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Background and aims Ultrasound of the liver is not good to pick up mild steatosis. Controlled attenuation parameter (CAP) evaluated in transient elastography (FibroScan) is widely available in India. However, data regarding the diagnostic accuracy and optimal cut-off values of CAP for diagnosing hepatic steatosis are scarce in Indian population. MRI-PDFF is an accurate technique for quantifying hepatic steatosis. Thus, this study examined the diagnostic accuracy and optimal cut-off values of CAP for diagnosing steatosis with MRI-PDFF as reference standard. Methods A total of 137 adults underwent CAP and MRI-PDFF measurements prospectively. A subset of participants (n = 23) underwent liver biopsy as part of liver transplantation evaluation. The optimal cut-off values, area under the receiver operating characteristic (AUROC) curves, sensitivity, and specificity for CAP in detecting MRI-PDFF ≥5% and ≥10% were assessed. Results The mean age and body mass index (BMI) were 44.2 ±10.4 years and 28.3 ±3.9 kg/m2, respectively. The mean hepatic steatosis was 13.0 ±7.7% by MRI-PDFF and 303 ±54 dB/m by CAP. The AUROC of CAP for detecting hepatic steatosis (MRI-PDFF ≥5%) was 0.93 (95% CI, 0.88–0.98) at the cut-off of 262 dB/m, and of MRI-PDFF ≥10% was 0.89 (95% CI, 0.84–0.94) at the cut-off of 295 dB/m. The CAP of 262 dB/m had 90% sensitivity and 91% specificity for detecting MRI-PDFF ≥5%, while the CAP of 295 dB/m had 86% sensitivity and 77% specificity for detecting MRI-PDFF ≥10%. Conclusions The optimal cut-off of CAP for the presence of liver steatosis (MRI-PDFF ≥5%) was 262 dB/m in Indian individuals. This CAP cut-off was associated with good sensitivity and specificity to pick up mild steatosis.

Background and Aim Type 2 diabetes (T2D) in associated with higher prevalence and worse outcomes of nonalcoholic fatty liver disease (NAFLD). However, data regarding the prevalence of clinically relevant liver fibrosis (CRLF) in Indian individuals with T2D are scarce. We investigated the prevalence of, and factors associated with, CRLF in Indians with T2D. Methods We conducted a prospective study of 601 consecutive adults with T2D. Steatosis was diagnosed using ultrasonography. Liver stiffness measurement (LSM) by transient elastography of ≥8.0 kPa was taken as cutoff suggesting CRLF. Individuals with LSM > 13.0 kPa underwent dynamic magnetic resonance imaging (MRI) of liver for detecting changes consistent with cirrhosis. Results The prevalence of steatosis was 84.2%. Higher body mass index (BMI, P = 0.022), alanine aminotransferase (ALT; P = 0.001), and lower high‐density lipoprotein (HDL; P = 0.002) were independent factors associated with steatosis. The prevalence of CRLF was 28.2%. Higher BMI (P = 0.001), aspartate aminotransferase (AST; P 13.0 kPa. Among them, 25 individuals underwent dynamic MRI of liver, which revealed features consistent with cirrhosis in 18 patients. Conclusion CRLF, an established risk factor for cirrhosis and overall mortality, affects at least one out of four (25%) Indians with T2D. These results support screening of all patients with T2D and NAFLD for liver fibrosis., Type 2 diabetes (T2D) and nonalcoholic fatty liver disease (NAFLD) often coexist. T2D promotes the progression of NAFLD to more severe liver pathologies. We found high prevalence of clinically relevant liver fibrosis in individuals with T2D and NAFLD.

