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HbA1c level
Comorbidities like hypertension / obesity
Duration of diabetes
Age at onset
Hypertension
CKD
Obesity
Atherosclerotic heart disease
Dyslipidaemia
0 – 10%
11 – 20%
21 – 30%
31 – 40%
Established or multiple risk factors for atherosclerotic cardiovascular disease
Heart Failure
Established or imminent Chronic Kidney Disease
Failure to achieve rapid attainment of glycemic goal
Comorbidities like obesity
Tolerability
HbA1c at presentation / glycemic goal
Risk of hypoglycemia
Comorbidities
Preference for the first meal of the day
Preference for evening meal to reduce morning hyperglycemia
Best chances of compliance tailored to individual patient
High HbA1c
Glycemic variability
Inadequate post prandial control
Yes, in patients with high HbA1c
Yes, in patients with comorbidities like CVD, CKD, hypertension
No, I don’t prefer initial combination therapy
DPP4 inhibitor
Sulfonylurea
SGLT2 inhibitor
Thiazolidinediones
GLP-1 receptor agonists
Yes
No
0 – 15%
16 – 30%
31 – 45%
46 – 60%
GLP-1 receptor agonist
DPP-4 inhibitor
Younger (<44 years)
Middle age (45 – 64 years)
Older (>65 years)
Obese
Elderly
High cardiovascular risk
Baseline HbA1c levels
Insulin resistance
Current anti-glycaemic drugs
Reduction in weight / No weight gain
Improved insulin sensitivity / beta cell function restoration
Low instances of hypoglycaemia
Reduction in fasting / post prandial glucose / HbA1c
Cardiovascular protection / metabolic benefits
Significant reduction in HbA1c (decrease of > 3% in 1 year)
Moderate reduction in HbA1c (decrease of 1-2% in 1 year)
Mild reduction in HbA1c (decrease of <1% in 1 year)
Weight loss
No change in weight
Weight gain
Well tolerated
Minor, but tolerated adverse effects
Poorly tolerated with severe adverse effects
Systolic blood pressure
Serum creatinine / estimated Glomerular Filtration Rate
Lipid profile
BMI
Reduction in daily pill burden
Simplified administration regimen
Long term patient adherence
Patients with cardiovascular disease
Obese patients
Long standing diabetes / diabetes with complications
Yes, presence of comorbidities / risk factors will favour prescription of this combination
Yes, presence of comorbidities / risk factors will act against prescription of this combination
No, presence of comorbidities / risk factors will not play a role in considering prescription of this combination
Yes- As it may give better longer glycaemic control than step wise approach
No- As I prefer step wise approach
This combination will reduce overall cost
This combination will have no effect on overall cost
This combination will increase the overall cost