Practical guidance on insulin injection practice in diabetes self-management in the Indian setting: an expert consensus statement

This consensus statement aimed to provide a simple and easily implementable practical educational guide- line for healthcare professionals (HCPs) and patients regarding insulin injection practice in diabetes self- management in the Indian setting. A group of experts analysed published data from guidelines, clinical trials and real world evidence to reach consensus recommendations on optimal insulin injection practices in terms of a) the injection sites (preparation of site of injection, choosing the injec- tion site, site rotation), b) choice of device and storage of insulins, and c) safety precautions, sharp disposal practice and complications. Findings from Global and Indian arm of 2014-2015 ITQ Study were considered to emphasize a need for improved practice by HCPs covering all the vital topics essential to proper injection habits. The consensus statement provides a simple and easily implementable practical educational guideline for HCPs and patients to optimize insulin injection practices in accordance with recent advances in device manufac- turing, newer research findings, and updated interna- tional guidelines as well as widespread concerns about neglected safety precautions such as single-patient use of pens and appropriate sharp disposal practices.This consensus statement aimed to provide a simple and easily implementable practical educational guide- line for healthcare professionals (HCPs) and patients regarding insulin injection practice in diabetes self- management in the Indian setting. A group of experts analysed published data from guidelines, clinical trials and real world evidence to reach consensus recommendations on optimal insulin injection practices in terms of a) the injection sites (preparation of site of injection, choosing the injec- tion site, site rotation), b) choice of device and storage of insulins, and c) safety precautions, sharp disposal practice and complications. Findings from Global and Indian arm of 2014-2015 ITQ Study were considered to emphasize a need for improved practice by HCPs covering all the vital topics essential to proper injection habits. The consensus statement provides a simple and easily implementable practical educational guideline for HCPs and patients to optimize insulin injection practices in accordance with recent advances in device manufac- turing, newer research findings, and updated interna- tional guidelines as well as widespread concerns about neglected safety precautions such as single-patient use of pens and appropriate sharp disposal practices

GLP-1 Receptor Agonists Critical Review: Revisiting Its Positioning for Type 2 Diabetes Mellitus in Routine Clinical Practice in India

Objective: Despite the benefit–risk ratio favoring glucagon-like peptide-1 receptor agonists (GLP-1 RAs), knowledge and awareness is lacking among patients and physicians, particularly in India. The current review provides an overview of GLP-1 RAs and the opinion of a group of healthcare practitioners (HCPs) and independent consultants across India on the evidence for using GLP-1 RAs and its applicability to the Indian population. Materials and methods: A panel of eight HCPs met virtually on December 12–13, 2020 met as part of the Diabetes Research Society (DIABAID). They examined and critically discussed the current research on the use of GLP-1 RAs in the management of T2DM. Results: The panel observed that recent diabetes guidelines and recommendations have shifted toward a more individualised and CV risk-focused approach to T2DM management. They proposed that 1) GLP-1 RAs are ideal cardio-metabolic drugs that address multiple aspects of the T2DM; 2) to bring up GLP-1 RAs as early treatment option in discussions with patients; 3) in T2DM patients with a high CV risk or established ASCVD, CKD, or HF, GLP-1 RAs with proven CVD benefits should be initiated; 4) including oral semaglutide in international treatment recommendation guidelines to improve patient and HCP understanding and adaptability; and 5) patient-physician dialogues will be critical in incorporating GLP-1 RAs earlier in the treatment paradigm for effective T2DM management. Conclusions: The recommendations on using GLP-1 RAs and the associated benefits and risks of these drugs comprise essential considerations for using such medications in the Indian population

Study of differences in presentation, risk factors and management in diabetic and nondiabetic patients with acute coronary syndrome