To compare the efficacy and safety of degludec U100 versus glargine U300 for the early postoperative management of patients with type 2 diabetes mellitus (T2D) undergoing coronary artery bypass graft (CABG) surgery.A total of 239 patients were randomly assigned (1:1) to receive a basal-bolus regimen in the early postoperative period using degludec U100 (n = 122) or glargine U300 (n = 117) as basal and glulisine before meals. The primary outcome was mean differences between groups in their daily BG concentrations. The major safety outcome was the occurrence of hypoglycemia.There were no differences in mean daily BG concentrations (157 vs. 162 mg/dl), mean percentage of readings within target BG of 70-180 mg/dl (74% vs. 73%), daily basal insulin dose (19 vs. 21 units/day), length of stay (median [IQR]: 9 vs. 9 days), or hospital complications (21.3% vs. 21.4%) between treatment groups. There were no differences in the proportion of patients with BG70 mg/dl (15.6% vs. 23.1%) or54 mg/dl (1.6% vs. 4.3%) between degludec-100 and glargine-300 groups.Treatment with degludec U100 is as effective and safe as glargine U300 for the early postoperative hospital management of patients with T2D undergoing CABG.

BACKGROUND AND AIM Type 2 diabetes (T2D) and low skeletal muscle mass (SMM) are associated with increased risk of nonalcoholic fatty liver disease (NAFLD). However, data regarding the association between low SMM and NAFLD-related liver fibrosis in individuals with T2D are scarce. Therefore, we aimed to investigate the association between low SMM and liver fibrosis in individuals with T2D and NAFLD. METHODS Controlled attenuation parameter (CAP) of ≥ 248 dB/m was taken as cutoff suggesting NAFLD. Clinically relevant liver fibrosis and advanced liver fibrosis were defined as liver stiffness measurement (LSM) by transient elastography (TE) of ≥ 8.0 and ≥ 9.6 kPa, respectively. SMM was measured using dual energy X-ray absorptiometry (DEXA). Low SMM was defined as appendicular SMM index of

Aims No head-to-head comparisons of two ultra-long acting insulins, degludec-100 and glargine-300, have been reported in the inpatient setting. We compared the efficacy and safety of these two insulins for the hospital management of patients with type 2 diabetes (T2D). Methods This target-to-treat, randomized controlled trial enrolled patients with T2D admitted for coronary artery bypass graft surgery (CABG). On the day of transition (day 2 of surgery) from intravenous insulin infusion to multiple subcutaneous insulin injections, patients were randomly assigned (1: 1) to receive a basal-bolus regimen using either degludec-100 or glargine-300 as basal and glulisine as bolus before meals. Insulin was adjusted daily to maintain a fasting blood glucose (BG) Results Between October 12, 2021, and February 10, 2022, 324 consecutive patients with T2D undergoing CABG were screened, 239 patients were randomly assigned to treatment; 122 to degludec-100 group and 117 to glargine-300 group. The mean daily BG concentration in the degludec-100 group (157 mg/dL [SD 25]) was not inferior to that in the glargine-300 group (162 mg/dL [SD 24]), with a mean BG difference of -5 mg/dL (95% CI, -11 to 2, p = 0.18). There were no differences between degludec-100 group and glargine-300 group in mean percentage of readings within target BG of 70-180 mg/dL (74% ± 29% vs. 73% ± 30%, p = 0.19), daily basal insulin dose (19 ± 8 vs. 21 ± 9 units/day, p = 0.13), length of stay in hospital (median [IQR]: 9 [8-11] vs. 9 [8-11] days, p = 0.51), or hospital complications (21.3% vs. 21.4%, p = 0.99). There were no differences in the proportion of patients with BG Conclusions Treatment with degludec-100 as a basal insulin is as effective and safe as glargine-300 for the hospital management of patients with T2D admitted to cardiac surgery service in the non-intensive care unit setting. