 Namaste. I am Dr. A. Sharda here. Namaste. I am Dr. Priya Chinappa. We are both from the Department of Endocrinology and Diabetes from Manipal Hospital Millers Road. Today being the World Diabetes Day, we are here to discuss what is new in diabetes and what are the updates in the drugs which are available for treating diabetes. So Dr. Priya, before we move on to drugs, what is this I hear very fashionable word reversal of diabetes. Is it possible? Yeah, it's actually true. A lot of patients keep coming to my OPD and asking me about reversal of diabetes. It is possible and there is a science behind it. What actually happens is over time and periods of excess calorie intake leads to fat deposition in the liver, decreased insulin sensitivity at that level spillover to the pancreas and fat deposition in the pancreas and decreased insulin secretion which actually leads to diabetes. So is it possible to reverse the diabetes? Yes, so they believe the science behind it is the same process that causes the diabetes can be reversed by excess calorie intake. So a calorie deficit by eating a balanced low calorie diet and achieving weight loss, they can actually achieve diabetes remission. Now actually it's better to use the word diabetes remission. Don't you think because using the word reversal patients might feel that they're cured of diabetes but they never actually achieve a cure. It is only remission and they have to be careful because if they go back to old habits and regain the weight, they can get diabetes again so they will have to be on a watch. So basically we can reverse diabetes only in people who are obese not people who are already thin. That's right exactly and I think that's very important for viewers to even understand that they need to lose a weight of at least 15 kilograms to achieve diabetes remission. Now that means somebody who is already thin they don't have the 15 kilograms to lose so they will not be able to achieve remission and this of course doesn't apply to type 1 diabetic patients. Now you know having stressed so much about weight loss and diabetic control of course lifestyle is important. Now what happens to patients who cannot achieve weight loss or diabetic control with lifestyle alone? That's very important because lifestyle that is healthy diet and regular physical activity is the cornerstone of type 2 diabetes management which is the commonest form of diabetes all over the world. But it is never sufficient hand in glove we will have to use medications many times and people who are obese there are two classes of medicines which we use. One is the SGLT2 inhibitor and the other one is the GLP1 receptor analog. Are these injectable or do we have tablets? That's an important question because a patient who is obese and has just developed diabetes they are not very happy to take injections. GLP1 analogs are available as injections also and recently peptide in a pill that is called ribalsis has been released which is the medicine inside called semi-glutide which was available as injection before. So for the last 10 years we have lyraglutide and dulaglutide which are both injectable medicine. Lyrraglutide is once daily injection and dulaglutide is once a week injection. But with this new pill which is available in India for the last 6 months patients are more happy to take the tablet instead of injection. Yes definitely I think that will really help and nobody likes to take injections and if they can substitute to the tablet it's good. But can you also tell us about this newer drug which was recently launched to the United States in May. I heard that's very effective for weight loss and for sugar control. Yeah that's very important that actually in addition to the GLP1 analog it has got a GIP receptor analog. So these two medications together is able to achieve better weight loss up to 11 kgs and also it can do better HVNC control up to 2.4% reduction. This has been released in US like you said in May 22. But it is not yet available in India but the other medications we are having here that is the GLP1 receptor analogs are doing a great job including the oral pill and the SGLT2 inhibitor which is available as a tablet is also very effective in reducing the weight and controlling diabetes without causing low sugar. That's very good that now we have so many options for obese patients with diabetes. I'm moving on from obesity one of the effects it has obesity is the fatty liver. So what is your experience in patients who are having diabetes with liver disease especially fatty liver? Yeah I think that's the new epidemic isn't it this fatty liver because when we see patients who come with a routine health checkup their master health checkup a lot of patients are reported to have fatty liver and it is said that about 20 to 50% of our diabetic patients in India actually have this fatty liver. That's a huge number you know. So how do you manage these patients? Yes so in the beginning we look at their ultrasound findings and the blood test the ALT is frequently elevated some patients may not have abnormal liver function tests though they have fatty liver on the ultrasound. Now initially weight loss is very effective at least a 5% weight loss if patients are able to achieve they can be reassessed after three months and a lot of the fatty liver is reversed. Now some patients unfortunately are not able to achieve it and they go on to develop inflammation and fibrosis which can progress to cirrhosis. Apparently this is the most common cause of end stage liver disease worldwide. This is non-alcoholic liver disease or fatty liver and these patients are also obviously advised to abstain from alcohol and if they have diabetes we control them with the usual medications that we have just discussed. Only when they go into end stage liver disease then we need to stop the medications and put them on insulin. So you know that's how the liver patients are managed. Now frequently you know we hear about kidney disease in diabetes. Can you tell us if kidney disease is diagnosed only with a high creatinine or can they have kidney disease with normal creatinine? Oh that's a very interesting question because diabetic patients tend to have kidney problems especially if they have had uncontrolled diabetes and long term diabetes and there is a genetic that is the family history of diabetes with kidney disease in the family. That's called diabetic kidney disease in the family. Like Dr. Priya just asked me we can have kidney problem in patients with diabetes with normal creatinine. So and this can be easily diagnosed by doing the routine urine examination and looking at the protein leak. So if this protein