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Cardio Diabetic Therapeutics – 551
When to Use? When Not to Use –OHA

three weeks. Hence adding another drug two days This is the time when OHA should not be used just
later may not be a prudent move. This is when no forthe sake of a mere attempt. This is the indication
other drug should be added with a masterly inaction. for insulin and definitely not OHAs over and over
again.
When target glycemic control has not been achieved
with the above mentioned combination, a second
drug has to be selected to add on. The choice of Indications:
second drug should be based on the need, concern • Failure of life style modification
and indication of the treated individual. Though many • Addition of SGLT2i to existing LSM in high CV risk
recommendations like AACE guidelines do not spec- individuals
ify the drug (Figure:2), ADA has recently suggested
SGLT2i specificallyforthose with high CV risk. Hence • Addition of DPP4i or SU to insulin regimen to re-
a preferred second add on would be SGLT2i for this duce insulin requirement, cost and achieve control
particular group of diabetic population. (Fig 2) • When patient refuses insulin injection
All the other drugs have to be chosen depending on
many factors like age, duration of diabetes, prone- Contraindications :
ness to hypoglycaemia, affordability, family support • Chronic liver diseaseis not an ideal choice
and other co-morbid conditions as per the recom-
mendations of AACE. • ESRD needs cautious use depending oneGFR.
Though only few newer drugs could be safely pre-
One more addition alone may not be adequate es- scribed in such situations, it is advisable to start
peciallyin those with longer duration of diabetes and insulin rather than OHA.
hence in these situations few more drugs may be
requiredin order to achieve target. Addressing every • In patients with cardiac failure, renal failure, pe-
component of ominous octet and adding more and ripheral circulatory failure, hepatic failure, respira-
more drugs may not achieve and maintain euglycae- tory failure and brain cell failure.
mia in certain instances. • During any surgicalprocedure

Figure:2 showing American Association of Clinical endocrinologists
2017 algorithm for glycemic control.

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