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Liraglutide, a daily injectable glucagon-like peptide-1 receptor (GLP-1r) agonist, has been shown to reduce liver fat content (LFC) in humans. Data regarding the effect of dulaglutide, a once-weekly GLP-1r agonist, on human LFC are scarce. This study examined the effect of dulaglutide on LFC in individuals with type 2 diabetes and non-alcoholic fatty liver disease (NAFLD).Effect of dulaglutide on liver fat (D-LIFT) was a 24 week, open-label, parallel-group, randomised controlled trial to determine the effect of dulaglutide on liver fat at a tertiary care centre in India. Adults (n = 64), who had type 2 diabetes and MRI-derived proton density fat fraction-assessed LFC of ≥6.0% at baseline, were randomly assigned to receive dulaglutide weekly for 24 weeks (add-on to usual care) or usual care, based on a predefined computer-generated number with a 1:1 allocation that was concealed using serially numbered, opaque, sealed envelopes. The primary endpoint was the difference of the change in LFC from 0 (baseline) to 24 weeks between groups. The secondary outcome measures included the difference of the change in pancreatic fat content (PFC), change in liver stiffness measurement (LSM in kPa) measured by vibration-controlled transient elastography, and change in liver enzymes.Eighty-eight patients were screened; 32 were randomly assigned to the dulaglutide group and 32 to the control group. Overall, 52 participants were included for per-protocol analysis: those who had MRI-PDFF data at baseline and week 24. Dulaglutide treatment resulted in a control-corrected absolute change in LFC of -3.5% (95% CI -6.6, -0.4; p = 0.025) and relative change of -26.4% (-44.2, -8.6; p = 0.004), corresponding to a 2.6-fold greater reduction. Dulaglutide-treated participants also showed a significant reduction in γ-glutamyl transpeptidase (GGT) levels (mean between-group difference -13.1 U/l [95% CI -24.4, -1.8]; p = 0.025) and non-significant reductions in aspartate aminotransferase (AST) (-9.3 U/l [-19.5, 1.0]; p = 0.075) and alanine aminotransferase (ALT) levels (-13.1 U/l [-24.4, 2.5]; p = 0.10). Absolute changes in PFC (-1.4% [-3.2, 0.3]; p = 0.106) and LSM (-1.31 kPa [-2.99, 0.37]; p = 0.123) were not significant when comparing the two groups. There were no serious drug-related adverse events.When included in the standard treatment for type 2 diabetes, dulaglutide significantly reduces LFC and improves GGT levels in participants with NAFLD. There were non-significant reductions in PFC, liver stiffness, serum AST and serum ALT levels. Dulaglutide could be considered for the early treatment of NAFLD in patients with type 2 diabetes.ClinicalTrials.gov NCT03590626 FUNDING: The current study was supported by an investigator-initiated study grant from Medanta-The Medicity's departmental research fund and a grant from the Endocrine and Diabetes Foundation (EDF), India. Graphical abstract.

