IntroductionCurrent guidelines on managing type 2 diabetes (T2D) in patients recommend individualized glycemic goal treatment with lifestyle intervention and Metformin as first-line therapy. Target glycated hemoglobin (A1C) goals in patients with T2D should be tailored to the individual, balancing the prospect of reduced microvascular complications with the adverse effects and cost of added treatments. Several factors contribute to worsening glycemia like weight gain, non-compliance to diet, diabetes comorbidities, insulin resistance, etc. Therefore, guidelines emphasize the importance of individualizing the choice of medications to treat diabetes, considering significant comorbidities and patient-related factors. <ul><li class="ql-align-justify">Monotherapy failure: Patients not achieving required glycemic control with Metformin and lifestyle intervention are recommended with a second medication.</li><li class="ql-align-justify">A1C &gt;9 percent (74.9 mmol/mol) or persistent symptoms of hyperglycemia: </li></ul><ol><li class="ql-align-justify">Insulin or a GLP-1 receptor agonist is the suggested second-line medication. Insulin is always practical and is preferred in catabolic diabetes (e.g.: polyuria, polydipsia, weight loss) or in case of difficulty distinguishing between type 1 and type 2 diabetes.</li><li class="ql-align-justify">In patients with established ASCVD or high ASCVD risk, specific GLP-1 receptor agonists have demonstrated cardiovascular benefit (liraglutide, subcutaneous semaglutide, or dulaglutide) are preferred, if they achieve the desired glycemic target. </li><li class="ql-align-justify">For patients without either catabolic symptoms or existing cardiac disease, GLP-1 receptor agonist may be favored when weight loss is essential. However, gastrointestinal (GI) side effects, contraindications, and cost may limit their use.</li></ol><ul><li class="ql-align-justify">A1C ≤9 percent: the choice of a second medication should be individualized based upon efficacy, the risk for hypoglycemia, the patient's comorbid conditions, impact on weight, side effects, and cost.</li><li class="ql-align-justify">For patients with existing cardiorenal comorbidities and persistent hyperglycemia while taking Metformin, a GLP-1 receptor agonist (liraglutide, subcutaneous semaglutide, or dulaglutide) or an SGLT2 inhibitor (empagliflozin, canagliflozin, dapagliflozin) that has demonstrated cardiorenal benefit is recommended.</li><li class="ql-align-justify">Dual agent failure: For patients who fail to achieve glycemic control despite dual agents, it is recommended to add either Insulin or two oral agents and a GLP-1 RA, or one oral agent, basal Insulin and a GLP-1 RA. </li><li class="ql-align-justify">For selected patients with type 2 diabetes (BMI ≥40 kg/m2 or BMI 35 to 39.9 kg/m2), when lifestyle measures inadequately manage hyperglycemia and optimal medical therapy, bariatric surgery may be an option.</li></ul>ConclusionWith current advancements in managing patients with type 2 diabetes, individualized treatment goals are the key. A management program focusing on lifestyle changes, diet, increased physical activity and exercise, weight reduction, and consultation with a registered dietitian or diabetes self-management education is ideal. Using appropriate treatment at an early management stage is essential in managing persistent hyperglycemia. &nbsp;Access the full article here: <a href="https://www.uptodate.com/contents/management-of-persistent-hyperglycemia-in-type-2-diabetes-mellitus/print?source=related_link" rel="noopener noreferrer" target="_blank">https://www.uptodate.com/contents/management-of-persistent-hyperglycemia-in-type-2-diabetes-mellitus/print?source=related_link</a>

Management of persistent hyperglycemia in type 2 diabetes mellitus

The positioning of various classes of drugs in managing persistent hyperglycemia is key.