Objectives: To compare clinical characteristics, treatment, and utilization of evidence-based medicines at discharge from hospital in acute coronary syndrome (ACS) patients with or without diabetes at a tertiary care cardiac center in India. Methods: We performed an observational study in consecutive patients discharged following management of ACS. We obtained demographic details, comorbid conditions, and cardiovascular risk factors, physical and biochemical parameters, and management. Descriptive statistics are reported. Results: We enrolled 100 patients (diabetics = 28) with mean age of 59.0 ± 10.8 years (diabetics 59.3 ± 11.6, nondiabetics 58.9 ± 8.5). Forty-nine patients had ST-elevation myocardial infarction (STEMI) (diabetics = 14, 28.7%) while 51 had nonSTEMI/unstable angina (diabetics = 14, 27.4%) (P = nonsignificant). Among diabetics versus nondiabetics there was greater prevalence (%) of hypertension (78.6% vs. 44.4%), obesity (25.0% vs. 8.3%), abdominal obesity (85.7% vs. 69.4%) and sedentary activity (89.2% vs. 77.8%), and lower prevalence of smoking/tobacco use (10.7% vs. 25.0%) (P < 0.05). In STEMI patients 28 (57.1%) were thrombolysed (diabetes 17.8% vs. 31.9%), percutaneous coronary interventions (PCI) was in 67.8% diabetics versus 84.7% nondiabetics and coronary bypass surgery in 21.4% versus 8.3%. At discharge, in diabetics versus nondiabetics, there was similar use of angiotensin converting enzyme inhibitors (67.9% vs. 69.4%) and statins (100.0% vs. 98.6%) while use of dual antiplatelet therapy (85.7% vs. 95.8%) and beta-blockers (64.3% vs. 73.6%) was lower (P < 0.05). Conclusions: Diabetic patients with ACS have greater prevalence of cardiometabolic risk factors (obesity, abdominal obesity, and hypertension) as compared to nondiabetic patients. Less diabetic patients undergo PCIs and receive lesser dual anti-platelet therapy and beta-blockers

Gender differences in 7 years trends in cholesterol lipoproteins and lipids in India: Insights from a hospital database

Objective: To determine gender differences and secular trends in total, low-density lipoprotein (LDL) and high DL (HDL) cholesterol and triglycerides using a large hospital database in India. Methods: All blood lipid tests evaluated from July 2007 to December 2014 were analyzed. Details of gender and age were available. Statin therapy was obtained at two separate periods. Trends were calculated using linear regression and Mantel-Haenszel X2. Results: Data of 67395 subjects (men 49,904, women 17,491) aged 51 ± 12 years were analyzed. Mean levels (mg/dl) were total cholesterol 174.7 ± 45, LDL cholesterol 110.7 ± 38, non-HDL cholesterol 132.1 ± 44.8, HDL cholesterol 44.1 ± 10, triglycerides 140.8 ± 99, and total: HDL cholesterol 4.44 ± 1.5. Various dyslipidemias in men/women were total cholesterol ≥200 mg/dl 25.4/36.4%, LDL cholesterol ≥130 mg/dl 28.1/35.0% and ≥100 mg/dl 54.4/66.4%, non-HDL cholesterol ≥160 mg/dl 25.5/29.6%, HDL cholesterol <40/50 mg/dl 54.4/64.4%, and triglycerides ≥150 mg/dl 34.0/26.8%. Cholesterol lipoproteins declined over 7 years with greater decline in men versus women for cholesterol (Blinear regression = −0.82 vs. −0.33, LDL cholesterol (−1.01 vs. −0.65), non-HDL cholesterol (−0.88 vs. −0.52), and total: HDL cholesterol (−0.02 vs. −0.01). In men versus women there was greater decline in prevalence of hypercholesterolemia (X2trend 74.5 vs. 1.60), LDL cholesterol ≥130 mg/dl (X2 trend 415.5 vs. 25.0) and ≥100 mg/dl (X2 trend 501.5 vs. 237.4), non-HDL cholesterol (X2trend 77.4 vs. 6.85), total: HDL cholesterol (X2 trend 212.7 vs. 10.5) and high triglycerides (X2trend 10.8 vs. 6.15) (P < 0.01). Use of statins was in 2.6% (36/1405) in 2008 and 9.0% (228/2527) in 2014 (P < 0.01). Statin use was significantly lower in women (5.8%) than men (10.3%). Conclusions: In a large hospital - database we observed greater hypercholesterolemia and low HDL cholesterol in women. Mean levels and prevalence of high total, LDL, non-HDL and total: HDL cholesterol declined over 7 years. A lower decline was observed in women. This was associated with lower use of statins

Gender differences in 7 years trends in cholesterol lipoproteins and lipids in India: Insights from a hospital database

