What are the RSSDI (Research Society for the Study of Diabetes in India) guidelines for managing an adult patient with type 2 diabetes mellitus?

RSSDI Guidelines for Type 2 Diabetes Management

I must clarify that the evidence provided does not contain the actual RSSDI (Research Society for the Study of Diabetes in India) clinical practice guidelines for type 2 diabetes management. The only RSSDI document available addresses hypertension management in diabetic patients, not comprehensive diabetes care 1. However, I can provide evidence-based recommendations from the most recent high-quality guidelines that would be applicable to the Indian population.

Core Pharmacologic Management Framework

First-Line Therapy

• Start all patients with metformin (unless contraindicated) combined with lifestyle modifications as mandatory first-line therapy 2.
• Metformin should be continued long-term, but monitor for vitamin B12 deficiency, especially in patients developing anemia or peripheral neuropathy 2.

Second-Line Agent Selection

When metformin plus lifestyle modifications fail to achieve HbA1c target of 7-8%, add either an SGLT-2 inhibitor or GLP-1 receptor agonist based on the following algorithm 3, 2:

Choose SGLT-2 Inhibitor When:

• Patient has congestive heart failure (either reduced or preserved ejection fraction) - SGLT-2 inhibitors prevent HF hospitalizations 3, 2.
• Patient has chronic kidney disease with eGFR 20-60 mL/min/1.73 m² and/or albuminuria - SGLT-2 inhibitors minimize CKD progression, reduce cardiovascular events, and reduce HF hospitalizations 3, 2.
• Cardiovascular mortality reduction is the primary goal 2.

Choose GLP-1 Receptor Agonist (Including Tirzepatide) When:

• Patient has increased stroke risk 2, 4.
• Patient needs substantial weight loss (>10% body weight reduction goal) 2, 4.
• Patient has advanced CKD with eGFR <30 mL/min/1.73 m² - GLP-1 RAs are preferred due to lower hypoglycemia risk and cardiovascular event reduction 3, 2.
• Patient has metabolic dysfunction-associated steatotic liver disease (MASLD) with obesity - tirzepatide specifically improves hepatic steatosis 4.
• All-cause mortality reduction is the primary goal 2.

Critical Safety Mandate

When SGLT-2 inhibitors or GLP-1 agonists achieve adequate glycemic control, immediately reduce or discontinue sulfonylureas or long-acting insulins to prevent severe hypoglycemia 2, 5, 4.

Glycemic Targets

• Target HbA1c between 7-8% for most adults with type 2 diabetes 3, 2, 5.
• Deintensify treatment when HbA1c falls below 6.5% to avoid hypoglycemia and overtreatment 2, 5.
• Self-monitoring of blood glucose is unnecessary when using metformin combined with SGLT-2 inhibitors or GLP-1 agonists, as these combinations carry minimal hypoglycemia risk 2, 4.

What NOT to Use

• Never add DPP-4 inhibitors to metformin - they do not reduce morbidity or all-cause mortality (strong recommendation, high-certainty evidence) 2, 5, 4.
• Do not combine tirzepatide with DPP-4 inhibitors as this provides no additional glucose lowering 4.

Insulin Initiation Criteria

Consider insulin initiation regardless of background therapy when 3:

• Evidence of ongoing catabolism exists (unexpected weight loss).
• Symptoms of hyperglycemia are present.
• HbA1c >10% (>86 mmol/mol) or blood glucose ≥300 mg/dL (≥16.7 mmol/L).

However, GLP-1 receptor agonists (including tirzepatide) are preferred over insulin for patients without insulin deficiency 3, 4.

Lifestyle Modifications (Mandatory Foundation)

Nutrition

• Restrict calorie intake to 1500 kcal/day 2.
• Limit fat to 30-35% of total energy intake 2.
• Increase consumption of nuts, fresh fruits, vegetables, and potassium-rich foods 1.
• Reduce intake of salt, sodium, and trans fats 1.

Physical Activity

• Target 30 minutes of physical activity at least five times weekly 2.
• For Indian patients specifically, physical activity demonstrates greater benefit for metabolic control than dietary modulation alone 1.
• Engage in at least 150 minutes/week of moderate-intensity aerobic exercise 3.
• Perform 2-3 sessions/week of resistance exercise on nonconsecutive days 3.
• Break up sedentary periods (≥30 minutes) by standing, walking, or performing light physical activity 3.

Exercise Precautions

• Patients taking insulin or insulin secretagogues may need added carbohydrate if pre-exercise glucose <100 mg/dL (5.6 mmol/L) 3.
• Patients with peripheral neuropathy must wear proper footwear and examine feet daily 3.
• Patients with autonomic neuropathy require cardiovascular evaluation before starting exercise programs 3.

Medication Review Schedule

• Reassess medication plan and medication-taking behavior every 3-6 months 3, 4.
• Adjust therapy based on glycemic control, weight goals, presence of metabolic comorbidities, and hypoglycemia risk 3.

Cost-Constrained Situations

When newer agents (SGLT-2 inhibitors, GLP-1 agonists) are unaffordable 5:

• Maximize glipizide dose (can lower HbA1c by 0.7-1.0% per dose increase).
• If HbA1c remains >8% after maximizing glipizide, add basal insulin (NPH 10 units at bedtime or 0.1-0.2 units/kg/day of long-acting analog).
• Immediately reduce glipizide dose by 50% when adding insulin to prevent severe hypoglycemia.
• Transition to SGLT-2 inhibitors or GLP-1 agonists as soon as financially feasible, then reduce or discontinue glipizide.

Hypertension Management in Diabetic Patients (RSSDI-Specific)

• Angiotensin II receptor blockers (ARBs) are recommended as first-line therapy for hypertension in patients with type 2 diabetes 1.
• For combination therapy, calcium channel blockers (CCBs) should be administered with ARBs instead of beta-blockers or diuretics to avoid cardiovascular events and hyperglycemia 1.
• Novel CCBs (e.g., cilnidipine) in combination with ARBs provide superior cardiovascular and renal protection in diabetic hypertensive patients 1.

Common Pitfalls to Avoid

• Do not delay treatment intensification when patients fail to meet glycemic targets - therapeutic inertia worsens outcomes 5.
• Do not continue sulfonylureas once SGLT-2 inhibitors or GLP-1 agonists achieve glycemic control - they increase hypoglycemia risk without mortality benefit 2, 5.
• Do not target HbA1c below 6.5% - this requires deintensification 2, 5.
• Do not use DPP-4 inhibitors as they lack mortality benefit 2, 5.