INTRODUCTIONThis article highlights the importance of postprandial glucose (PPG) on long-term glycemic control and its relation to cardiovascular disease (CVD). PPG significantly contributes to overall effective management of microvascular and macrovascular complications in Type 2 diabetes (T2D).MAIN RESULTS A1C continues to be the gold standard for assessing glycemic control in patients with T2D. However, long-term A1C targets cannot be achieved by focussing only on fasting plasma glucose (FPG) alone. Recent evidence has demonstrated that controling PPG serves as a beneficial tool for long-term management of T2D and reducing the incidence of CVD.<ul><li class="ql-align-justify">The ADA/European Association for the Study of Diabetes guidelines recommends target PPG &lt;180 mg/dL, and the IDF recommends target PPG &lt;160 mg/dL.</li><li class="ql-align-justify">Impact of PPG on A1C – Even though the data concerning the relevance of PPG to A1C was initially varied, the following recent studies have revealed it’s notable role in achieving target glycemic control.</li><li class="ql-align-justify">A study done to define the contributions of FPG and PPG to A1C in patients with non-insulin-treated type 2 diabetes concluded that PPG is the predominant contributor in patients with satisfactory to good control of diabetes. In contrast, the contribution of fast FPG increases with worsening diabetes.</li><li class="ql-align-justify">An analysis of six studies of treatment intensification with insulin or additional OADs (oral anti-diabetic agents) concluded that when A1C is &gt;7.0% despite OAD therapy, FPG dominates glucose exposure, contributing an average of 76–80% to hyperglycemia and that the type of antihyperglycemic treatment used may be more significant than the A1C level alone.</li><li class="ql-align-justify">&nbsp;Impact of PPG on CVD </li><li class="ql-align-justify">In the Study to Prevent Non-Insulin-Dependent Diabetes Mellitus (STOP-NIDDM), patients with IGT(Impaired Glucose Tolerance) were randomized to receive either placebo or acarbose, an α- glucosidase inhibitor (AGI) that lowers PPG. In addition to a 25% relative risk reduction in developing type 2 diabetes and a 34% risk reduction for hypertension, patients treated with acarbose had a 49% risk reduction of developing CV (CardioVascular) events. Additionally, in a substudy of STOP-NIDDM, patients treated with acarbose showed a reduced incidence of silent Mis (Myocardial Infarctions) compared to those receiving placebo.</li><li class="ql-align-justify">Assessment of risk factors in IGT for Atherosclerosis and Diabetes study showed a closer correlation between PPG and carotid intima-media thickness than FPG in patients with IGT.</li><li class="ql-align-justify">The progression of atherosclerosis has also been shown to be slowed and even reversed by therapies that reduce PPG.</li><li class="ql-align-justify">Epidemiological and other studies have demonstrated a strong association between PPG and CV risk through oxidative stress, carotid intima-media thickness, and endothelial dysfunction.</li><li class="ql-align-justify">PPG monitoring – Readings should be obtained after breakfast rather than after lunch or dinner because post-breakfast excursions tend to be more significant and consistent, with lower daily variation. CGM technology, including the FreeStyle Libre and FreeStyle Libre Pro “flash” CGM systems, is highly recommended as they do not require fingerstick calibration.</li><li class="ql-align-justify">Treatment options for reducing PPG – Several options are available that target PPG, helping achieve overall improved glycemic control and patient outcomes. Newer agents such as GLP-1 receptor agonists or fixed-ratio combinations that may be added to basal insulin have proven highly effective in reducing PPG without added risks of weight gain and hypoglycemia. However, one size does not fit all, which makes individualized patient profiling a crucial step in managing T2D. Other well-established options include AGI, Amylin analogs, Glinides, SGLT2 inhibitors, and DPP-4 inhibitors.</li></ul>SUMMARYControlling PPG is as essential as controlling FPG in people with T2D. Many patients can achieve an FPG target while their A1C remains high. At this point, agents targeting PPG are essential. Studies have consistently demonstrated that PPG is a significant contributor to A1C and an independent risk factor for CVD.Note: Kindly access the full article with the below link:<a href="https://doi.org/10.2337/cd18-0040" rel="noopener noreferrer" target="_blank">https://doi.org/10.2337/cd18-0040</a>

Importance of Postprandial Glucose in Relation to A1C and Cardiovascular Disease

Need of the hour – Focusing on PPG over FPG in relation to A1C for improved cardiovascular outcomes in patients with Type 2 Diabetes.

INTRODUCTIONThis educational video highlights the ADA-EASD (American Diabetes Association-European Association for the Study of Diabetes) consensus statement on the management of hyperglycemia and how these updates can optimize improved patient outcomes. There is an increasing need to focus on preventing complications to ensure a better quality of life for patients with Type 2 Diabetes (T2D). This educational video brings attention to the significance of managing post prandial glucose for improved outcomes and better survival for patients with Type 2 Diabetes (T2D). The video focuses on the determinants, risk factors and optimal targets of post prandial glucose. Furthermore, it highlights the methods of managing post prandial spikes using effective lifestyle interventions and insulin-based treatment regimens. This session is aimed at primary care physicians, family physicians, general practitioners, endocrinologists, diabetologists, cardiologists, and other physicians involved in the management of diabetes.&nbsp;The session consists of the following lectures:<ul><li class="ql-align-justify">ADA-EASD consensus statement on the management of hyperglycemia: What’s coming?</li><li class="ql-align-justify">Management of post prandial glucose spike</li></ul>Dr. John Buse, PhD, MDVerne S. Caviness Distinguished ProfessorChief Division of EndocrinologyDirector Diabetes CenterDirector NC Translational and Clinical Sciences InstituteSenior Associate Dean, Clinical ResearchUniversity of North Carolina School of Medicine&nbsp;﻿Dr. Kamanga Brown, MDEndocrinologistEndocrine UnitDepartment of Internal MedicineUniversity of Zambia

