What are the RSSDI (Research Society for the Study of Diabetes in India) guidelines for the management of diabetes mellitus?

RSSDI Guidelines for Management of Diabetes Mellitus

I cannot provide specific RSSDI (Research Society for the Study of Diabetes in India) guidelines as none of the evidence provided contains RSSDI-specific recommendations. However, I can provide comprehensive diabetes management guidelines based on the highest quality international evidence available, which RSSDI guidelines typically align with and adapt for the Indian population.

Initial Treatment Approach

Start metformin 500 mg daily with comprehensive lifestyle modifications immediately at diagnosis for all newly diagnosed Type 2 Diabetes patients, unless contraindications exist. 1, 2

Exceptions Requiring Immediate Insulin Therapy:

• Ketosis or diabetic ketoacidosis present 2, 3
• Random blood glucose ≥250 mg/dL 1, 2
• HbA1c ≥8.5-10% 1, 2
• Unclear distinction between Type 1 and Type 2 diabetes 2, 3

Metformin dosing schedule: Start 500 mg daily with food, increase by 500 mg every 1-2 weeks to target dose of 2,000 mg daily in divided doses. 3

Glycemic Targets

Target HbA1c of <7% for most patients, with individualized targets between 7-8% for adults based on hypoglycemia risk. 1, 2

• More stringent targets (6.0-6.5%) may be appropriate for select patients when achievable without hypoglycemia 1
• Deintensify treatment when HbA1c <6.5% to prevent hypoglycemia 2
• Check HbA1c every 3 months until target achieved 2, 3

Treatment Intensification Timeline

If glycemic targets are not achieved after 3 months on metformin monotherapy, immediately add a second agent—prioritize SGLT-2 inhibitor or GLP-1 receptor agonist. 1, 2

Second-Line Agent Selection Based on Comorbidities:

For patients with established cardiovascular disease: Add SGLT-2 inhibitor or GLP-1 receptor agonist with proven cardiovascular benefit 1, 2

For patients with heart failure or chronic kidney disease: Prioritize SGLT-2 inhibitor with proven benefit 1, 2

For patients with obesity (BMI >35 kg/m²): GLP-1 receptor agonists are preferred due to greater weight loss potential and cardiovascular benefits 1, 3

For patients with increased stroke risk: Prioritize GLP-1 receptor agonists 2

Avoid DPP-4 inhibitors as second-line therapy due to lack of mortality benefit compared to SGLT-2 inhibitors and GLP-1 receptor agonists. 2

Lifestyle Management (Essential Throughout Treatment)

Lifestyle modifications must continue throughout the entire course of diabetes treatment, not just as an initial step. 1, 2

Physical Activity Requirements:

Adults with Type 2 diabetes should engage in ≥150 minutes/week of moderate-to-vigorous intensity aerobic activity, spread over at least 3 days/week with no more than 2 consecutive days without activity. 4

• Resistance exercise 2-3 sessions/week on nonconsecutive days 4
• Interrupt prolonged sitting every 30 minutes for blood glucose benefits 4
• Flexibility and balance training 2-3 times/week for older adults 4

Children and adolescents should engage in ≥60 minutes/day of moderate-to-vigorous intensity aerobic activity, with muscle-strengthening activities at least 3 days/week. 4, 3

Medical Nutrition Therapy:

Provide Medical Nutrition Therapy (MNT) at diagnosis and at least annually thereafter, preferably by a registered dietitian. 4, 1

• Mediterranean, DASH, or vegetarian/vegan dietary patterns reduce HbA1c by 1.0-2.0% 2
• Limit sodium consumption to <2,300 mg/day 4
• Alcohol: ≤1 drink/day for women, ≤2 drinks/day for men 4

Diabetes Self-Management Education

Provide comprehensive diabetes self-management education and support (DSMES) at diagnosis, annually, with changes in health status, and with transitions of care. 1, 2

• DSMES should address psychosocial issues including depression, anxiety, and diabetes-related distress 4
• Education on matching prandial insulin doses to carbohydrate intake when applicable 4

Insulin Therapy

GLP-1 receptor agonists are generally recommended as the first injectable medication before insulin. 1

Initiate insulin therapy without delay if patients do not achieve glycemic goals on oral agents or if presenting with severe hyperglycemia. 4, 1

Type 1 Diabetes Insulin Management:

• Multiple daily injections of prandial and basal insulin or continuous subcutaneous insulin infusion 4
• Use rapid-acting insulin analogs to reduce hypoglycemia risk 4
• Starting dose typically 0.5 units/kg/day for metabolically stable patients 4

Hypoglycemia Management

Treat conscious hypoglycemia with 15-20g of glucose (preferred treatment), recheck blood glucose after 15 minutes, and repeat treatment if hypoglycemia persists. 4, 1

• Prescribe glucagon for all individuals at significant risk of severe hypoglycemia 4
• Patients with hypoglycemia unawareness should raise glycemic targets to strictly avoid further episodes for several weeks 4

Monitoring Requirements

• HbA1c every 3 months until target achieved, then ongoing monitoring 1, 2
• Monitor vitamin B12 levels periodically in patients on metformin, particularly those with anemia or peripheral neuropathy 4, 1
• Self-monitoring of blood glucose tailored to individual needs, especially for those on insulin or medications with hypoglycemia risk 1, 3

Comorbidity Management

Address comorbidities at diagnosis and throughout treatment: 2

• Dyslipidemia management
• Blood pressure control
• Annual screening for microalbuminuria
• Annual retinopathy screening
• Cardiovascular risk factor management

Critical Pitfalls to Avoid

Delayed treatment intensification is the most common error—do not wait beyond 3 months if glycemic targets are not met. 4, 1

• Failure to prioritize SGLT-2 inhibitors or GLP-1 receptor agonists as second-line agents when indicated 1, 2
• Neglecting cardiovascular and renal benefits when selecting medications 1, 2
• Discontinuing lifestyle modifications once pharmacotherapy begins 1, 2
• Inadequate patient education and self-management support 4, 1
• Not monitoring for vitamin B12 deficiency in long-term metformin users 4, 1

Special Populations

Bariatric Surgery Consideration:

Bariatric surgery may be considered for adults with BMI >35 kg/m² and Type 2 diabetes, especially if diabetes or comorbidities are difficult to control with lifestyle and pharmacologic therapy. 4

Adolescents with Severe Obesity:

• Determine Type 1 vs Type 2 diabetes definitively; when uncertain, treat as Type 1 with insulin 3
• Metformin remains first-line, with GLP-1 receptor agonists as second-line for BMI >35 kg/m² 3
• Involve entire family in lifestyle modifications 3