SGL2 Inhibitors in 2020

Dr KK Aggarwal

President CMAAO and HCFI

In 2020, the American Diabetes Association is making two paradigm-shifting recommendations in the treatment of type 2 diabetes.

1.      Prescribe Sodium glucose co-transporter 2 (SGLT2) inhibitors or glucagon-like peptide 1 (GLP-1) receptor agonists to patients at high risk for atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, in addition to patients with already established disease, as previously recommended.

2.      Consideration for use of those drugs be independent of the patient's baseline A1c or individualized A1c target. Previously, additional pharmacologic agents were recommended only when A1c was above target despite using first-line metformin and lifestyle interventions.

Atherosclerotic CV Disease: Add Empagliflozin

Heart Failure: Empagliflozin, canagliflozin or dapagliflozin. For patients with heart failure with reduced ejection fraction (HFrEF) who have persistent symptoms and an elevated serum natriuretic peptide level on optimal pharmacologic and device therapy, add dapagliflozin.

CKD:  Canagliflozin in patients with diabetes and proteinuria: In patients with type 2 diabetes who have nephropathy (urine albumin excretion >300 mg per day) and eGFR >30 mL/min per 1.73 m², add Canagliflozin (CREDENCE trial).

In addition, SGLT2 inhibitors in general may have a role as a third agent in those who cannot or will not take insulin, when full doses of metformin and a sulfonylurea have not produced satisfactory metabolic control, or in patients in whom risk of hypoglycaemia is high (frail, older adults) or in whom avoidance of weight gain is a priority. 

Minimizing Hypoglycemia in Diabetes

Minimizing Hypoglycemia in Diabetes

Dr KK Aggarwal

President CMAAO and HCFI

December 11 in the Journal of Clinical Endocrinology and Metabolism: The US Department of Health and Human Services has identified hypoglycemia as one of the top three preventable and measurable adverse drug events.

Hypoglycemia is defined in

• Level 1: Glucose < 70 mg/dL and ≥ 54 mg/dL
• Level 2: Glucose < 54 mg/dL that needs immediate action.
• Level 3: A severe event characterized by altered mental and/or physical status requiring assistance.

Remember the three measures

Measure 1: Identify high risk patients

·        First, if the patient has experienced a previous Level 2 or Level 3 hypoglycemic event within the past year. If not, then:

·        Second, if the patient has a prescription for insulin and/or insulin secretagogues and has an A1c < 7% documented within the past 6 months. If not, then:

·        Third, if the patient has a prescription for insulin and/or insulin secretagogues and at least one relevant comorbidity.

Measure 2: Educate patients ( 65+) and care givers at greater risk for hypoglycemia

Measure 3: Patient report hypoglycemic events

A Starting Point...

Ultra-processed foods can cause diabetes

Ultra-processed foods can cause diabetes

Dr KK Aggarwal

President CMAAO and HCFI

Food, which has been significantly changed from its original state, with salt, sugar, fat, additives, preservatives and/or artificial colours added.

Ultra-processed foods like candy, soft drinks, pizza and chips do not contain enough of the beneficial nutrients that the body requires.

Unprocessed or minimally processed foods: Vegetables, grains, legumes, fruits, nuts, meats, seafood, herbs, spices, garlic, eggs and milk.

Processed foods: When ingredients such as oil, sugar or salt are added to foods and they are packaged, the result is processed foods. Examples are simple bread, cheese, tofu, and canned tuna or beans. These foods have been altered, but not in a way that’s detrimental to health.

Ultra-processed foods: These foods go through multiple processes (extrusion, molding, milling, etc.), contain many added ingredients and are highly manipulated. Examples are soft drinks, chips, chocolate, candy, ice-cream, sweetened breakfast cereals, packaged soups, chicken nuggets, hotdogs, fries and more.

 

High consumption of these ultra-processed foods is associated with an increased risk of type 2 diabetes, independent of other risk factors including weight and nutritional quality of the diet, a new study indicates.