Highlights from the ADA 82nd Scientific session

IntroductionThis&nbsp;educational video&nbsp;summarizes&nbsp;one&nbsp;session&nbsp;from the&nbsp;IDF Virtual congress 2021&nbsp;that&nbsp;reviewed reaching the therapeutic goals in type 2 diabetes and what we have learned .&nbsp;The video&nbsp;is&nbsp;aimed at primary care physicians, family physicians, general practitioners, endocrinologists, diabetologists, cardiologists, and other physicians involved in the management of diabetes.The educational video consists&nbsp;of the following lecture:<ul><li>Reaching therapeutic goals in type 2 diabetes: what we have learned&nbsp;</li></ul>The video presentation will cover the following:<ul><li>How the evolution of insulin has improved our approach to preventing hypoglycemia in patients with diabetes.</li><li>The use of the fixed dose combinations, and some other strategies to managing type two diabetes.&nbsp;</li><li>The new ways of insulin delivering how we are closing the loop in patients with type two diabetes.</li></ul>Expert facultyProf. Eduard Montanya&nbsp;Senior Professor of Medicine at the University of Barcelona, Head of the Diabetes Section of Bellvitge University Hospital, Spain&nbsp;

Highlights from the IDF Virtual congress 2021

IntroductionThese educational videos present the revolutionary diabetes therapies and their impact on cardiovascular and renal outcomes, as presented during the 81st ADA Scientific Sessions. &nbsp;The educational videos consist of the following lectures:<ul><li class="ql-align-justify">Highlights from the 81st ADA Scientific Sessions:</li><li class="ql-align-justify">Joint ADA/EASD Symposium—Novel insights and old controversies around insulin and glucagon-like signaling (presented on 27 June 2021)</li><li class="ql-align-justify">Management of type 1 diabetes in adults—2021 draft ADA/EASD consensus report (presented on 28 June 28 2021)</li><li class="ql-align-justify">SGLT2is and GLP-1RAs – Are they worth it?</li><li>Intersection of diabetes, heart failure, and kidney disease – Challenges and new insights</li><li>Translating diabetes and heart failure clinical trial findings into clinical practice </li></ul>Expert facultyProf. Richard E. Pratley, MDMedical Director, AdventHealth Diabetes Institute, Senior Scientist and Diabetes Program Head, Advent Health Translational Research Institute Orlando, Florida Prof. Naveed Sattar, MDProfessor of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom

Highlights from the ADA 81st Scientific session

INTRODUCTIONThis educational video focuses on the management of hypoglycemia as well as impaired awareness of hypoglycemia. It discusses the prevalence of hypoglycemia across all age groups and the need to focus on patient education and counseling to prevent recurrent episodes of hypoglycemia. It also highlights different techniques to help patients remain to get ahead of their hypoglycemic events. This session is aimed at primary care physicians, family physicians, general practitioners, endocrinologists, diabetologists, cardiologists, and other physicians involved in the management of diabetes.This session consists of the following lectures:Impaired awareness of hypoglycemia and management of hypoglycemia After attending the interactive session, the learner should be able to:<ul><li class="ql-align-justify">Understand the burden of hypoglycemia in patients with type 2 diabetes&nbsp;</li><li class="ql-align-justify">Assimilate the key role of patient education for effective management of impaired awareness of hypoglycemia</li><li class="ql-align-justify">Acquire the knowledge of techniques that can help patients track and prevent recurrent episodes of hypoglycemia </li></ul>Expert facultyDr. Partha KarConsultant Endocrinologist at Portsmouth Hospitals NHS Trust, United KingdomNational Specialty Advisor, Diabetes at NHS England

Impaired awareness of hypoglycemia and management of hypoglycemia

Super Module 1: Laying the Foundations

Understanding the close correlation between Diabetes and Nutrition

Diabetes and Nutrition

Join our celebration on World Diabetes Day

Dr. Partha Kar

INTRODUCTIONThis educational video focuses on the importance of insulin for optimal management of patients with Type 2 Diabetes (T2D). It discusses the factors to be considered when prescribing insulin as well as the recommended methods of initiation and intensification to achieve overall improved outcomes. This session is aimed at primary care physicians, family physicians, general practitioners, endocrinologists, diabetologists, cardiologists, and other physicians involved in the management of diabetes.The session consists of the following lectures:Reaching glycemic target with basal insulin – is it enough?After attending the interactive session, the learner should be able to:<ul><li class="ql-align-justify">Understand the mechanism of drug failure in patients with T2D due to disease progression and decline in beta cell function of pancreas</li><li class="ql-align-justify">Learn the multifactorial approach for creating individualised insulin care for patients with T2D</li><li class="ql-align-justify">Highlight insights from current guidelines to initiate insulin for achieving glycemic control and minimizing the incidence of atherosclerotic cardiovascular disease (ASCVD)</li><li class="ql-align-justify">Gain knowledge of treatment algorithms for intensification of insulin for overall better T2D care</li></ul>Expert facultyProf. Babatope KolawoleConsultant Physician/EndocrinologistObafemi Awolowo University Teaching Hospital﻿Osun state, Nigeria