Aims: To study the feasibility of diabetes education through telemedicine in patients with diabetes mellitus (DM) hospitalized for coronavirus disease 2019 (COVID-19) management. Methods: This was a prospective study of 100 patients with DM who were admitted in a COVID isolation ward for management of COVID-19. Patients managed with multiple subcutaneous insulin injections were eligible. During teleconsultation, diabetes education including insulin injection technique was given by a diabetes educator via a phone call (audio and video) during hospitalization. They were also re-assessed after 2 weeks of discharge from the hospital via teleconsultation or in-person. Results: Out of 100 patients, 72.0% had prior history of diabetes while 28.0% were newly diagnosed. The median age of our cohort was 56 years and median duration of diabetes was 7.0 years. Telemedicine as a mode of consult for diabetes education was accepted by 96.0% of patients during hospitalization. At 2 weeks’ follow-up, 77.0% patients were following insulin instructions correctly and were satisfied with this mode of consultation. Conclusion: Diabetes education using telemedicine as a technology is feasible, acceptable, and effective in the management of most patients with DM. Telemedicine appears to be an effective way to replace routine visits in special situations.

Background: Increasing prevalence of diabetes (type 1 and type 2) and obesity along with declining age of onset of type 2 diabetes, often create a diagnostic error in subtyping patients with young onset diabetes. Correct diagnosis of type of diabetes in this age group has clinical implications for management and longterm prognosis. In this study, we aimed to profile all consecutive young onset diabetes patients with respect to their clinical, biochemical, and genetic characteristics. Material and Methods: In this prospective study, conducted at a tertiary facility, all patients with diabetes onset between 18-30 years and diabetes duration less than 5 years were included. Assessment included detailed clinical and biochemical evaluation, autoantibody testing, c-peptide and genetic screening. Results: Total 100 patients were studied, out of which 80% were males and 55% were obese. Mean age of onset and median duration of diabetes were 24.98 ± 3.27 years and 18.0 months respectively. Initial clinical presentation was weight loss and osmotic symptoms in 58%, diabetic ketoacidosis in 5% and 25% patients were incidentally diagnosed. 20.8% of clinically autoimmune diabetes patients had negative antibody testing, 35.5% of clinically nonautoimmune diabetes had positive antibody testing. Overall, evidence of autoimmunity and decreased insulin secretion were found in 45% and 45% patients respectively. Ultrasound abdomen revealed small/atrophic pancreas in 9% of patients out of which nearly half did not had history of pancreatitis. Three patients were detected as MODY (1 = HNF1A and 2 = PAX4 mutations). One patient had Wolfram like syndrome (WFS1 mutation), 30 patients had variants of unknown significance. Conclusion: Evidence of autoimmunity was seen in 45%, monogenic diabetes in 4%, obesity in 55% of the study population. Higher incidence and aggressive nature of diabetes in young individuals are probably due to contributing effect of autoimmunity accompanied by increasing prevalence of obesity. Disclosure P.K. Reddy: None. G. Jevalikar: None. A.A. Singhal: None. P. Kaur: None. A. Gupta: None. S.K. Mishra: None. J.S. Wasir: None. M.S. Kuchay: Speaker’s Bureau; Self; Abbott, Boehringer Ingelheim International GmbH, Novo Nordisk A/S. B. Bansal: None. K. Farooqui: None. H. Kaur: None. A. Mithal: Speaker’s Bureau; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Johnson & Johnson, Lilly Diabetes, Novo Nordisk A/S.

Aim To develop an evidence-based expert group consensus document on the best practices and simple tools for titrating basal insulins in persons with type 2 diabetes mellitus (T2DM). Background Glycemic control is suboptimal in a large proportion of persons with T2DM, despite insulin therapy, thereby increasing the risk of potentially severe complications. Early initiation of insulin therapy and appropriate dose titration are crucial to achieving glycemic targets. Attitudes and practices among healthcare professionals (HCPs) and perceptions about insulin therapy among persons with diabetes contribute largely to suboptimal glycemic control. Improving HCP–patient communication, encouraging the use of additional educational tools, and providing support for the titration process to increase confidence, both at the initiation visit and at home, facilitate the optimization of dose titration. In Indian settings, specific guidelines and a consensus statement are lacking on the optimal insulin initiation dose, frequency of dose titration, and basal insulin profile needed to achieve optimal titration. In clinical practice, physicians and persons with diabetes often do not adhere to the titration algorithms that currently exist for the purpose of achieving optimal titration as they perceive these to be very cumbersome. In this context, a group of experts met at an advisory board meeting and arrived at a consensus on best practices for the titration of basal insulin in persons withT2DM in India, using the modified Delphi methodology. Review Results After a review of evidence and further discussions, the expert group provided recommendations on insulin initiation dose, ideal period for titration in practice, titration regimen for use in practice, basal insulin profile for titration, and choosing a self-monitoring blood glucose schedule for titration. Conclusions In the management of T2DM, insulin can be effectively titrated by following a few simple recommendations. The use of second-generation basal insulin aids in mitigating the risk of hypoglycemic events. The implementation of a simplified titration regimen is crucial to achieving glycemic targets and long-term treatment goals.