Ultra-processed foods consumption has previously being linked to increased risks of cancer, cardiovascular diseases, mortality, depressive symptoms, and metabolic disorders.

The study published online  in JAMA Internal Medicine involved 104,707 participants in the ongoing, web-based NutriNet-Santé study in France.

Rates of type 2 diabetes among the lowest and highest ultra-processed foods consumers were 113 and 166 per 100,000 person-years, respectively.

Over a median follow-up of 6 years, the consumption of ultra-processed foods was found to be associated with a significantly higher risk of type 2 diabetes, with a hazard ratio (HR) of 1.15 for each 10% increase of ultra-processed foods in the diet.

Other physical and chemical processes, such as high-temperature heating, are associated with the production of contaminants posing health risks, such as acrylamide, found mainly in fried potatoes, biscuits, cakes, and coffee, which have been associated with insulin resistance.

Ultra-processed foods usually go through several physical and chemical processes such as extruding, molding, pre-frying, (or) hydrogenation, possibly leading to the production of new compounds with potential cardiometabolic disruption properties.

They also typically contain food substances of no or rare culinary use (some varieties of refined sugars, hydrogenated oils) and various types of cosmetic additives (emulsifiers, sweeteners, thickening agents, colorants), with cardiometabolic effects postulated for some.  

ADA updates its 2019 Standards of Medical Care in Diabetes

Dr KK Aggarwal

The American Diabetes Association (ADA) has updated its 2019 Standards of Medical Care in Diabetes by incorporating recently related published research.

• Based on the results of the REWIND (Researching Cardiovascular Events With a Weekly Incretin in Diabetes) trial, dulaglutide, the once-weekly GLP-1 agonist, is now recognized among other GLP1 receptor agonists that have demonstrated macrovascular benefits in people with type 2 diabetes in section 9 “Pharmacologic Approaches to Glycemic Treatment” and Section 10 “Cardiovascular Disease Risk Management”. The REWIND trial indicated that dulaglutide reduced the risk for nonfatal myocardial infarction, nonfatal stroke and cardiovascular death in adults with type 2 diabetes with and without established cardiovascular disease. This update has also been approved by the American College of Cardiology

• Section 13 “Children and adolescents” now advises liraglutide for some children and adolescents following its approval by the US FDA for use in pediatric patients with type 2 diabetes who are 10 years of age and older, and the Liraglutide in Children and Adolescents with Type 2 Diabetes study, which examined its effects on the youth… “If glycemic targets are no longer met with metformin ± basal insulin, liraglutide therapy should be considered in children 10 years or older, if no history or family history of medullary thyroid carcinoma.”

• The new international consensus report on continuous glucose monitoring (CGM) time-in-range goals has been added in Section 6, Glycemic Targets, and Section 7, Diabetes Technology. A table has been added to help standardize CGM metrics for clinical care and an example of an ambulatory glucose profile has been added to encourage consistency in CGM data report interpretation

These updates have been published online July 31, 2019 in the journal Diabetes Care. 

(Source: ADA News Release, Medscape)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

A1c is an unreliable diagnostic test for diabetes

Using the hemoglobin A1c to diagnose diabetes tends to underestimate the prevalence of the disease, suggests a study presented at ENDO 2019, the Endocrine Society’s annual meeting in New Orleans, Louisiana.

In the study, 9,000 adults without a diabetes diagnosis were randomized to an A1c test and an oral glucose tolerance test (OGTT). Comparison of the results showed that using A1c as a diagnostic test missed about 73% cases of diabetes that were detected by OGTT. Race and ethnicity were found to have a significant impact on the accuracy of the test. A1c was more likely to detect abnormal glucose levels in non-Hispanic whites than in non-Hispanic blacks or Hispanics.

As per the authors of the study, A1c, when used solely to define diabetes is a highly unreliable test and significantly underestimates the prevalence of diabetes. A1c should be used along with OGTT for improved accuracy of detection.