leak is in fact the first indication of kidney problem in a diabetic and fortunately we are now having proven benefits of glucose lowering medications like SGLT2 inhibitors which can reverse the protein leak and also stop the progression to further development of diabetic kidney disease and kidney failure leading to increase in creatinine. Many of my patients are actually having good proteinuria has been reversed or minimized and they are able to postpone the increase in the creatinine for many many years. That's very good. So early detection and monitoring for the proteinuria is important. Now how do we manage the diabetes once the creatinine goes up? In the beginning like I said with only proteinuria SGLT2 inhibitors are extremely good and the drug called metformin can also be safely used. But when the creatinine is a little up they develop what is called mild to moderate liver failure. In that case we can still use the SGLT2 inhibitors till the creatinine is manageable 1.4, 1.5 with the GFR of around 45 for some and 30 for some of the molecules and the GLP1 analogs are also indicated up to a mild to moderate kidney problem only if the creatinine has increased to a stage of dialysis or the GFR is less than 30 to 15 then we need to use only insulin. Likewise like in the liver disease initially we can use certain medications in people with diabetic kidney disease in fact it is beneficial for the kidney outcomes. So like in end stage liver disease, end stage renal disease we need to go on insulin but till such time there are lot of medications and they can actually benefit isn't it? Yes. Now what about this heart failure because in heart failure also there is lot of breathlessness and water retention, puffiness of face, swelling of legs etc. In patients who have diabetes and heart failure any particular medications would you use? Yes, actually this heart failure is a very important complication of diabetes and I think it is often unrecognized and it is the most frequent reason for ER visits this heart failure and recklessness. Now some of the medications that we discussed the SGLT2 inhibitors really help patients with heart failure these drugs the way they work they bypass the pancreas and the liver but they act on the kidney and they decrease the glucose reabsorption so glucose is excreted and along with that water so the water retention and everything actually comes down. So these drugs are even indicated for heart failure and it is found to reduce the readmission rate of heart failure patients. That is very interesting. So can these drugs be used in patients who have heart failure without diabetes? That's an excellent question and yes because earlier we used to use these drugs only for diabetic patients but they are indicated in patients with heart failure without diabetes because it helps in reducing the volume overload. Now that we have spoken about heart failure some of these patients have had angioplasty and bypass surgeries with diabetes so how would we manage them? So that is also a very important part because the patients who have diabetes are 4 times more to heart attacks than patients who do not have diabetes. So we have to keep this in mind whenever we are seeing patients with diabetes I am not looking just at the glucose control that is an important part of my job but the most important part we need to be alive to look after the diabetes. So the heart problems are very important to look at the risk factors family history of heart problems smoking history their blood pressure their cholesterol that is called the ABC. We need to manage the A1C's the blood pressure and cholesterol and also look at the family history. So these patients are supposed to have what is called atherosclerotic heart disease as opposed to heart failure which is a pump failure of the heart. We have patients with atherosclerosis which is actually a pipe problem. The blood vessels which are in the heart and the brain which supply our legs these are called the macrovascular problem. They all get blocked over the years of diabetes blood pressure and high cholesterol and that is called atherosclerosis and for these patients especially in addition to diabetes control blood pressure control cholesterol control we prefer the GLP1 receptor analogs which we have discussed in patients with obesity also because these molecules have shown that we can reduce the cardiovascular that is heart related mortality in the bypass patient or the angioplasty patient by about 22% and even the death due to all cause has also been shown to reduce in people with heart disease and diabetes. If the patient cannot tolerate or use the GLP1 receptor analog for any reason then we can also consider the SGLT2 inhibitors which we discussed earlier this also has been shown to benefit these group of patients tremendously. So I think what we are trying to say is you know once a diabetic patient walks into our clinic we need to first look at whether you know they need to lose weight or not and try to help them lose weight if lifestyle fails we give them certain medications like either GLP1 agonist the injectable or the oral or SGLT2 which will help them lose weight and then once they develop certain complications we need to consider these medications again is that what you are trying to say? That is true and like I said we have lot of evidence and in the last decade we are looking at diabetic patient not at the sugar level and selecting the medicines all over the world we are looking at a patient with diabetes what are the other risk factors with the patient whether there is a kidney problem whether there is a heart problem or a heart failure and then trying to treat the patient as a whole so it is a lot of personalized medications and there is a big place in the armamentarium of diabetes first being metformin then we have weight neutral medicines like DPP4 inhibitors which actually increase our own endogenous GLP1 levels although they are not as effective as GLP1 receptor analogs especially in weight loss because they do weight neutrality but still they have a big place in the armamentarium so each patient who comes to us needs personalized attention and looking at the entire spectrum of problems in the patient and not look at just the glucose which was the approach a couple of decades ago and this has taken a long way now and we all do risk management of the patient rather than just glucose control having said that diabetes control is of paramount importance but in addition other risk factors for heart disease, kidney problems liver fatty liver especially and obesity needs to be managed to have a very healthy productive and long life thank you