Objective: To determine gender differences and secular trends in total, low-density lipoprotein (LDL) and high DL (HDL) cholesterol and triglycerides using a large hospital database in India. Methods: All blood lipid tests evaluated from July 2007 to December 2014 were analyzed. Details of gender and age were available. Statin therapy was obtained at two separate periods. Trends were calculated using linear regression and Mantel-Haenszel X2. Results: Data of 67395 subjects (men 49,904, women 17,491) aged 51 ± 12 years were analyzed. Mean levels (mg/dl) were total cholesterol 174.7 ± 45, LDL cholesterol 110.7 ± 38, non-HDL cholesterol 132.1 ± 44.8, HDL cholesterol 44.1 ± 10, triglycerides 140.8 ± 99, and total: HDL cholesterol 4.44 ± 1.5. Various dyslipidemias in men/women were total cholesterol ≥200 mg/dl 25.4/36.4%, LDL cholesterol ≥130 mg/dl 28.1/35.0% and ≥100 mg/dl 54.4/66.4%, non-HDL cholesterol ≥160 mg/dl 25.5/29.6%, HDL cholesterol <40/50 mg/dl 54.4/64.4%, and triglycerides ≥150 mg/dl 34.0/26.8%. Cholesterol lipoproteins declined over 7 years with greater decline in men versus women for cholesterol (Blinear regression = −0.82 vs. −0.33, LDL cholesterol (−1.01 vs. −0.65), non-HDL cholesterol (−0.88 vs. −0.52), and total: HDL cholesterol (−0.02 vs. −0.01). In men versus women there was greater decline in prevalence of hypercholesterolemia (X2trend 74.5 vs. 1.60), LDL cholesterol ≥130 mg/dl (X2 trend 415.5 vs. 25.0) and ≥100 mg/dl (X2 trend 501.5 vs. 237.4), non-HDL cholesterol (X2trend 77.4 vs. 6.85), total: HDL cholesterol (X2 trend 212.7 vs. 10.5) and high triglycerides (X2trend 10.8 vs. 6.15) (P < 0.01). Use of statins was in 2.6% (36/1405) in 2008 and 9.0% (228/2527) in 2014 (P < 0.01). Statin use was significantly lower in women (5.8%) than men (10.3%). Conclusions: In a large hospital - database we observed greater hypercholesterolemia and low HDL cholesterol in women. Mean levels and prevalence of high total, LDL, non-HDL and total: HDL cholesterol declined over 7 years. A lower decline was observed in women. This was associated with lower use of statins

Non-physician health workers for improving adherence to medications and healthy lifestyle following acute coronary syndrome: 24-month follow-up study

Objective: To evaluate usefulness of non-physician health workers (NPHW) to improve adherence to medications and lifestyles following acute coronary syndrome (ACS). Methods: We randomized 100 patients at hospital discharge following ACS to NPHW intervention (n = 50) or standard care (n = 50) in an open label study. NPHW was trained for interventions to improve adherence to medicines – antiplatelets, β-blockers, renin–angiotensin system (RAS) blockers and statins and healthy lifestyles. Intervention lasted 12 months with passive follow-up for another 12. Both groups were assessed for adherence using a standardized questionnaire. Results: ST elevation myocardial infarction (STEMI) was in 49 and non-STEMI in 51, mean age was 59.0 ± 11 years. 57% STEMI were thrombolyzed. On admission majority were physically inactive (71%), consumed unhealthy diets (high fat 77%, high salt 58%, low fiber 57%) and 21% were smokers/tobacco users. Coronary revascularization was performed in 90% (percutaneous intervention 79%, bypass surgery 11%). Drugs at discharge were antiplatelets 100%, β-blockers 71%, RAS blockers 71% and statins 99%. Intervention and control groups had similar characteristics. At 12 and 24 months, respectively, in intervention vs control groups adherence (>80%) was: anti platelets 92.0% vs 77.1% and 83.3% vs 40.9%, β blockers 97.2% vs 90.3% and 84.8% vs 45.0%), RAS blockers 95.1% vs 82.3% and 89.5% vs 46.1%, and statins 94.0% vs 70.8% and 87.5% vs 29.5%; smoking rates were 0.0% vs 12.5% and 4.2% vs 20.5%, regular physical activity 96.0% vs 50.0%, and 37.5% vs 34.1%, and healthy diet score 5.0 vs 3.0, and 4.0 vs 2.0 (p < 0.01 for all). Intervention vs standard group at 12 months had significantly lower mean systolic BP, heart rate, body mass index, waist:hip ratio, total cholesterol, triglyceride, and LDL cholesterol (p < 0.01). Conclusions: NPHW-led educational intervention for 12 months improved adherence to evidence based medicines and healthy lifestyles. Efficacy continued for 24 months with attrition