The American Diabetes Association recommends measuring HbA1c to diagnose prediabetes and diabetes due to its “greater convenience (fasting not required), greater preanalytical stability and less day-to-day perturbations during stress and illness.” HbA1c value of ≥6.5% has been established as the diagnostic figure associated with diabetes.

However, A1c has lower sensitivity to diagnose diabetes. A1c can give false results in some people.

·         People of African, Mediterranean, or Southeast Asian descent, or people with family members with sickle cell anemia or a thalassemia are particularly at risk of interference. People in these groups may have a less common type of hemoglobin, known as a hemoglobin variant that can interfere with some A1c tests.

·         A falsely low A1c result may be seen in people with anemia, heavy bleeding.

·         A falsely high A1c result is seen in individuals who are very low in iron, e.g., those with iron deficiency anemia.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

ADA 2019 Standards of Medical Care in Diabetes emphasize patient-centered care

The American Diabetes Association (ADA) has published its latest 2019 Standards of Medical Care in Diabetes. There have been several changes and updations from the earlier editions of the guidelines.

For patient-centered glycemic management in type 2 diabetes, a new Goals of Care graphic decision cycle has been included, which details the need for ongoing assessment and shared decision-making to achieve care goals, help reduce therapeutic inertia and improve patient self-management.

The criteria for the diagnosis of diabetes were changed to include two abnormal test results from the same sample i.e., fasting plasma glucose and A1c from same sample.

A patient-centered communication style that uses person-centered and strength-based language and active listening, elicits patient preferences and beliefs, and assesses literacy, numeracy, and potential barriers to care should be used to optimize patient health outcomes and health-related quality of life (QOL).

For older (>65 years) adults with diabetes, optimal nutrition and protein intake is recommended; regular exercise, including aerobic activity and resistance training, are also encouraged in all older adults who can safely engage in such activities.

No one-size-fits-all eating pattern can be recommended for all patients with diabetes. Hence, an individualized medical nutrition therapy program as needed to achieve treatment goals, preferably provided by a registered dietitian, is recommended for all people with type 1 or type 2 diabetes, prediabetes, and gestational diabetes mellitus

A simple and effective approach to glycemia and weight management emphasizing portion control and healthy food choices maybe considered for those with type 2 diabetes who are not taking insulin, who have limited health literacy or numeracy, or who are older and prone to hypoglycemia.

For patients with type 2 diabetes and chronic kidney disease (CKD), use of a sodium–glucose cotransporter 2 inhibitor (SGLT2) or glucagon-like peptide 1 (GLP-1) receptor agonist shown to reduce risk of chronic kidney disease progression, cardiovascular events, or both has been advised. 

Patients who require the additional glucose-lowering efficacy of an injectable medication, a GLP-1 receptor agonist is now recommended as the first choice before insulin for most patients with type 2 diabetes.

Gabapentin is included as a new medication to be considered for the treatment of pain due to diabetic neuropathy.

For the first time, the section on cardiovascular disease and risk management has been endorsed by the American College of Cardiology (ACC). Heart failure has been recognized as a major cause of cardiovascular morbidity and mortality in people with diabetes and the need to consider heart failure when determining optimal diabetes care. The ADA also recommends the use of ACC’s atherosclerotic cardiovascular disease (ASCVD) risk calculator, the ASCVD Risk Estimator Plus for the routine assessment of 10-year ASCVD risk in people with diabetes.

The new recommendations were published online Dec. 17 in Diabetes Care and will be published as a supplement to the January 2019 print issue of the journal.  

(Source: ADA, Diabetes Care)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Why Lord Ganesha Never suffered From Diabetes inspite of having pot belly obesity

Today the developing world is facing an epidemic of potbelly obesity-related diabetes and the same has been linked to eating refined carbohydrates especially refined sugar.

Lord Ganesha is depicted with big tummy and sweet (laddoo) in one of his hands and yet he never suffered from diabetes.

