A good glycemic control or cardio protection

1. A good glycemic
control or cardio
protection?
Dr. Vani Thayyil

2. What are the guideline recommendations?
Metformin remains the first line drug
regimen along with Lifestyle
In case of ASCVD- SGLT2i or GLP1 As
Cost remains the major concern in many
countries
• SUs become the drug of choice
In case of Hypoglycemia concern- DPP4i,
GLP1 As, SGLT2i, TZD
Personalized diabetes
care regimen- Patient
centric approach
Early and intensive
glycemic control to
prevent major macro
and micro vascular
complications

3. Prevalence of T2DM in lower middle income
countries
74% increase in the
prevalence of T2DM in India
LMI countries cost is the
major issue
WHO guideline- SU becomes
the second line of drug
Offers tight, early and
economic glycemic control

4. Major concerns
Cost
Microvascular complications
CVD affects 32.2% people with T2DM
Weight gain
Hypoglycemia
Covid 19- latest

5. The greater the HbA1c reduction, the
lowest the MACE risk

6. The greater the HbA1c reduction, the
lowest the MACE risk
Data with newer OADs

7. Older OADs?
• All major trials included Metformin, SU and Insulin at Baseline
• This proves the efficacy and safety.
ACCORD ADVANCE UKPDS VADT

8. Macro and Micro Vascular Complication
Macro and Micro vascular disease at baseline are
independently associated with increased risk of
MACE.
Managing our patients through glycemic control
from the time of diagnosis is really important

9. Early glycemic control, lesser risk of
Micro vascular complication
The plot shows how delay in glycemic control can lead to increased risk of
micro vascular complication compared to strict glycemic control from the
first year of diagnosis.

10. Early glycemic control, lesser risk of
Macro vascular complication
The plot compared the prevalence of macro vascular complications, micro
vascular complication and death in patient who had HbA1c above 6.5%

11. The ADVANCE study and microvascular
outcomes
ADVANCE showed that
irrespective of estimated
glomerular filtration rate
(eGFR), overall intensive
glycemic control leads to 11%
reduction in major
macrovascular and
microvascular outcomes.

12. Therapeutic Legacy
• Therapeutic inertia may lead to :
Early glycemic control with its therapeutic legacy reduces the risk of Macro and
Micro vascular complications
Diabetic
retinopathy
MI Stroke
Heart
Failure
Composite
CV events

13. Hypoglycemia
• Data from UKCPRD 2020 study shows that the number of hypoglycemic events was really low

14. Severe Hypoglycemia
ADVANCE Data- Overall severe hypoglycemia rates were not very different to the control
arm

15. Weight
In CAROLINA study, the glycemic control, there was no difference
between both arms. And in terms of weight gain as well, there was no
difference between the sulfonylurea arm versus the DPP-4 arm.

16. COVID- 19
Individuals with
poor glycemic
control are the
ones to be
severely affected
by COVID- 19 with
a high chance of
mortality from the
infection.

17. Conclusion
Tight and strict glycemic control is always beneficial in long run taking
care of both micro and macro vascular complications
New generation SUs like gliclazide offers a cost effective yet powerful
glycemic control with reduced risk of hypoglycemia and legacy effect
Weight gain is not an issue with newer generation SUs

18. Thank You