Expert Consensus Statement on Simplified Glycemic Care in Patients With Type 2 Diabetes Mellitus

Abstract

The growing burden of type 2 diabetes mellitus (T2D) in India, characterized by rising prevalence, complex treatment regimens, and substantial economic and psychological impact, necessitates a simplified, patient-centered approach to glycemic management. This expert consensus document presents evidence-based recommendations for streamlined glycemic care focused on enhancing treatment adherence, minimizing pill burden, and improving clinical outcomes. An expert panel of endocrinologists and diabetologists convened across eight advisory board meetings to review current evidence and generate practical strategies. Emphasis was placed on the early use of combination therapies, particularly sodium-glucose cotransporter-2 (SGLT-2) inhibitors and dipeptidyl peptidase-4 (DPP-4) inhibitors, with or without metformin, tailored to individual patient profiles. The consensus underscores the importance of fixed-dose combinations (FDCs) to improve adherence and cost-effectiveness. In addition to pharmacologic strategies, lifestyle interventions, including medical nutrition therapy, physical activity, and sleep hygiene, are advocated. Special considerations are provided for managing T2D with comorbid conditions such as cardiovascular disease, chronic kidney disease, hypertension, obesity, and dyslipidemia, emphasizing the pleiotropic benefits of SGLT-2 inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists. The recommendations also address barriers in the Indian healthcare landscape, including limited access to care and treatment inertia. This consensus aims to support clinicians, researchers, and policymakers in implementing an integrative, simplified care model that addresses the multifaceted challenges of T2D management in India. By adopting these recommendations, healthcare providers can enhance patient outcomes, reduce complications, and alleviate the socioeconomic burden of T2D.

Keywords: combination therapy; dipeptidyl peptidase-4 (dpp-4) inhibitors; lifestyle modifications; monotherapy; sodium-glucose cotransporter-2 (sglt-2) inhibitors; type 2 diabetes mellitus (t2d).

Figure 1. Indications of combination therapy for glycemic control.

Image credit: Dr. Sanjay Jain

Figure 2. Benefits and adverse effects of common antihyperglycemic drugs for glycemic control.

SGLT-2: sodium-glucose cotransporter-2; DPP-4: dipeptidyl peptidase 4; GLP-1: glucagon-like peptide-1 Image credit: Dr. Sanjay Jain

Figure 3. Management of T2D and comorbidities (lifestyle modifications and antihyperglycemic drugs).

ACEi: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker; ASCVD: atherosclerotic cardiovascular disease; CKD: chronic kidney disease; CVD: cardiovascular disease; DPP-4i: dipeptidyl peptidase 4 inhibitor; GLP-1 RA: glucagon-like peptide 1 receptor agonist; HF: heart failure; HFpEF: heart failure with preserved ejection fraction; HFrEF: heart failure with reduced ejection fraction; HFmEF: heart failure with mid-range ejection fraction; SGLT2i: sodium-glucose cotransporter 2 inhibitor; T2D: type 2 diabetes; TZD: thiazolidinedione; SU: sulphonylureas * In individuals with HF, CKD, established CVD, or multiple risk factors for CVD, the decision to use GLP-1 RA or SGLT-2i with proven benefit should be independent of background use of metformin. TZD: Low dose is better tolerated. ^a GLP-1RA with proven CV benefit: liraglutide, semaglutide, exenatide; ^b SGLT-2 inhibitors with proven CV and renal benefit: empagliflozin, canagliflozin, dapagliflozin; ^c DPP-4 inhibitors: should not be used in patients on GLP-1 RAs; ^d SGLT-2 inhibitors for heart failure: empagliflozin, dapagliflozin; ^e Insulin glargine or degludec; ^f SU: newer sulphonylureas are preferred; ^g GLP-1 RA for weight loss: semaglutide, liraglutide, dulaglutide, exenatide. Modified and adapted from: Samson et al. [42] and Davies et al. [11] Image credit: Dr. Dinesh Jiwane