Physicians Academy
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Table Of Contents
Editorial :
 The Real Paradigm Shift in Management of T2DM
Article 1 :
 Introduction of DMS irrigation to heal Endo–Perio lesions and Cysts
Article 2 :
 Alagille Syndrome in a Neonate
Picture of The Month :
 POTM-April 2018
Drug Update :
 SEGLUROMET (ertugliflozin+metformin)
Abstracts from Other Journals :
 Abstracts from Other Journals-April 2018

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Apr 2018 ( Volume -12 Number -4)

The Real Paradigm Shift in Management of T2DM
Sarosh Ahmed Khan, MBBS; MD; FACP
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The Real Paradigm Shift in Management of T2DM

Sarosh Ahmed Khan, MBBS; MD; FACP

The year 2018 can be seen as the time from where our management of type 2 diabetes mellitus has undergone a sea change. Now we will be addressing this pandemic of T2DM with a different angle.

We know that 90% of patients with T2DM are overweight or obese. We also know that as weight, body mass index and waist hip ratio have increased, the world has seen a corresponding rise in the number of T2DM.

Anecdotal reports on weight loss leading to excellent control of T2DM have been published from time to time. But there was no concerted effort to pursue in this direction. Has life style modification to reduce weight been under stressed? Or have we not realised its importance? The answer to both, it seems, is in the affirmative and that should be an eye opener for all of us.

We can also deduce from studies on the sodium-glucose co-transporter 2 inhibitors (SGLT2i) that the cardiovascular benefit, as against safety only, is mainly because of the loss of glucose and sodium these induce leading to weight loss. A few kilograms of loss translates into a better metabolic profile of the patient. And then we got the ground breaking studies on glucagon like peptide 1 receptor agonists (GLP1-RA) liraglutide and dulaglutide. The Leader Trial and REWIND Trial (1,2) amplified the concept of weight loss and the benefits associated with it. Full details of the REWIND study will be reported at the American Diabetes Association Scientific Sessions in San Francisco in 2019.

But the study which has proved to be the game changer is the DiRECT Trial conducted in Scotland and the Tyneside region of England(3). On a very low calorie diet, after stopping all treatment for DM and hypertension, the results were astonishing. At 12 months, they recorded weight loss of 15 kg or more in 36 (24%) participants in the intervention group and no participants in the control group (p<0·0001). Diabetes remission was achieved in 68 (46%) participants in the intervention group and six (4%) participants in the control group (odds ratio 19·7, 95% CI 7·8–49·8; p<0·0001).

That for me is the real paradigm shift in the management of patients with T2DM. We also expect the newer guidelines for DM from ADA and AACE would be certainly made with these important studies taken into consideration. 


1.    Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med 2016; 375:311-322

DOI: 10.1056/NEJMoa1603827

2.    Nainggolan L. REWIND: Once-Weekly GLP-1 Agonist Cuts CVD in Type 2 Diabetes. November 5, 2018.

3.    Lean MEJ, Leslie WS, Barnes AC et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. The Lancet. Feb 2018. 391 (10120): 541-551 

Author Information: Dr. Sarosh A. Khan is Senior Consultant, Internal Medicine and Director Naseem Medical Center, Baghe-Mehtab, Srinagar, Kashmir, India. Pin: 190019. He is the Editor in Chief of Physicians Academy. Affiliations: Governing Council Member of American College of Physicians (India Chapter) from 2014-2017. Email:

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