Type 2 Diabetes Management Algorithms?

Diabetes is increasing in prevalence all over the world. India is known as the “Diabetes Capital of the World.” Many practice guidelines and approach algorithms for management of type 2 diabetes exist, but there are no guidelines specific for the Asian Indian population.

The article by the India Diabetes Management Algorithm Proposal Group entitled “A proposed India-specific algorithm for management of type 2 diabetes” ¹ in this issue is a stepping stone toward formulating management guidelines addressing a critical need in a population in which limited authoritative guidelines are available. Separate guidelines for the Asian Indian patients with type 2 diabetes are the need of the hour as these patients differ from the rest of the world in terms of early age of onset of diabetes, occurrence of diabetes in nonobese and sometimes lean people, differences in the relative contributions of insulin resistance and β-cell dysfunction, marked postprandial glycemia, low access to health care and medications in people of low socioeconomic stratum, and ethnic dietary practices (e.g., ingestion of high-carbohydrate diets. ^{2 –8} Even within India there are a wide variety of cultural differences, including dietary patterns, literacy rates, socioeconomic factors, and awareness levels, that may alter the clinical applicability of the proposed guidelines.

In the management of type 2 diabetes, metformin remains the first line of treatment for overweight/obese patients. ⁹ But because many of the Asian Indian type 2 diabetes patients are nonobese or are lean and thin, the authors ¹ propose the use of sulfonylurea as a first-line treatment for such patients. An added advantage of sulfonylurea is its low cost when compared with many other treatment options like dipeptidyl peptidase-4 inhibitors, sodium–glucose co-transporter-2 inhibitors, and α-glucosidase inhibitors. In my experience also, sulfonylureas work well in these patients, especially when cost is a constraint. The article also proposes the use of dipeptidyl peptidase-4 inhibitors as first-line drugs if cost is not of major concern.

Despite the regional heterogeneity in diet within India, carbohydrates form a major bulk of the diet, thus leading to marked postprandial glycemia. Hence therapies directed at greater reduction in postprandial glycemia are desirable. The authors ¹ also state that “α-glucosidase inhibitors are attractive therapeutic options as add-on drugs in Asian Indians as their mechanism of action helps in blunting the postprandial glucose spikes caused by large amounts of refined cereals in the diet.” ^7,8

Regarding the use of insulin, the proposed guidelines provide the flexibility of using NPH insulin, premix insulin, or insulin analog, in contrast to the American Diabetes Association/European Association for the Study of Diabetes guidelines, where analog insulin is specifically recommended. The conventional insulins are comparable to analog insulins in terms of glycemic control. But, cost and availability are a major concern in the Asian Indian population, where the majority of the patients are still residing in villages or small towns. Use of analog insulins, which are three times more costly than the conventional insulins, leads to reduced compliance and adherence to treatment in the long term.

Formulation of any guidelines requires evidence from large-scale randomized studies. Because guidelines affect clinical decision making, therefore it is important to show that the guidelines are based on evidence that the components of the proposed algorithm are objectively effective in this population. There is limited evidence available to support the use of these type 2 diabetes mellitus therapies specifically in Asian Indians in India. This is a limitation that has been pointed out by the authors. ¹ The proposed algorithm is an expert consensus. It paves a way for further studies in the future to generate more data on the applicability of the specific therapies in Asian Indian populations.