Stewardship

The theme of stewardship is familiar to practitioners and students of health care. Antibiotic stewardship, steroid stewardship and insulin stewardship are some examples of the use of this framework in clinical medicine^1-3. This concept has also been extrapolated to create a rubric known as glycemic guardianship⁴.

Sulfonylureas in Service

As part of this ongoing campaign to improve diabetes care, we propose the term sulfonylurea stewardship. Sulfonylurea stewardship may be defined as a systematic approach to prescribe and monitor sulfonylurea therapy, in persons with type 2 diabetes, in a rational and responsible manner, balancing efficacy with safety and tolerability, so as to achieve optimal short-term as well as long-term outcomes. Their long record of service, prominent listing in World Health Organization’s Lists of Essential Medicines⁵, as well as treatment guidelines, and widespread usage across the globe, bear testimony to their usefulness.

Multifaceted Concept

Sulfonylurea stewardship may be practiced at a macro-, meso- and micro- level (Table 1). The various components of sulfonylurea stewardship, listed in Table 1,
correlate with the teachings of ‘good clinical  sense’, therapeutic parsimony’, and ‘first do no harm’^6,7. Good clinical sense is defined as" the presence of sensory faculties, their usage and interpretation, by which one is able to practice good clinical medicine". Pragmatic clinical sense, based on evidence, and embellished by astute observation and experience, must be a part and

 parcel of all decision making. Therapeutic parsimony alludes to the adage to use minimal therapeutic interventions, in place of multiple ones, as long as equivalent therapeutic outcomes are achieved⁷.

This promotes usage of fixed dose combinations, with lower frequency of administration, so as to reduce complexity of regimens. The teaching, ‘First do not harm’, reminds us to prioritize patient safety. These maxims fit under the umbrella of glycemic guardianship, i.e., activities carried out by all stakeholders to ensure optimal care of diabetes. 

Responsibility

All these maxims can be addressed through sulfonylurea stewardship. The responsibility for this stewardship should be shouldered by all health care professionals and planners. Endocrinologists and diabetologists, however, must take the lead in advocating and propagating the importance of sulfonylurea stewardship, as a part of glycemic guardianship. Concerted, and continued focus on academic and clinical excellence, research, and advocacy is required to reap the benefits of modern sulfonylureas.

Safe And Smart Usage

There are voices which feel that sulfonylureas should be discontinued⁸. These should be engaged, through dialogue and discussion, to describe the heterogeneity of this drug class, and the benefits of modern sulfonylureas such a as glimepiride and gliclazide XR⁹.
Contemporary evidence, as published in this issue of Asian Journal of Diabetology, should be shared with clinicians and other concerned stakeholders. This will improve confidence in the “safe and smart” sulfonylureas, enhance rational usage, and lead to better outcomes in diabetes care.

References

1. Mudenda S, Daka V, Matafwali SK. World Health Organization AWaRe framework for antibiotic stewardship: Where are we now and where do we need to go? An expert viewpoint. Antimicrob Steward Healthc Epidemiol. 2023;3(1):e84.
2. Kalra S, Kumar A, Sahay R. Steroid stewardship. Indian J Endocrinol Metab. 2022;26(1):13-6.
3. Lathia T, Punyani H, Kalra S. Insulin stewardship for inpatient hyperglycaemia. JPMA. 2021;71(1 (B)):379-82.
4. Kalra S, Verma SK, Bhattacharya S. Glycemic guardianship: World Health Organization leads the way. IJCP. 2022;23(4):5-6.
5. Reddy A. Diabetes and the WHO model list of essential medicines. Lancet Diabetes Endocrinol. 2022;10(1):20-1.
6. Kalra S, Gupta Y. Good clinical sense in diabetology. J Pak Med Assoc. 2015;65(8):904-6.
7. Kalra S, Gupta Y, Sahay R. The law of therapeutic parsimony. Indian J Endocrinol Metab. 2016;20(3):283-4.
8. Lee TTL, Hui JMH, Lee YHA, Satti DI, Shum YKL, Kiu PTH, et al. Sulfonylurea is associated with higher risks of ventricular arrhythmia or sudden cardiac death compared with metformin: A population-based cohort study. J Am Heart Assoc. 2022;11(18):e026289.
9. Kalra S, Aamir AH, Raza A, Das AK, Khan AA, Shrestha D, et al. Place of sulfonylureas in the management of type 2 diabetes mellitus in South Asia: a consensus statement. Indian J Endocrinol Metab. 2015;19(5):577-96.