ICMR GUIDELINES FOR MANAGEMENT OF TYPE 2 DIABETES 2018 Indian Council of Medical Research, Ansari Nagar, New Delhi – 110 029 ICMR GUIDELINES FOR MANAGEMENT OF TYPE 2 DIABETES 2018 S.NO CONTENTS PAGE NO. FOREWORD i PREFACE ii ACKNOWLEDGEMENT iii PREAMBLE iv SECTION 1 : INTRODUCTION 1.1 Definition 1 1.2 Epidemiology 1 1.3 Types of diabetes 1 1.4 Differentiating between type 1 and type 2 diabetes 2 1.5 Goals for management 4 1.6 Diabetes education 4 1.7 Prevention of diabetes 5 SECTION 2 : SCREENING FOR TYPE 2 DIABETES 2.1 Whom and when to screen? 7 2.2 How to screen? 7 2.3 Where to screen? 8 2.4 Retesting 8 2.5 Other aspects 8 SECTION 3 : DIAGNOSTIC CRITERIA 3.1 Diagnostic criteria for diabetes 9 ICMR Guidelines for Management of Type 2 Diabetes 2018 3.2 Symptoms of diabetes 9 3.3 Criteria for the diagnosis of prediabetes 9 3.4 Oral Glucose Tolerance Test (OGTT) 10 3.5 Testing for type 2 diabetes in children and adolescents 11 SECTION 4 : TARGETS FOR CONTROL OF DIABETES 4.1 Targets for metabolic control in diabetes 12 4.2 Glycemic targets during pregnancy 13 SECTION 5 : MONITORING AND FOLLOW-UP OF PEOPLE WITH DIABETES 5.1 How to monitor and follow up people with diabetes? 14 5.2 Self monitoring with blood glucose (SMBG) with glucose 14 monitor 5.3 What to do during Annual check up 15 SECTION 6 : NON-PHARMACOLOGICAL MANAGEMENT OF DIABETES 6.1 Lifestyle goals in diabetes 16 6.2 Medical Nutrition Therapy (MNT) 16 6.3 Physical activity and exercise 21 6.4 Yoga and diabetes 22 SECTION 7 : PHARMACOLOGICAL MANAGEMENT OF DIABETES 7.1 Anti-hyperglycemic drugs 24 7.2 Insulin therapy 39 7.3 Non-insulin injectable therapy (GLP-1 receptor agonists) 47 ICMR Guidelines for Management of Type 2 Diabetes 2018 SECTION 8 : COMPLICATIONS OF DIABETES 8.1 Acute complications 48 8.2 Chronic complications 49 8.3 Coronary artery disease 51 8.4 Diabetic nephropathy 52 8.5 Diabetic retinopathy 54 8.6 Diabetic neuropathy 56 8.7 Diabetic foot 57 SECTION 9 : DIABETES AND PREGNANCY 9.1 Pre-gestational diabetes 63 9.2 Gestational diabetes mellitus (GDM) 63 9.3 Management of hyperglycemia in pregnancy 65 9.4 Post-partum follow up 66 SECTION 10 : COMORBID CONDITIONS 10.1 Hypertension 67 10.2 Dyslipidemia 68 10.3 Obesity 68 10.4 Tuberculosis 68 SUMMARY OF GUIDELINES 69 ICMR Guidelines for Management of Type 2 Diabetes 2018 ICMR Guidelines for Management of Type 2 Diabetes 2018 i ICMR Guidelines for Management of Type 2 Diabetes 2018 ii Dr. Tanvir Kaur Scientist ‘F’ Non Communicable Disease Indian Council of Medical Research ICMR Guidelines for Management of Type 2 Diabetes 2018 iii PREAMBLE Diabetes has become a global problem and the epidemic is most pronounced in South East Asia particularly India where an estimated 72 million people are believed to have diabetes and another 80 million have pre-diabetes. More than 90 – 95% of all patients with diabetes have type 2 diabetes. The treatment of type 2 diabetes has undergone rapid changes in the last decade, and several new drugs have been introduced in the market. In 2005, the Indian Council of Medical Research (ICMR) brought out the ‘Guidelines for Management of Type 2 Diabetes’ as a small book and this has found wide application all over India. As more than a decade has elapsed since the publication of that document, ICMR felt that a revision of the Guidelines for Management of Type 2 Diabetes was indicated. An expert group was constituted by ICMR, to look at the old guidelines and to suggest modifications as may be needed, based on the latest developments in the management of type 2 diabetes. After several rounds of iteration, a document was prepared which was then circulated to a few additional experts. After getting the comments from these experts, an ICMR Workshop entitled ‘ICMR GUIDELINES FOR MANAGEMENT OF TYPE 2 DIABETES 2018’ was held at Chennai on 10th January 2018 and a group of experts was invited by ICMR. The Workshop was divided into different sections. Each part of the document was studied in detail and necessary changes were made to the document. The document was then placed in the ICMR website, giving an opportunity for anyone else who wished to view the documents and give their comments or suggestions to do so. A few additional suggestions were received which were also incorporated in the final document. We now have great pleasure in publishing the ‘ICMR Guidelines for Management of Type 2 Diabetes 2018’. We trust that this booklet will be useful not only for practicing physicians and general practitioners but also for medical students (both undergraduates and postgraduates) and also for nurses, educators and other paramedical personnel. We welcome feedback and suggestions from readers so that when the next set of guidelines is