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Evaluation of usage of Empagliflozin in Patients of Diabetes with cardiorenal comorbidities

BASIC DETAILS

Patient code (Do not write name here) *

Date *

Diagnosis : Type 2 diabetes Mellitus (T2DM) with cardiorenal comorbidity {{--

Yes No

--}}

Patient's Age (years) *

Gender *

Male Female

HbA1c *

Weight (in Kg) *

Obesity (BMI) *

Underweight (<18.5 kg/m²) Normal BMI (18.5-22.9 kg/m²) Over weight (23.0 -24.9 kg/m²) Obese (>25 kg/m²)

Active Smoker *

Yes No

Alcohol intake *

Yes No

Tobacco use *

Yes No

Family history of Heart failure / CKD *

Yes No

Physical inactivity *

Yes No

Clinical examination *

Systolic BP	mmHg
Diastolic BP	mmHg

Dose of Empagliflozin used *

10 mg 25 mg

Other antidiabetics and systemic Medications used *

Drug	Dose	Frequency
Metformin	500 1000	OD BD
DPP4is Sitagliptin Linagliptin Vildagliptin		OD BD
Glimepiride	1 mg 2 mg	OD BD
Pioglitazone	15 mg 30 mg	OD BD
ARBs/ACE inhibitors ARNI (Sacubitril/valsartan)		OD BD OD BD
Beta blocker {{-- Beta blocker --}} Metoprolol Bisoprolol		OD BD
Diuretic		OD BD
Statin and combinations		OD BD
Others		OD BD

Examination & Investigations *

Parameter	Baseline	Observation after 3 months
HbA1C (%)
Fasting Blood Glucose (mg/dl)
Post Prandial Blood Glucose (mg/dl)
Body Weight (Kg)
eGFR

Adverse events seen *

Yes No

Clinician's Global Assessment of safety (Tick Appropriate) *

Excellent Good Fair Poor

Clinician's Global Assessment of Effectiveness (Tick Appropriate) *

Excellent Good Fair Poor

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