Alkem

{{ Form::open(['url' => '#', 'name' => 'validateForm', 'id' => 'validateForm', 'enctype' => 'multipart/form-data']) }} @csrf

Back

SitaMetPio

Assessment of usage pattern, effectiveness and safety of FDC of Sitagliptin, Metformin and Pioglitazone in Indian type 2 diabetes patients

BASIC DETAILS

Patient code (Do not write name here) *

Date *

Diagnosis (Type 2 diabetes Mellitus)

Demographics and risk factors

Patient's Age (Years)*

Gender*

Male Female

Height (cm) *

Weight (kg) *

Risk factors

Obesity (BMI) *

Underweight (<18.5 kg/m²) Normal BMI (18.5-22.9 kg/m²) Overweight (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 diabetes *

Yes No

Physical inactivity *

Yes No

Complication at the time of diagnosis *

Neuropathy Nephropathy Stroke CAD Retinopathy Any Other

Clinical examination *

Systolic BP (mm Hg)

Diastolic BP (mm Hg)

History of usage of drugs *

Metformin SU AGI Pioglitazone DPP4i SGLT-2i Insulin/Insulin Analogues GLP 1 receptor agonists

Drug now prescribed *

Sitagliptin (100 mg) + Metformin (500 mg) + Pioglitazone (15 mg) Sitagliptin (100 mg) + Metformin (1000 mg) + Pioglitazone (15 mg)

Key reason to choose this FDC (tick as applicable) *

High baseline HbA1c Insulin resistance improvement Cardiovascular benefit Excellent efficacy Good safety profile Less weight gain

Investigations *

	Baseline	Post 3 months treatment
HbA1c
FPG (mg/dl)
PPG (mg/dl)
Body weight (kg)
HOMA IR levels if available (normal level 0.5-1.4)

Other parameters

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

Excellent Good Fair Poor

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

Excellent Good Fair Poor

Safety profile

Have you seen pedal edema with this FDC *

Yes No

Have you observed any other adverse drug reactions with usage of FDC *

Yes No

@include('user.footer')