. CONCLUSION: Patients with lower CD4 counts had significantly higher dysglycemia and IR. Serum testosterone levels were progressively lower (insignificant) with decreasing CD4 counts.

A Practitioner's Toolkit for Insulin Motivation in Adults with Type 1 and Type 2 Diabetes Mellitus: Evidence-Based Recommendations from an International Expert Panel.

AIM: To develop an evidence-based expert group opinion on the role of insulin motivation to overcome insulin distress during different stages of insulin therapy and to propose a practitioner's toolkit for insulin motivation in the management of diabetes mellitus (DM). BACKGROUND: Insulin distress, an emotional response of the patient to the suggested use of insulin, acts as a major barrier to insulin therapy in the management of DM. Addressing patient-, physician- and drug-related factors is important to overcome insulin distress. Strengthening of communication between physicians and patients with diabetes and enhancing the patients' coping skills are prerequisites to create a sense of comfort with the use of insulin. Insulin motivation is key to achieving targeted goals in diabetes care. A group of endocrinologists came together at an international meeting held in India to develop tool kits that would aid a practitioner in implementing insulin motivation strategies at different stages of the journey through insulin therapy, including pre-initiation, initiation, titration and intensification. During the meeting, emphasis was placed on the challenges and limitations faced by both physicians and patients with diabetes during each stage of the journey through insulinization. REVIEW RESULTS: After review of evidence and discussions, the expert group provided recommendations on strategies for improved insulin acceptance, empowering behavior change in patients with DM, approaches for motivating patients to initiate and maintain insulin therapy and best practices for insulin motivation at the pre-initiation, initiation, titration and intensification stages of insulin therapy. CONCLUSIONS: In the management of DM, bringing in positive behavioral change by motivating the patient to improve treatment adherence helps overcome insulin distress and achieve treatment goals.

Utility of Precision Medicine in the Management of Diabetes: Expert Opinion from an International Panel.

AIM: The primary objective of this review is to develop a practice-based expert group opinion on the role of precision medicine with a specific focus on sulfonylureas (SUs) in diabetes management. BACKGROUND: The clinical etiology, presentation and complications of diabetes vary from one patient to another, making the management of the disease challenging. The pre-eminent feature of diabetes mellitus (DM) are chronically elevated blood glucose concentrations; however, in clinical practice, the exclusion of autoimmunity, pregnancy, pancreatic disease or injury and rare genetic forms of diabetes is crucial. Within this framework, precision medicine provides unique insights into the risk factors and natural history of DM. Precision medicine goes beyond genomics and encompasses patient-centered care, molecular technologies and data sharing. Precision medicine has evolved in the field of diabetology. It has helped improve the efficacy of SUs, a class of drugs, which have been effectively used in the management of diabetes mellitus for decades, and it has enabled the expansion of SUs use in diabetes patients with genetic mutations. REVIEW RESULTS: After due discussions, the expert group analyzed studies that focused on the use of SUs in diabetes patients with genomic variations and rare mutations. The expert group opined that SUs are important glucose-lowering drugs and that precision medicine helps in improving the efficacy of SUs by matching them to those patients who will benefit most. CONCLUSION: Precision medicine opens new vistas for the effective use of SUs in unexpected patient populations, such as those with genetic mutations.

Diabetes and COVID-19: A Review.

Coronavirus Disease 2019 (COVID-19) is an emerging disease and since its first identification in Wuhan, China, in December 2019, there has been a rapid increase in cases and deaths across the world. COVID-19 has been shown to have an immense impact in infected persons with diabetes, worsening their outcome, especially in elderly, smokers, obese, those having CVD, CKD, poor glycemic control and long duration of diabetes. In this review we summarize the current understanding of `the impact of COVID-19 on diabetes and discusses the pathophysiological mechanisms and management of diabetes and its complication in this scenario.

Therapeutic Experience of Saxagliptin as First Add-on after Metformin in Indian Type 2 Diabetes Patients: A Non-interventional, Prospective, Observational Study (ONTARGET-INDIA).

INTRODUCTION: Dipeptidyl peptidase 4 (DPP4) inhibitors are widely used in type 2 diabetes mellitus (T2DM) patients but the data available in existing clinical trial programmes on DPP4 inhibitors include limited number of patients from India. Hence, this study attempted to understand usage, efficacy and safety of saxagliptin as first add-on after metformin in Indians with T2DM. METHODOLOGY: It was a multicenter, prospective, non-interventional and observational study planned to enrol T2DM patients who were inadequately controlled with metformin alone and had been recently (i.e., within past 15 days) prescribed saxagliptin as an add-on to metformin. Type 1 diabetes mellitus, use of glucose lowering drugs apart from metformin or saxagliptin, pregnancy, lactation, and medical condition, which could interfere with safe completion of the study were excluded. RESULTS: A total of 1109 participants (658 men and 451 women) with mean ± SD age of 51.17 ± 11.85 years were enrolled from 50 centres throughout India. Significant reduction was observed in mean ± SD change of HbA1c as - 0.86% ± 1.76 from baseline to after 3 months of therapy (P < 0.0001). The quality of life assessed by World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire was reported to be "good" or "neither good nor bad" by majority of the participants at baseline and after 3 months of treatment. A total of 15 adverse events (AEs) were reported in the study, however, no serious adverse event (SAE) occurred during the study. All AEs were of mild intensity and did not require any intervention. CONCLUSION: Overall, saxagliptin in combination with metformin was generally well tolerated in Indian T2DM patients and new safety event identified is an increased risk of hospitalisation in heart failure patients. This study is also registered on Clinicaltrials.gov (NCT02588859).