There are two interpretations of this. The first is a spiritual interpretation and i.e. that in mythology Ganesha depicts principles of stress management and sweet laddoo means control of desires. The big tummy symbolizes retaining all information gathered from hearing with two big elephant ears.

The second is a medical interpretation where the big tummy represents the susceptibility of Indians to metabolic syndrome, the present epidemic related to abdominal obesity. Indians have a weakness for eating sweets as well as being vulnerable to developing pot belly obesity.

This is shown as uncontrolled desire to eat sweets (Laddoos) and the prevention of the same is shown by all the fruits or leaves, offered to Ganesha, that have anti diabetic properties.

The main Ganesha Mantra can also be interpreted as explaining anti diabetes properties of Ganesha offerings.

“Gajananam Bhoota Ganadi Sevitam; Kapittha Jambu phalasara bhakshitam; Umasutam Shoka Vinasha karanam; Namami Vighneswara pada pankajam”.

The Mantra means

a.  ”Oh Elephant-faced, worshipped by the existing beings, of all living beings, tasting the elephant apple (kaith) and jambolana (jamun), the Son of Uma, destroyer of grief, I bow to the lotus feet of Ganesha who is lord of all.”

 

b. Or Gajananam (the big tummy one worshipped by all) Bhoota (Durva grass and Bilva patra used for worshipping Ganesha) Ganadi (in equal quantity) Sevitam (if consumed); Kapittha (Kaith) Jambu (Jamun) phalasara (fruits) bhakshitam (to be consumed); Umasutam (son of Uma) Shoka (diseases) Vinasha karanam (get rid of); Namami (I bow to) Vighneswara (destroyer of grief) pada pankajam (feet of lord)”

 

The mantra talks about four medicinal herbs: Durva grass and Bilva patra (Bel leaves) used for Ganesha worship; fruit of elephant apple (Kaith) and fruit of Jambolona (or Jamun). All four have anti diabetic properties and can be mixed in equal quantity and prepared as a medicinal juice.

Medically, Durva grass (Cynodon dactylon) has been shown to possess anti diabetic, cholesterol lowering, immune-modulatory, DNA protective, aphrodisiac, male fertility, anti cancer and anti inflammatory activities. Similarly Bilva Patra has both anti diabetic and fertility promoting properties.

Elephant apple (Limonia acidissima) also named as Wood Apple, Elephant Apple, Monkey Fruit, Curd Fruit, Koth Bel, Kaitha  and Kath Bel, has been shown to possess strong anti diabetic properties.

Jamun (Syzygium cumini) also has DNA protective, antioxidant and antidiabetic properties and is an essential ingredient of most antidiabetic Ayurveda preparations.

Worth trying: Regularly take equal mixed quantity of Durva grass, Kaith fruit and Jamun fruit juices to prevent diabetes and to reduce the ill effects of metabolic syndrome.

Note: This article is the author’s personal interpretation based on listening to many Ayurveda experts.

Amongst celebrities why do only cine stars commit suicide and not cricketers or politicians: What can be done to prevent them?

Actress Jiah Khan dies

The death of Jiah Khan, the film actress, reopens up the debate on cine star celebrity deaths. Why do so many suicides occur in the film Industry? Despite similar failure rates, there are no suicides in politics or in cricket.

In cricket, we see cricketers under stress, they even lose their place in the team for years and yet they do not go in depression. The reasons may be the presence of a counselor in every team and opportunities to play in domestic games.

Will the film industry come out with guidelines for suicide and stress prevention?

We have seen cases of Raj Kiran and Parveen Babi (56) who were reported missing for years and nobody bothered. The same never happens in cricket. Parveen Babi was later found dead in her flat.

 In the past, many (eight) cine celebrities have committed suicides.  These include Guru Dutt (39), Divya Bharti (19), Nafisa Joseph (26), Kuljeet Randhwa (30), Kunal Singh (31), Silk Smitha (35), Viveka Babajee (37) and now Jiah Khan (25).