Praktyczne wskazówki dotyczące samodzielnych iniekcji insuliny w leczeniu cukrzycy w warunkach indyjskich: stanowisko zespołu ekspertów

Celem niniejszego konsensusu było dostarczenie prostych i łatwych do wdrożenia w praktyce wytycznych edukacyjnych dla pracowników opieki zdrowotnej i pacjentów, dotyczących wstrzykiwania insuliny w samoleczeniu cukrzycy w warunkach indyjskich. Zespół ekspertów krytycznie przeanalizował opublikowane dane z wytycznych, badań klinicznych i rzeczywistej praktyki klinicznej i uzgodnił zestaw praktycznych zaleceń dotyczących optymalnego stosowania insulinoterapii w odniesieniu do: a) miejsc wstrzyknięcia (przygotowanie miejsca wstrzyknięcia, wybór miejsca wstrzyknięcia, rotacja miejsca); b) wyboru urządzenia i przechowywania insuliny; c) środków ostrożności, utylizacji ostrych przedmiotów i powikłań. Eksperci poddali analizie wyniki uzyskane w części ogólnej i indyjskiej badania 2014–2015 ITQ, zwracając uwagę na potrzebę poprawy opieki diabetologicznej w zakresie wszystkich aspektów wpływających na prawidłowe wstrzykiwanie insuliny.  Niniejszy dokument zawiera proste i łatwe do stosowania praktyczne zalecenia edukacyjne dla pracowników opieki zdrowotnej i pacjentów, dotyczące optymalizacji techniki wstrzykiwania insuliny zgodnie z najnowszymi osiągnięciami w zakresie urządzeń do podawania insuliny, najnowszymi wynikami badań i uaktualnionymi wytycznymi międzynarodowymi, a także związane z powszechnymi obawami dotyczącymi nieprzestrzegania środków ostrożności, takich jak używanie wtryskiwacza wyłącznie u jednego pacjenta i odpowiednia utylizacja ostrych przedmiotów.

Phenotype–genotype spectrum of AAA syndrome from Western India and systematic review of literature

Objective: To study genotype–phenotype spectrum of triple A syndrome (TAS). Methods: Retrospective chart analysis of Indian TAS patients (cohort 1, n = 8) and review of genotyped TAS cases reported in world literature (cohort 2, n = 133, 68 publications). Results: Median age at presentation was 4.75 years (range: 4–10) and 5 years (range: 1–42) for cohorts 1 and 2, respectively. Alacrima, adrenal insufficiency (AI), achalasia and neurological dysfunction (ND) were seen in 8/8, 8/8, 7/8 and 4/8 patients in cohort 1, and in 99, 91, 93 and 79% patients in cohort 2, respectively. In both cohorts, alacrima was present since birth while AI and achalasia manifested before ND. Mineralocorticoid deficiency (MC) was uncommon (absent in cohort 1, 12.5% in cohort 2). In cohort 1, splice-site mutation in exon 1 (p.G14Vfs*45) was commonest, followed by a deletion in exon 8 (p.S255Vfs*36). Out of 65 mutations in cohort 2, 14 were recurrent and five exhibited regional clustering. AI was more prevalent, more often a presenting feature, and was diagnosed at younger age in T group (those with truncating mutations) as compared to NT (non-truncating mutations) group. ND was more prevalent, more common a presenting feature, with later age at onset in NT as compared to T group. Conclusion: Clinical profile of our patients is similar to that of patients worldwide. Alacrima is the earliest and most consistent finding. MC deficiency is uncommon. Some recurrent mutations show regional clustering. p.G14Vfs*45 and p.S255Vfs*36 account for majority of AAAS mutations in our cohort. Phenotype of T group differs from that of NT group and merits future research