Type 2 Diabetes Mellitus — RSSDI Management Guidelines
India has approximately 7 crore people with diabetes — the second-highest in the world after China. The RSSDI (Research Society for the Study of Diabetes in India) 2024 guidelines adapt global ADA/EASD frameworks to Indian phenotypic and dietary patterns. Indians develop diabetes at lower BMI, younger age, and with greater insulin resistance than Western populations — requiring India-specific treatment strategies.
Type 2 Diabetes Mellitus (T2DM) is a chronic metabolic disorder characterised by insulin resistance and progressive beta-cell failure. India carries approximately 17% of the global diabetes burden, with prevalence rising from 7.1% (NFHS-4, 2015-16) to 9.6% (NFHS-5, 2019-21) among adults. The 'Asian Indian Phenotype' — characterised by higher body fat percentage at lower BMI, central adiposity, and higher insulin resistance — explains why Indians develop diabetes at BMI 23-25 while Caucasians develop it at BMI > 30.
Without proper management, T2DM leads to microvascular (retinopathy, nephropathy, neuropathy) and macrovascular (CAD, stroke, peripheral arterial disease) complications. Diabetes is the leading cause of blindness, kidney failure, and non-traumatic lower limb amputation in Indian adults. Early diagnosis and aggressive management can prevent or delay these complications.
Diagnostic criteria (WHO / ADA / RSSDI):
| Test | Diabetes | Prediabetes |
|---|---|---|
| Fasting plasma glucose (FPG) | ≥ 126 mg/dL (7.0 mmol/L) | 100-125 mg/dL (IFG) |
| 2-hr post-75g glucose load (OGTT) | ≥ 200 mg/dL (11.1 mmol/L) | 140-199 mg/dL (IGT) |
| HbA1c | ≥ 6.5% | 5.7-6.4% |
| Random plasma glucose + symptoms | ≥ 200 mg/dL | N/A |
Diagnosis requires two abnormal results from separate days, unless the patient has classic symptoms (polyuria, polydipsia, weight loss) with random glucose ≥ 200 mg/dL — which is diagnostic on a single sample. HbA1c reflects average glucose over the previous 2-3 months and is the standard monitoring test once treatment starts.
Step 1 (at diagnosis): Lifestyle modification (Indian diabetic diet, 150 min/week aerobic exercise, weight loss target 5-10%) + Metformin 500 mg BD, titrate to 1 g BD over 2-4 weeks. Metformin is first-line unless contraindicated (eGFR < 30, severe heart failure, contrast administration).
Step 2 (HbA1c > target after 3 months): Add a second agent based on comorbidities:
- Established ASCVD or high risk: SGLT2 inhibitor (Empagliflozin 10-25 mg, Dapagliflozin 5-10 mg) or GLP-1 receptor agonist (Semaglutide, Liraglutide)
- Heart failure (HFrEF): SGLT2 inhibitor (preferred)
- CKD: SGLT2 inhibitor (if eGFR 20-60); GLP-1 RA if eGFR < 20
- No specific comorbidity: DPP-4 inhibitor (Sitagliptin 100 mg), SGLT2i, GLP-1 RA, or Pioglitazone (avoid in heart failure)
- Cost-constrained setting: Sulfonylurea (Glimepiride 1-4 mg) — risk of hypoglycaemia and weight gain
Step 3 (HbA1c > target after 6 months): Triple oral therapy or add basal insulin (Glargine, Detemir) at 10 U/day or 0.1-0.2 U/kg, titrate by 2 U every 3 days to fasting glucose 80-130.
Step 4: Prandial insulin (regular or rapid-acting analogue) added to basal if post-prandial glucose uncontrolled. Basal-bolus regimen (4 injections/day) for severe insulin deficiency.
| Population | HbA1c Target | Fasting | Postprandial |
|---|---|---|---|
| Most adults | < 7.0% | 80-130 mg/dL | < 180 mg/dL |
| Older adults with limited life expectancy | < 8.0% | 90-150 | < 200 |
| Pregnancy (pre-existing T2DM) | < 6.5% | < 95 | < 140 (1-hr), < 120 (2-hr) |
| Children/adolescents | < 7.5% | 90-130 | < 180 |
Individualise target based on age, comorbidities, hypoglycaemia risk, life expectancy. Avoid intensive targets in elderly with cardiovascular disease due to hypoglycaemia risk.
Every patient with T2DM should undergo annual screening for complications:
- Eyes: Fundus examination for diabetic retinopathy (or fundus photography). Referral to ophthalmologist if any retinopathy detected.
- Kidneys: Urine albumin/creatinine ratio (UACR) + serum creatinine + eGFR. Microalbuminuria (30-300 mg/g) is the earliest marker of diabetic nephropathy.
- Feet: Inspection (calluses, ulcers, deformities), palpation of dorsalis pedis and posterior tibial pulses, monofilament testing for protective sensation, ABI measurement if peripheral arterial disease suspected.
- Cardiovascular: ECG annually; consider stress test if symptoms or multiple risk factors. Lipid profile, BP, BMI at every visit.
- Neuropathy: Symptom assessment (numbness, tingling, burning), monofilament, vibration sense (128 Hz tuning fork), ankle reflex.
- Vaccinations: Annual influenza, pneumococcal (PCV13 + PPSV23), hepatitis B if not immune, COVID-19.
T2DM is one of the most operationally complex chronic diseases — combining diet, exercise, multiple drug classes, and lifelong complication screening. For UPSC CMS aspirants, the RSSDI algorithm, HbA1c targets, and the SGLT2i indications are highly testable clinical topics.