So is celebrity status a risk factor for suicide? 

Suicides are also common in medical profession but not in nursing profession. They are hardly seen in cricketing celebrities.   

Lifestyle disorders, including heart attack, diabetes, paralysis, liver disease, kidney disease and cancer are still the commonest causes of death amongst celebrities. 

·         KL Sehgal (42), Geeta Dutt (41) and Meena Kumari (39) died of alcohol-related liver diseases.

·         12 celebrities died of cancer: Nazia Hassan 35 (lung cancer), Nargis 51 and Jatin Kanakia 46 (cancer pancreas), Jennifer Kapoor 51, Nutan 54, Rehman 58 (throat cancer), Rajender Kumar 69, Firoze Khan 69, Prithvi Raj Kapoor 70, Mac Mohan 72 (lung cancer), Shamim Desai (stomach cancer), Sujit Kumar 75.

·         Both Jagjeet Singh 70 and Amrish Puri 72 died of brain hemorrhage.

·         Actors who died because of heart disease: Madhubala 36 (hole in the heart), Bob Cristo 72 (rupture of heart); heart attack: Simple Kapadia 51, Mohd. Rafi 55, Mohan Gokhale 45, Sanjeev Kumar 47, Vivek Shauq 47, Shafi Inamdar 47, Nirmal Pandey 48, Amjad Khan 51, Mukesh 53, RD Burman 54, Kishore Kumar 58, Ravi Baswani 63, Prem Nath 65, Naveen Nishchol 65, Hemant Kumar 69, Suchitra Mitra 86, Dev Anand 88, MF Hussain 85, Vinod Mehra 45, Sunil Dutt 75, Abir Goswami 37, Surinder Kapoor 85, Praveen Babi 55 (diabetes and heart disease) and Rituparno Ghosh 50.

·         Mazhar Khan 45 and Shammi Kapoor 79 died due to kidney failure.

·         Only three died of infections: Geeta Bali 36 due to small pox, Bhimsen Joshi 89 and Jagmohan Mundra 62 due to pneumonia.

·         Only two celebrities were murdered: Gulshan Kumar 41 and Priya Rajvansh 63.

·         There was only one pregnancy-related death: Smita Patil 31.

·         Two died of prolonged illness: Mani Kaul 66 and Goga Kapoor 70.

·         One died of multi organ failure: Bhupen Hazarika 85.

Out of 61 celebrity deaths collected so far,  25 died of heart disease, 12 died of cancer, 3 died of liver disease, 2 of brain attack, 2 with prolonged illness, one pregnancy-related, 3 infections, 8 suicides, 2, kidney failures, 2 murders and one multiorgan failure. 

On the other hand, amongst politicians a large number of them have died of unnatural deaths but there are no suicides. The number one cause of death however remains heart attacks or lifestyle illnesses.

Politicians who have died in air crashes include Netaji Subhash Chander Bose (alleged to have died in a plane crash), Homi J. Bhaba, S. Mohan Kr. Mangalam, Sanjay Gandhi, Ashok Birla, Surendra Nath, Madhav Rao Scindia, GMC Balyogi, OP Jindal, YSR Reddy and Dorjee Khandu. Three died in road accidents, Rajesh Pilot, Sahib Singh Verma and Giani Zail Singh.

Eleven politicians who have died of a heart attack are Pandit Jawahar Lal Nehru 74, Zakir Hussain 72, Fakhruddin Ali Ahmed 71, Lal Bahadur Shastri 61, Krishna Kant 75, Dr. BC Roy 80, Dayanand Bandodkar 62, G Ramachandran 70, Sarojini Naidu 70, PV Narsimha Rao 83 and Arjun Singh 80.

Most cine celebrities died of heart attack before the age of 50 and none of the politicians died of heart attack before the age of 50.

Many politicians were assassinated: Indira Gandhi, Rajiv Gandhi, LN Mishra, Mahatma Gandhi, Beant Singh, Phoolan Devi and Abdul Gani Lone.

