Dr. V Mohan in his exclusive series on Diabetes for M3 India, answers questions posted by readers on his previous article- Have latest anti-diabetic drugs replaced the old ones?

---

For our comprehensive coverage and latest updates on COVID-19 click here.

---

Question 1. In a patient with T2DM and CKD stage 4 and 5, should Gliclazide or Glimepride be used, or only insulin?

Dr. V Mohan: At CKD stages 4 and 5, it is advisable to use insulin only. DPP4 inhibitors, especially Linagliptin can be used at any stage of CKD even without any dose adjustments. Other DPP4 inhibitors like Sitagliptin can be used but in lower doses. Sulphonylureas usually tend to produce hypoglycaemia at these stages of CKD and it is better to avoid them.

---

Question 2. Please guide on initiation and titration of various type of insulin regime.

Dr. V Mohan: It is difficult to answer this in a question and answer session like this as it will need a whole lecture. However, I will broadly classify it as initiation of insulin regime in type 1 and type 2 diabetes. In type 1 diabetes, right from the beginning, a basal/bolus regime would be needed in most cases with one long-acting insulin given at night and small doses of short-acting insulin given with each meal. In type 2 diabetes, insulin is usually given after the oral drugs fail, although I do use the insulin at the time of diagnosis of diabetes if there is evidence of glucotoxicity and lipotoxicity. If you are giving it after secondary failure of oral drugs, then usually, a basal insulin given at night should be sufficient. However, if the postprandial sugars continue to be high, then premixed insulin or insulin co-formulations may be better.

---

Question 3. What is the role of Tinegliptin?

Dr. V Mohan: The only advantage of Tinegliptin is that it is cheap. However, there are no long term CVOT or other safety trials. There is also a concern about QTc prolongation with Tinegliptin which has never been fully resolved. If it is to be used, we should not combine it with other agents like hydroxychloroquine, azithromycin or other drugs which can lead to QTc prolongation. Having said that, Tinegliptin has become quite popular in our country.

---

Question 4. Among sulfonylureas, which one has less incidence of hypoglycaemia and good renal safety (Glimepride or Gliclazide)?

Dr. V Mohan: My favourite sulphonylurea is Gliclazide although I do use Glimepride also. Both these drugs definitely have lower incidence of hypoglycaemia than older sulphonylureas like Glibenclamide and both have good renal safety. However, if the CKD is severe, it is better to avoid all sulphonylureas.

---

Question 5. Which newer anti-diabetic drugs can be prescribed during first, second, and third trimester of pregnancy other than injectable insulin? Please suggest.

Dr. V Mohan: During pregnancy, I always prefer insulin. However, quite a lot of people use Metformin if the GDM is mild. Most of the other anti-diabetic drugs are not recommended during pregnancy.

---

Question 6. Should SGLT2 inhibitors be restarted after a patient gets recurrent arthritis, cystitis, pyelonephritis, and genital mycotic infections?

Dr. V Mohan: After giving it a break, there is no harm in giving one more trial of SGLT2 inhibitors. If the problems are recurrent, it is better to withdraw them completely.

---

Question 7. Is tablet Linagliptin alone sufficient for a T2DM patient with CKD?

Dr. V Mohan: In some cases, if the diabetes is mild, Linagliptin alone may be sufficient. In others, insulin or other OHA may be required.

---

Question 8. SGLT2 inhibitors cause high excretion of sugar in urine that usually results in recurrent urinary infection. How can one overcome this problem?

Dr. V Mohan: More than recurrent urinary infection, genital mycotic infections are more common. If one drinks large quantities of water, (at least 3 litres per day) urinary infections can usually be avoided.

---

Question 9. Among the DPP-4 inhibitors, is there any inter-class difference with respect to their efficacy or are they all equally efficacious? I read that Sitagliptin and Teneligliptin have been shown to be more effective in Indian population than other DPP-4 inhibitors? Is this true?

Dr. V Mohan: There is no evidence that any particular DPP4 inhibitor is more effective than the other. However, with respect to their CVOT outcomes there are big differences. Only Sitagliptin and Linagliptin have been shown to be completely safe by CVOT trials, whereas Saxagliptin has been shown to increase hospitalisation for heart failure. With the other Gliptins, we do not have any CVOT trials at all.

---

Question 10. Can we prescribe DPP4 inhibitors or SGLT2 inhibitors in pregnant woman?

Dr. V Mohan: It is better to avoid these drugs in pregnant women.

---

Question 11. Which class of drugs are to be used in patients having serum creatinine level 2- 4 with comorbidities like HTN?

Dr. V Mohan: One has to take the whole picture of the patient into consideration. What is the duration of diabetes? What is the HbA1c? What are the current medications, the patient is on, and so on. Then, the appropriate anti-diabetic drug has to be decided.

---

Question 12. Which drug is to be used with people undergoing regular dialysis safely without much alterations? Lina or Glipizide/Gliclazide?

Dr. V Mohan: Linagliptin is considered to be safe at any level of renal failure including those undergoing dialysis. At the stage of dialysis, it may be better to avoid sulphonylureas.

---

Question 13. In older women is SGLT2 safe to use as some are prone to vulovaginitis? Will it further increase the risk?

Dr. V Mohan: Not only in older women but also in older men, we have to use SGLT2 carefully not just because of the genital infections, but also because of electrolyte imbalance, hypotension, dehydration, etc.

---

Question 14. Is it rational to prescribe sulphonylurea with DPP4 inhibitor?

Dr. V Mohan: Studies have shown that there is no harm in combining a sulphonylurea with DPP4 inhibitor. In fact, we have shown in one of our publications that even when sulphonylureas and Metformin were not producing sufficient effect, addition of DPP4 inhibitor controlled the diabetes quite well.

---

Question 15. Can SGLT2 inhibitors be given to patients having EGFR less than 45?

Dr. V Mohan: Currently, SGLT2 inhibitors are preferred for EGFR upto 45. However, there are ongoing studies looking at the use of SGLT2 inhibitors even in those with lower EGFR.

---

Question 16. A patient on Telmisartan 80 mg is found to have serum creatinine 3.0 and no increment in the value of creatinine. Do we have to stop Telmisartan and switch over to another anti-hypertensive?

Dr. V Mohan: According to nephrologists, there is no need to stop the Telmisartan unless there is hyperkalemia or other contradictions.

---

Question 17. Among the sulphonylurea drugs, which SU is the most favoured drug? Are plain or modified release preparations preferable when we opt for Gliclazide molecule?

Dr. V Mohan: Among the sulphonylurea drugs, Gliclazide and Glimepride are the safest to use. The modified release form of the Gliclazide is generally preferred.

---

Question 18. What is the likelihood of one developing acute pancreatitis when taking DPP4 inhibitors? Is it real? What precautions do we need to take before prescribing these drugs?

Dr. V Mohan: The risk of pancreatitis when using the DPP4 inhibitors is extremely low in real-world experience. However, if somebody already has a history of pancreatitis, it is better to avoid these agents.

---

To read other articles in this series, click

Have latest anti-diabetic drugs replaced the old ones?: Ask Dr. V Mohan

Can COVID-19 induce diabetes?: Ask Dr. V Mohan

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. V Mohan is the Chairman & Chief of Diabetology at Dr. Mohan’s Diabetes Specialities Centre & Madras Diabetes Research Foundation, Chennai, India.