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Váro-centric Diabetes Management
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: email@example.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
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