Only two politicians died of cancer: Shri VP Singh and Chandra Shekhar (blood cancer)

One politician died of surgical complications: Sikandar Bakht and one died of multi organ disease: S. Venkataraman.

No suicidal deaths have been seen in cricketers or in politicians.

10th National Summit on Stress Management

Inaugurating a 2-day 10th national summit on Stress Management and a workshop on “How to be Healthy and Happy”, Mr. Rakesh Mehta, Election Commissioner of Delhi said that meditation should be taught as a part of our school curriculum. Yoga, pranayama and meditation, if taught early, can take care of rising problems of diabetes, heart attack and blood pressure in the society.

Speaking on the occasion, Padma Shri & Dr. BC Roy National Awardee, Dr. KK Aggarwal, President Heart Care Foundation of India and Vice-Chairman, World Fellowship of Religions, said that by learning the Vedic lifestyle, one acquires the strength to bear any illness. Spiritual people develop disease but learn not to suffer from it. Ninety percent of happiness lies in our hands. One can choose to be happy and healthy either by making informed choices or re-experiencing the past experiences.

The seminar was organized by Heart Care Foundation of India jointly with Prajapati Brahmkumaris Aishwarya Vidyalaya, eMedinewS and World Fellowship of Religions at Om Shanti Retreat Centre, Pataudi Road, Manesar, Gurgaon.

BK Brij Mohan said that meditation and not medication is the answer for most of the lifestyle disorders. Rajyoga meditation is the answer for today’s stressful environment.

BK Asha said that even observing silence for 20 to 30 minutes a day can help one achieve inner happiness. BK Sapna present on the occasion said that meditation under a pyramid is much more powerful than under the sky.

Dr. Anil Goyal, President (Elect), Delhi Medical Association said that even doctors need to de-stress. The incidence of heart attack in doctors is no less than that in the general public. Doctors should practice what they preach.

Others who spoke on the occasion were Dr. Ramesh Hotchandani, President IMA New Delhi Branch; Dr. NK Gupta, Past Vice President, IMA South Delhi Branch; Dr. Pawan Gupta, Past President, IMA Haryana; Dr. AK Kansal, Past President, IMA, Janakpuri Branch.

Emedinews: Dr Good Dr Bad: A patient with diabetes was found to have high pesticide levels in the blood

Situation: A patient with diabetes was found to have high pesticide levels in the blood
Dr Bad: They are not related
Dr Good: They are related
Lesson: Individuals with moderately high blood levels of organ chlorine pesticides have a greater chance of developing type 2 diabetes.
Source: Aug. 4 in Diabetes Care

#AskDrKK: Is diabetes and hypertension responsible for heart diseases in the young?

#DrKKAnswers: Diabetes and hypertension are less common in young heart patients than in older patients. However, most young people have insulin resistance.

HCFI Update: Depression and Diabetes

Depression is implicated in diabetes said Padmashri & Dr B C Roy National Awardee, Dr K K Aggarwal, President Heart Care Foundation of India and MTNL Perfect Health Mela.

For many years it was thought that depression was a complication of diabetes. More recent research, however, points to depression as a possible trigger.

A Kaiser Permanente study of 1,680 subjects found that those with diabetes were more likely to have been treated for depression within six months before their diabetes diagnosis. About 84 percent of diabetics also reported a higher rate of earlier depressive episodes.

A 2004 Johns Hopkins study tracking 11,615 initially non diabetic adults aged 48-67 over six years found that "depressive symptoms predicted incident type 2 diabetes."

According to an evaluation of 20 studies over the past 10 years, the prevalence rate of diabetics with major depression is three to four times greater than in the general population. While depression affects maybe three or five percent of the population at any given time, the rate is between 15 and twenty percent in patients with diabetes, according to the American Diabetic Association. Women, in particular are at greater risk.

