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Editorial Diabetes Váro-centric Diabetes Management Sanjay Kalra Department of Endocrinology, Bharti Hospital, Karnal, India W hile efficacy and safety are proven for all modern glucose-lowering drugs, their tolerability may vary. This is especially true in terms of weight gain. This communication proposes a váro-centric model of diabetes care. This approach helps choose appropriate glucose-lowering therapy, based upon weight (body mass index). The váro-centric model suggests a weight-centric approach to selection of drugs. While respecting the tenets of patient-centred care and good clinical sense, it serves as a clinical and teaching tool for rational prescription in diabetes. Keywords Body mass index, dipeptidyl peptidase 4 inhibitors (DPP4i), glucagon like peptide receptor agonists (GLP1RA), insulin, pioglitazone, sodium glucose cotransporter 2 inhibitors (SGLT2i), sulfonylureas Disclosure: Sanjay Kalra has nothing to declare in relation to this article. No funding was received in the publication of this article. This article is a short opinion piece and has not been submitted to external peer reviewers. Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit. Received: June 30, 2017 Published Online: November 17, 2017 • Varo—a person dealing with things sensibly and realistically in a way that is based on practical rather than theoretical considerations (Urban Dictionary). • Város—weight, burden, overweight (Greek). • Vero—merchandise, trade good (Esperanto). The phrase “patient-centered” defines modern diabetes care, and rightfully so. 1 In patient-centered diabetology, the patient’s specific needs and requirements are taken into consideration while planning therapy. This helps achieve glycemic targets in a safe and well-tolerated manner. Current guidelines try to match the framework set by accepted definitions of patient centered care, as well as the bio-psychosocial model of health. 2,3 The American Diabetes Association/European Association for Study of Diabetes (ADA/EASD) provide a horizontal choice of second-line drugs, and third-line combinations, to be prescribed in case of metformin inadequacy. 1 It is clear that pleiotropic benefits, rather than efficacy per se, inform the choice of treatment. This style leaves the selection of a particular drug class (or classes) to the treating physician. For the student, or inexperienced caregiver, such a guideline does not assist in deciding techniques, tactics, and troubleshooting while treating diabetes. Citation: US Endocrinology, 2017;13(2):53–4 Corresponding Author: Sanjay Kalra, Department of Endocrinology, Bharti Hospital, Karnal, India. E: brideknl@gmail.com The American Association of Clinical Endocrinology/American College of Endocrinologists (AACE/ ACE) try to simplify matters by proposing a vertical hierarchy of drug classes. 4 Here, glucose-lowering drugs are listed in descending order of appropriateness, based upon safety and tolerability. The main criterion for ranking seems to be the effect on weight, as weight loss is clearly mentioned, along with achievement of euglycemia, as a targeted outcome in type 2 diabetes care. Such a rubric, however, ignores the needs of underweight, lean, and normal-weight persons with diabetes. To assist in clinical decision-making, we have proposed the concept of metabolic triage, 5 based upon the metabolic fulcrum. In this model, persons with type 2 diabetes are triaged into three categories: eubolic, extremely catabolic, and maladaptive anabolic. This classification is based upon phenotype, and is backed by insights from pathophysiology, biochemistry and endocrinology. 6,7 A type 2 diabetes person in catabolism will have predominant insulin deficiency, with a low insulin/glucagon ratio, and AMP-activated protein kinase (AMPK) hyperactivity. A maladaptive anabolic individual, on the other hand, will be predominantly insulin resistant, have a high insulin/glucagon ratio, and require AMPK activation. These factors help in choosing appropriate glucose-lowering treatment, 5 including injectable therapy. 8 TOU CH MED ICA L MEDIA 53