OBJECTIVE Sodium–glucose cotransporter 2 (SGLT-2) inhibitors have been shown to reduce liver fat in rodent models. Data regarding the effect of SGLT-2 inhibitors on human liver fat are scarce. This study examined the effect of empagliflozin (an SGLT-2 inhibitor) on liver fat in patients with type 2 diabetes and nonalcoholic fatty liver disease (NAFLD) by using MRI-derived proton density fat fraction (MRI-PDFF). RESEARCH DESIGN AND METHODS Fifty patients with type 2 diabetes and NAFLD were randomly assigned to either the empagliflozin group (standard treatment for type 2 diabetes plus empagliflozin 10 mg daily) or the control group (standard treatment without empagliflozin) for 20 weeks. Change in liver fat was measured by MRI-PDFF. Secondary outcome measures were change in alanine transaminase (ALT), aspartate transaminase (AST), and γ-glutamyl transferase (GGT) levels. RESULTS When included in the standard treatment for type 2 diabetes, empagliflozin was significantly better at reducing liver fat (mean MRI-PDFF difference between the empagliflozin and control groups −4.0%; P < 0.0001). Compared with baseline, significant reduction was found in the end-of-treatment MRI-PDFF for the empagliflozin group (16.2% to 11.3%; P < 0.0001) and a nonsignificant change was found in the control group (16.4% to 15.5%; P = 0.057). The two groups showed a significant difference for change in serum ALT level (P = 0.005) and nonsignificant differences for AST (P = 0.212) and GGT (P = 0.057) levels. CONCLUSIONS When included in the standard treatment for type 2 diabetes, empagliflozin reduces liver fat and improves ALT levels in patients with type 2 diabetes and NAFLD.

Aims: To evaluate the real-world efficacy, durability, and side-effect profile of once weekly GLP1RA: dulaglutide in Indian type 2 diabetes mellitus (T2DM) patients. Materials and Methods: A retrospective observational study. Data for efficacy (HbA1c and weight), adherence/discontinuation and patient reported side-effects, of 117 patients who were prescribed dulaglutide were analyzed. Results: Final analysis was done on complete data of 74 patients (6 months follow-up), this indicated that dulaglutide is effective (mean-reduction at 6 months of: HbA1c; 0.87% and weight; 3.8 kg). Subjects with a poorer glycemic control (greater HbA1c) or greater weight at initiation had a better fall in HbA1c and weight reduction at the end of the study. The most common side-effects were gastrointestinal (15% nausea and 6% loose motions). Also, 25% (n = 19) of our study subjects discontinued dulaglutide because of gastrointestinal side-effects. Conclusion: Our real-world experience is well aligned to systematic data of the randomized controlled trials (RCTs) regarding the efficacy of dulaglutide in the treatment of T2DM (our study vs. RCTs; HbA1c reduction: 0.87% vs. 0.78% to 1.64%, weight reduction: 3.8 vs. 0.3 to 3 kg). The most common side-effects and reason for discontinuation were gastrointestinal side-effects. Finally, by virtue of their observed benefit, we expect a superior cardiovascular risk-reduction with dulaglutide use in our population.

Background/Objective: Patients with type 2 diabetes face challenges when it comes to following recommendations (nutrition, exercise and medications). Using technology to understand glycemic responses can increase patient awareness about dietary and lifestyle changes. Coupled with coaching by an expert nutritionist, such a program may help improve patient adherence, resulting in a reduction in HbA1c and body mass index (BMI). Method: Fifty-seven patients with type 2 DM not at goal (HbA1c ≥ 6.5%) either on lifestyle modification, OHA with or without insulin, consenting to participate in the study were enrolled in the DIABEFLY program which included Ambulatory glucose monitoring (AGM) and correlating it with dietary intake for 14 days using a technology platform (FITTERFLY wellness app). Patients were explained their AGM graphs, in relation to their daily food and activity log, to make them aware of their personalised glycemic responses to various foods and accordingly diet plan was suggested. Nutritionists (coaches) interacted with patients over calls on Day 1, 7, 14, 30, 60 and Day 90 to explain recommendations, address any diabetes related queries and evaluate adherence to diet & exercise plans. Patients also had access to daily chat support for 90 days and received daily messages on glycemic responses, healthy food choices, exercise options, stress management, sleep, medication adherence, self-monitoring of blood glucose and complications of diabetes. Strictly, no advice on type or dosage of medication was given by the coaches. Statistical analysis for outcomes was done by t-test using SPSS software. Result: Out of 57 patients, mean age was 46 years, of which 70% were male and 30% were females. The baseline HbA1c was found to be 8.3% ± 1.68 which significantly decreased (p Discussion: With the availability of AGM devices, powerful food databases and technology to correlate these two had led to a new era of diabetes coaching. The personalised glycemic responses so calculated for every patient lead to more concrete understanding of changes necessary for better glycemic control. Regular interactions or reminders from an expert may act as a unique and necessary way of reinforcement to follow recommendations. In our study, though increased engagement with the programme resulted in a significant reduction in HbA1c and BMI. Conclusion: Personalized Glycemic response led coaching benefits patients with Type 2 diabetes mellitus helping them achieve two critical outcomes - lowering of HbA1c and reduction of BMI as early as three months. Keywords: AGM; Personalised glycemic response; Diabetes lifestyle coaching