Whether a cause or an effect, the combination of diabetes and depression can be deadly. Because of physiologic and behavioral interactions between diabetes and depression, each becomes more difficult to control, increasing the risks of cardiovascular disease, diabetic retinopathy causing blindness, neuropathy and other complications.

Obesity is a risk factor for macrovascular disease. Depressed people tend to eat more and exercise less, which results in weight gain and sabotages efforts at controlling blood sugar levels. Depressed adults with diabetes have significantly higher body mass indexes than nondepressed adults with diabetes.

Depression in diabetics is a greater risk factor for heart disease than high blood sugar.

If depression can trigger diabetes or make it much worse, it stands to reason that effectively managing one's depression can help bring one's diabetes under control.

The take home message is

1. If you have diabetes get screened for depression

2. And if you have depression get screened for diabetes

Dr KK Answers: Is there a link between diabetes and hearing impairment?

Low HDL, coronary heart disease, peripheral neuropathy, and having poor health are potentially preventable correlates of hearing impairment for people with diabetes. This was observed in the analysis of data from 536 participants, aged 20-69 years, with diagnosed or undiagnosed diabetes who completed audiometric testing during 1999-2004 in the National Health and Nutrition Examination Survey.

Source:  Diabetes Care 2011 Jul;34(7):1540-5. 

Dr KK Answers: Can reducing weight help patients with diabetes?

An observational analysis of participants in the Look AHEAD (Action For Health in Diabetes) study has concluded that modest weight losses of 5 to <10% is associated with significant improvements in cardio vascular disease risk factors at 1 year, but larger weight losses had greater benefits.

5 to 10 kg weight reduction led to 0.5% point reduction in HbA1c , a 5-mmHg decrease in diastolic blood pressure, a 5-mmHg decrease in systolic blood pressure, a 5 mg/dL increase in HDL cholesterol and a 40 mg/dL decrease in triglycerides. The clinically significant improvements in most risk factors were even greater in those who lost 10-15% of their body weight.

Source: Diabetes Care 2011 Jul;34(7):1481-1486

Don’t discard diabetic drug Pioglitazone even after the FDA’s Safety Announcement

The U.S. Food and Drug Administration has announced that the use of the popular diabetic drug pioglitazone for more than one year may be associated with an increased risk of bladder cancer.

According to the FDA’s Safety Announcement, information about this risk will be added to the Warnings and Precautions section of the label for pioglitazone-containing medicines.

However the Endocrine Society, American Association of Clinical Endocrinologists and American Diabetes Association inspite of the FDA announcement have urged diabetes patients not to panic and stop the drug without their doctor’s advice.  Stopping diabetic drug can result in higher levels of blood glucose that may cause serious short term health problems and could increase the risk of diabetes-related complications in the long term.

As per the advice all diabetics should adhere to the following guidance provided by the FDA:

1.       All diabetics should be told that there may be an increased chance of having bladder cancer when taking pioglitazone

2.        One should not take pioglitazone if receiving treatment for bladder cancer;

3.        One should consult right away if one has any of the symptoms of bladder cancer including blood or red color in urine; urgent need to urinate or pain while urinating; pain in back or lower abdomen;

According to the FDA Safety Announcement, the five-year interim analysis of an ongoing ten-year study showed that although there was no overall increased risk of bladder cancer with pioglitazone use, an increased risk of bladder cancer was noted among patients who had been on pioglitazone the longest and had been on higher doses over time.

Large number of diabetics are on pioglitazone which reduces insulin resistance and is useful in metabolic syndrome. The drug is already in criticism for gaining weight and possible heart failure.

About the author: Padmashri & Dr. B.C. Roy National Awardee, Dr. KK Aggarwal is a Senior Consultant, Physician, Cardiologist at Delhi based Moolchand Medcity; President Heart Care Foundation of India; Chairman Ethical Committee Delhi Medical Council and has served as the Research and Academic Wing Heads of National Indian Medical Association.

emedinews@gmail.com, http://www.heartcarefoundation.org/, www.emedinews.in