Missing the wood for the trees: cardiocentricity in current diabetes guidelines
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LETTER TO THE EDITOR
Missing the wood for the trees: cardiocentricity in current diabetes guidelines Sanjay Kalra 1 & Banshi Saboo 2 & Nagendra Kumar Singh 3 & Sarita Bajaj 4 Received: 21 June 2020 / Accepted: 7 November 2020 # Research Society for Study of Diabetes in India 2020
Diabetes is a complex syndrome, and guidelines are expected to simplify the process of clinical decision making. The consensus by the American Diabetes Association (ADA and the European Association for the Study of Diabetes (EASD [1]) stratifies persons with type 2 diabetes based on established atherosclerotic cardiovascular disease (ASCVD)/chronic kidney disease (CKD) and supports use of glucagon-like peptide 1 receptor agonists (GLP1RA) and sodium glucose cotransporter 2 inhibitors (SGLT2i). Better-established drug classes, supported by experience and evidence [2], have been relegated to third-line status. This consensus, by focusing on vascular disease as the main determinant of glucose-lowering medication, has missed the wood for the trees. Diabetes is equivalent to a dense tropical jungle, full of heterogenous flora and fauna. Obstacles encountered in such an environment necessitate individualization of coping strategies at every bend and corner. This is absolutely true for diabetes care as well. The term “established ASCVD” is difficult to understand. Many people with diabetes have subclinical ASCVD [3]. Where these individuals will fit in the current algorithm is uncertain. A similar dilemma occurs in atypical CVD, or anginal equivalent symptoms. Single-minded emphasis on established ASCVD, without acknowledging subclinical and atypical CVD, is as limited in relevance as the glucocentricity of earlier guidelines. CKD offers similar challenges for the practicing diabetes care provider. eGFR-based triage does make pharmacodynamic
* Sanjay Kalra [email protected] 1
Department of Endocrinology, Bharti Hospital, Karnal, India
2
Department of Diabetology, DiaCare Hospitals, Ahmedabad, India
3
Department of Diabetology, Diabetes and Heart Research Centre, Dhanbad, India
4
Department of Medicine, MLN Medical College, Allahabad, India
sense, but deflects attention from other aspects of renal health, such as albuminuria. Current guidance relegates adverse events and patient satisfaction to the sidelines. Adverse events that occur with GLP1RA and SGLT2i are not insignificant, and should be considered before issuing blanket recommendation for their use. Persons with symptomatic severe hyperglycemia, or those who are “sick,” are not right candidates for GLP1RA and SGLT2i. For example, how does one classify a person with recent acute coronary syndrome, heart failure, stroke, or acute kidney injury? Should preexisting GLP1RA or SGLT2i be continued during the acute illness? What time lag should be allowed to lapse before prescribing GLP1RA or SGLT2i [4, 5]? Medicine is built upon physiology and biochemistry. The consensus makes no mention of the pathophysiologic basis of diabetes, or the need to assess insulin resistance or secretory de
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