All new anti diabetic agents should have cardiovascular safety- Prof. Azizur Rehman


All new anti diabetic agents should have
cardiovascular safety- Prof. Azizur Rehman
Heart failure is the most common cause of
hospitalization in elderly-Mirza Yousaf Baig

SWAT: The third scientific session during the PSIM Mid-Summer meeting at Swat was devoted to Cardio metabolic Diseases. It was chaired by Prof.M.Akbar Chaudhry along with Prof. Zafar Iqbal Chaudhry, Prof. Mumtaz Marwat while Dr.Nabeel Akbar was the moderator.

Dr. Mirza Yousaf Baig from Ziauddin University Hospital Karachi was the first speaker who discussed management of heart failure. He pointed out that it is complex syndrome wherein there is more emphasis on relaxing. There are reported to be 26 million people with heart failure and its prevalence increases with age. According to estimates about 15% of the people over the age of eighty years suffer from heart failure. It is considered the most common diagnosis and cause of hospitalization in the elderly. It has high mortality and five years survival is just about 50%. Morbidity and mortality due to heart failure is increasing.

Heart failure, he further stated, is a progressive disease and it has still poor understanding. It has multiple endemic etiologies. Its complications include renal injury, shock liver and it reserves ejection fraction. EF, it was further stated, does not relate to mortality and hospitalization. Ejection Fraction can be impaired which is known as stage-1, it can be unchanged or it can be deteriorated. It is essential to find out that what lead to this heart failure; one should look for metabolic problems or hereditary factors. He then talked about guidelines directed medical therapy and referred to the use of ACE Inhibitors, ARBs and Beta Blockers. He also gave highlights from the SHIFT Trial and talked about AHA and ESC guidelines for the management of heart failure. RASS inhibitors improve symptoms but it has no effect on mortality. With the use of ARBs MRA are reduced. Use of diuretics is recommended. Physical exercise and atrial septal shunt are effective but we need to work on prevention of heart failure, he added.

Management of
Type-2 Diabetes

Prof. Azizur Rehman from Rashid Latif Medical College discussed management of Type-2 diabetes. Most often the diagnosis of diabetes, he stated, is incidental. Once the diagnosis is made, the treatment modalities include life style changes, use of oral agents and injectable. For its management we have many options. Metformin, sulphonylureas, pioglitazone, insulin are all effective. GLP1 RA are potent glucose lowering agent, they do not have weight gain and are also offer cardiovascular safety. However, they are injectable, costly, have some GI side effects and there are reports of pancreatitis and bladder cancer. DPP4 are also effective. He then referred to the safety and efficacy of SGLT2 inhibitors i.e. DAPA and EMPA. They are potent AIc lowering agents. There is no hypotension, DKA and renal shut down.

During the discussion it was pointed out that all new anti diabetic agents should have cardiovascular safety. As regards AHA and ESC guidelines and consensus statement, they apply to the community not individuals. It is important to assess the patient before starting the treatment from the beginning. These guidelines do not address the multiple co-morbidities. Hence, these guidelines cannot be applied as such. One has to modify them with a patient centered approach. The importance of shared decision making was emphasized and it was suggested that one should discuss it with the patient. It is also important to review the treatment plan on every visit. Metformin will remain the No. 1 drug of choice for management of diabetes. One can add on or remove other agents. Metformin should be combined with life style changes. DPP4 Inhibitors, SGLT2 and sulphonylureas are all effective in type-2 diabetes. Patients with heart failure and CKD should be managed with GLP1 RA and SGLT2 inhibitors along with basal insulin. Metformin plus SGLT2 inhibitors can be continued as a combination. It is advisable to stop sulphonylureas when one continues insulin or reduce it dosage. HbA1c less than 7 are good but this is what one can achieve with lot of problems although HbA1c of 6.5 is ideal. It was reiterated that Metformin remains the No.1 drug for management of diabetes and it is important to opt for early cardiovascular Evaluation.

Prof. Imran Hasan Khan from Lahore talked about Good and Bad Cholesterol and said that there is lot of confusion which exists about it. Over the years, many diets which were first considered good and preferred were later told should be avoided. LDL is considered bad while HDL cholesterol is good. Lipids, he said, should not be measured during illness. Pregnancy and recent weight gain will increase lipids. Use of total cholesterol can be misleading for designing treatment. Canada and Denmark are using non-fasting cholesterol as it is considered a better predictor for risk of coronary artery disease, stroke and total mortality. Speaking about dietary interventions he suggested use of fresh fruits and vegetables, thirty minutes exercise daily for three to five times in a week. Use of Statins, he said, should be stopped three months before planned pregnancy.

During the discussion it was pointed out that it is not safe to measure cholesterol during fasting. Restrictions are good but do not eliminate anything. Foods should be Halal, delicious and moderation in diet is recommended. Dietary restrictions should be judicious. Prof. Javed Akram emphasized the importance of personalized medicine. With the use of Statins for five years, maximum risk reduction is about 35%. However, screening test must be developed before starting Statins. Prof. Akbar Chaudhry in his concluding remarks laid emphasis on doing justice to management of diabetes mellitus.

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