Hemoglobin (Hb) Hope is a rare Hb variant which is clinically silent but causes spuriously high glycated hemoglobin (HbA1c). We report a case of a 45-year-old gentleman, planned for elective total hip replacement, who presented with very high HbA1c with normal blood glucose and fructosamine levels. With the suspicion of erroneous HbA1c, an Hb electrophoresis was done, and he was found to have a rare hemoglobin variant called Hb Hope. We also reviewed almost all case reports of Hb Hope variant causing spuriously high HbA1c levels from India.

Objective: To share our clinical experience with exenatide in obese North Indian subjects with type 2 diabetes. Materials and Methods: We share our experience with use of exenatide in 74 patients treated at Indraprastha Apollo Hospital, a tertiary care centre in New Delhi, India Subjects included obese / overweight subjects (mean weight and BMI; 97.67 ± 5.6 kg and 34.56 kg/m 2 ) with known history of type 2 DM (Mean: 9 ± 5.6 years) and maintaining suboptimal glycemic control (HbA1c >7%) on oral antidiabetic agents, with or without basal insulin. Metformin and sulphonylureas were continued (with dose adjustment if indicated), as was basal insulin (glargine / detemir). TZDs and DPP4 inhibitors were discontinued. The dose of exenatide was increased to 10 mcg twice a day after 4-12 weeks. 56 patients completed minimum 3 month therapy. 42 patients completed 6 months, 32, 9 months and 25 completed 12 months. Data of patients who had completed at-least 3 months of therapy was included for analysis. Results and Discussion: 69.77, 67.44, and 13.95% of the patients were receiving metformin, secretagogues or thiazolidinediones alone or in combination; 17.76% of the patients were on basal insulin. The change in fasting and post-prandial blood glucose levels were significant at 3, 6, 9 and 12 months with p0 -value

Hypercalcemia caused by advanced chronic liver disease (CLD) without hepatic neoplasia is uncommonly reported and poorly understood condition. We are reporting two cases of advanced CLD who developed hypercalcemia in the course of the disease. This diagnosis of exclusion was made only after meticulous ruling out of all causes of hypercalcemia. The unique feature of this type of hypercalcemia is its transient nature that may or may not require treatment. This clinical condition in patients with CLD should be kept in mind while evaluating the cause of hypercalcemia in them.

To identify proportion of various types of diabetes and differences between type 1 and type 2 diabetes in patients with youth onset diabetes (onset below 25 completed years of age). In addition, concurrent autoimmune diseases in type 1 diabetes were studied in a subset of patients.A total of 577 patients (192 girls) with diabetes onset at median age of 14 y (range 1 mo-25 y) with median duration of 1 y (range day of diagnosis- 43 y) were included. Clinical details, investigations and complications were recorded in a proforma. Diabetes was classified using clinical criteria supported by laboratory tests of C peptide and anti GAD-65 antibody in a subset of patients.Type 1 diabetes accounted for 368/421 (87.4 %) patients with age of onset18 y and 99/156 (63.5 %) of patients with onset between 19 and 25 y of age. Proportion of type 2 diabetes was 36/421 (8.5 %) and 41/156 (26.2 %) in these two groups. Older age at onset, diabetes in one or both parents, absence of ketosis /weight loss and presence of acanthosis were significant predictors of type 2 diabetes. Hypothyroidism (TSH10) and biopsy proven celiac disease was found in 11.6 and 9.7 % of type 1 diabetes patients respectively.Type 1 diabetes is the most common type of diabetes in youth, however, a significant proportion of youth have type 2 diabetes. In these patients a combination of clinical factors, biochemical parameters and course over few months helps to guide the diagnosis.