By Dr R M Chhabra, Senior Consultant Physician
Based on 2021 data, the estimated number of individuals with diabetes in India, as per OGTT criteria, was 101 million. Diabetes prevalence varies significantly across regions, ranging from 4.8% in Uttar Pradesh to 26.4% (19.33-33.7) in Goa.
Some of the common challenges for physicians during management include factors such as age (especially among the elderly), diabetes duration, HbA1c control, glycemic variability, weight fluctuations, hypoglycemia, insulin therapy, and comorbidities (cardiac, renal, hepatic, etc.). Additionally, the cost of medical treatment poses another significant challenge.
The primary goals of diabetes management are to maintain near-normal blood glucose levels and prevent micro and macrovascular complications. Effective glycemic control has demonstrated cardio and renal protective effects. Current criteria for diagnosing diabetes involve measuring fasting (60-100 mg%), postprandial (< 200 mg%), and random (<140 mg%) blood sugar levels, along with GTT (glucose tolerance test) and urine examination.
Diabetes management strategies should include lifestyle modifications, including nutrition, exercise, and pharmacotherapy. However, patient compliance and adherence to treatment regimens are crucial for successful management, as non-adherence can lead to uncontrolled hyperglycemia and an increased risk of complications.
Exercise plays a crucial role in diabetes management, yet many individuals in India are not sufficiently active. Unlike in other countries where outdoor activities and regular exercise are common, Indians often lead sedentary lifestyles. This lack of physical activity can hinder the effectiveness of diabetes treatment.
Pharmacotherapy is pivotal in modern diabetes management, alongside exercise and yoga. However, the abundance of anti-diabetic drugs available can make selecting the most suitable treatment daunting. Key considerations include drug efficacy, approval by regulatory authorities like the FDA, and the drug’s ability to control fasting and postprandial blood sugar levels. Additionally, factors such as minimizing hypoglycemia risk, glycemic variability, impact on weight, availability, cost, dosing convenience, and safety concerning renal and cardiac outcomes are crucial.
Currently, anti-diabetic drugs fall into two categories: those acting via the insulin-dependent pathway and those via the non-insulin-dependent pathway. Insulin-dependent pathway drugs such as DPOR, SAR, UA, metformin, etc., sensitize insulin or enhance its secretion, primarily functioning in the intestines and kidneys through the insulin pathway.
On the other hand, non-insulin pathway drugs like SGLT inhibitors induce glycosuria, leading to sugar excretion in urine. However, this characteristic makes them unsuitable for diabetes diagnosis. Understanding hypoglycemia mechanisms is vital for selecting appropriate drugs, considering factors such as decreased insulin secretion due to beta cell damage, impaired incretin effects, etc.
Various drugs, such as SGLT inhibitors, GLP-1 receptor agonists, and DPP-4 inhibitors, target these mechanisms. No single agent can address all disturbances in type 2 diabetes, necessitating combination therapy for optimal glycemic control. Combination therapy initiation is recommended early to delay treatment failure, with guidelines specifying thresholds for initiating dual therapy based on HbA1c levels. Insulin initiation presents challenges due to clinical inertia, patient education needs, fear of hypoglycemia, etc., which must be addressed for effective management and complication prevention.
Dr R M Chhabra is Senior Consultant Physician, Director, Chhabra Medical Centre, Pitampura, Delhi; Saroj Super Speciality Hospital, Shalimar Bagh, New Delhi