prepared by ICMR, these suggestions can be incorporated. We also wish to thank ICMR for their guidance and support and all the experts for the time and effort they spent in making this document. A special word of thanks to Dr. Ranjit Unnikrishnan who painstakingly compiled all the suggestions and comments and helped finalize the document. Dr. Nikhil Tandon, Dr. V. Mohan, Professor & Head, Director, Department of Endocrinology, Madras Diabetes Research Foundation & All India Institute of Medical Sciences, Dr. Mohan’s Diabetes Specialties Centre, Ansari Nagar, 4, Conran Smith Road, Gopalapuram New Delhi Chennai ICMR Guidelines for Management of Type 2 Diabetes 2018 iv SECTION 1 INTRODUCTION 1.1 Definition Diabetes mellitus is a syndrome of multiple etiologies characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both. This disorder is often associated with long term complications, involving organs like eyes, kidneys, nerves, heart and blood vessels. 1.2 Epidemiology In recent decades, India has witnessed a rapidly exploding epidemic of diabetes. Indeed, India today has the second largest number of people with diabetes in the world. The International Diabetes Federation (IDF) estimates that there are 72.9 million people with diabetes in India in 2017, which is projected to rise to 134.3 million by the year 2045. The prevalence of diabetes in urban India, especially in large metropolitan cities has increased from 2% in the 1970s to over 20% at present and the rural areas are also fast catching up. 1.3 Types of diabetes According to the American Diabetes Association and the World Health Organisation, diabetes can be classified into four main types (see Box). Classification of Diabetes z Type 1 diabetes z Type 2 diabetes z Gestational diabetes z Other types of diabetes (Monogenic diabetes, pancreatic diabetes, drug-induced diabetes etc.) ICMR Guidelines for Management of Type 2 Diabetes 2018 1 Of these, the two most important forms of diabetes are type 1 and type 2 diabetes. Type 1 diabetes is primarily due to autoimmune-mediated destruction of pancreatic beta cells, resulting in absolute insulin deficiency and thus requiring insulin for good health and survival. While type 1 diabetes is also on the increase, the actual numbers of people with type 1 diabetes in India is, relatively speaking, still small. Type 2 diabetes, on the other hand, accounts for over 90-95% of all people with diabetes and is characterized by insulin resistance and abnormal insulin secretion, either of which may predominate. The diabetes epidemic relates particularly to type 2 diabetes, and predominantly due to the changing lifestyles, urbanization, demography and increased longevity. 1.4 Differentiating Between Type 1 and Type 2 Diabetes Table 1.1 below provides a few clinical points to differentiate between type 1 and type 2 diabetes. Table 1.1 Points to differentiate between type 1 and type 2 diabetes Type 1 diabetes Type 2 diabetes Age at diagnosis Usually childhood and Usually postpubertal; adolescence, but can occur most common in middle to in adults as well later age groups Diabetes in 1st degree Unusual Common relative Severe osmotic Can occur Rare symptoms/ Ketosis at diagnosis Markers of insulin Absent Present resistance C-peptide assay Absence of beta-cell reserve Preserved beta-cell reserve Pancreatic Present Absent autoantibodies ICMR Guidelines for Management of Type 2 Diabetes 2018 2 Type 1 diabetes will not be discussed further in these guidelines and they pertain chiefly to type 2 diabetes. Type 2 diabetes is a metabolic-cum-vascular syndrome characterized by predominant insulin resistance with varying degrees of insulin secretory defect. It is a progressive disease often associated with central obesity, dyslipidaemia and hypertension. It is more common in overweight and obese individuals of middle to late age but is increasingly being seen in younger age groups and in those with lower body mass index (BMI) as well. The “Asian Indian phenotype” refers to a peculiar constellation of abnormalities in south Asians, whereby for any given level of BMI, they tend to have higher total body fat, visceral fat, insulin resistance and prevalence of diabetes compared to white Caucasians (Figure 1.1). Figure 1.1: The “Asian Indian phenotype” Greater ethnic susceptibility and genetic familial aggregation of type 2 diabetes Lower age at onset of Low birth weight – thin fat Type 2 diabetes Indian Lower threshold for Inflammatory BMI for diabetes markers; CRP Serum insulin ASIAN INDIAN levels/ insulin Abdominal PHENOTYPE resistance obesity and visceral fat Characteristic dyslipidemia: HDL cholesterol triglycerides & Levels of adiponectin small dense LDL Increased prevalence of type 2 diabetes