MANAGEMENT OF DIABETES

Dr RUKMAN MECCA M I 51 st batch Calicut med college

History
Specific symptoms
Glycosuria Polyuria Polydipsia Polyphagia Weight loss Nocturia

Hyperglycaemia Malaise/fatigue Altered vision

Risk factors for complications

Personal or family history of

Smoking Hypertension

CV disease

Dyslipidaemia

Examination
Body Mass Index Type 1(lean)
Cardiovascular system: Blood pressure, Eyes: Visual acuity

Retinopathy (examine with pupil dilation) Feet: Sensation and circulation Skin condition- acanthosis nigrans(type1) Pressure areas Interdigital problems Abnormal bone architecture

 Peripheral nerves:

Tendon reflexes Sensation-touch Urinalysis: Albumin Ketones Nitrites and/or leucocytes

Diagnosing
In asymptomatic, 2 abnormal values

FBS(70-130) ppbs(<180) In symptomatic(wt loss, poly uria, poly dypsia) only one abnormal value is needed Presence of ketonuria with abnormal blood glucose levels at diagnosis suggests type 1 diabetes HbA1c gives idea about previous glycemic control.

How is diabetes managed?

STEPS OF MANAGEMENT
1. 2. 3.

DIET MONITORING BLOOD GLUCOSE REDUCING COMPLICATIONS

MICRO MACRO

4. 5. 6. 7. 8. 9.

INSULIN THERAPY OHA RETINAL SCREENING ANNUAL FOOT EXAMINATION CARDIO VACSULAR RISK ASSES PSYCHOLOGICAL EVALUATION

DIET
Carbohydrate foods - rich in fibre - low energy density

-contribute up to 50% of the total energy intake

The main thrust of management is to lower total fat

intake and to find substitutes for saturated fats

Exercise should add on to this diet modifications.(150

min / week )

Insulin
Rapid acting(peak at 1 -2hr)
o Lispro o Aspart o Glulisine

Short acting(peak at 2-5 hr)

o

Regular{soluble}

insulin
Intermediate (peak at 12-24 hr)

o Insulin Zn susp o Neutral protamine hagedorn/isophane Long acting(peak upto 24 hr)

o Protamine zn susp o Insulin glargine(persistant action)

 Most app regime in type 2-once daily long acting while

continuing oral metformin &sulphonyl ureas

Usual starting dose is 10 units & titrated based on FBS

MorningBlood Glucose

EveningBlood Glucose

Schedule

High Ok high

Ok High High

Night basal Morn basal Twice daily soluble

Anti diabetic agents

Biguanides Sulfonylureas - glucosidase inhibitors Thiazolidinediones

Prandial glucose regulator

Biguanides
Biguanides are derivatives of the antimalarial

agent Chloroguanide
The most commonly used member of

biguanides is Metformin.

Biguanides
Indication:
Type 2 diabetes failed on diet Metformin can be given alone or in

combination with sulfonylureas or Insulin

Biguanides
Mode of action
Antihyperglycemic
It does not stimulate pancreas to secrete insulin

and does not cause hypoglycemia even in large doses.

Also it has no effect on secretion of Glucagon or

Somatostatin.

Biguanides
Mode of action:
Decreases the intestinal absorption of

CHO
Increases glucose uptake (GLUT 4) Increases glucose utilization

(glycogensynthase)
Increases glycolysis via anaerobic

pathway (lactic acidosis)

Biguanides
Pharmacokinetics:
Metformin is well absorbed from small

intestine- does not bind to plasma

proteins- excreted unchanged in urine.

Half life of Metformin is 1.5 - 4.5 hours,

taken in three doses with meals

Biguanides
Side effects:
occur in 20-25 % of patients.

include.. Diarrhea, abdominal discomfort, nausea, metallic taste and decreased absorption of vitamin B12.

Biguanides
Contraindications
Patients with renal or hepatic impairment.
Heart failure, Chronic lung disease.

sepsis

These conditions predispose to increased lactate production which causes lactic

acidosis which is fatal.

SULFONYLUREAS
discovered during the 2nd. World war
SUs are drugs that used orally to

control blood glucose levels of type 2

diabetes.

SULFONYLUREAS
Chlorpropamide
Tolbutamide Gliclazide Glibenclamide Glipizide Glimepiride

SULFONYLUREAS
Mechanism of action:
Pancreatic effect

Extra-pancreatic effect

SULFONYLUREAS
Pancreatic effect:
Increase insulin release from

pancreas
Suppress secretions of Glucagon

SULFONYLUREAS
Extra pancreatic effect: Increases the number of insulin receptors Increases post-receptor insulin sensitivity Increases glucolysis Increases glycogen storage in muscle and liver Decreases the hepatic output of glucose

SULFONYLUREAS
Pharmacokinetics:

effectively absorbed from GI tract

Food reduce the absorption More effective when given 30 minutes

before eating.
Plasma protein binding is high

90

99 %

SULFONYLUREAS
Pharmacokinetics:
All sulfonylurea are metabolized by liver

and their metabolites are excreted in urine with about 20 % excreted unchanged.
Sulfonylurea should be administered with

caution to patients with either renal or hepatic insufficiency.

SULFONYLUREAS
Adverse Reactions :
SUs may induce hypoglycemia especially in

elderly patients with impaired hepatic or renal

functions

SULFONYLUREAS
Contraindications :

Type 1 DM

Pregnancy and Lactation.

Significant hepatic or renal failure.

 Glucosidase Inhibititor
Acarbose
Indicated for type 2 diabetes

In addition with diet

In addition with other anti-diabetic therapies

Acarbose
Mode of action:
Poorly absorbed 1% (act locally in G.I.T.) Inhibits glucosidase, so inhibits CHO

degradation

Dose:
50mg to 100mg 3 times daily before

meals

Acarbose
Side effects:
Flatulence (77%) Diarrhea Abdominal pain (21%) Decreased iron absorption

Thiazolidenedione
Rosiglitazone Pioglitazone

Thiazolidenedione
Mode of action:
Insulin sensitizer (increase insulin sensitivity in

muscle, adipose tissue & liver)

They are not insulin secretagogues (Not insulin

releasers)

Thiazolidenedione
Drawbacks:
They are not effective alone in case of severe insulin

deficiency and should be combined with sulfonylurea or metformin or both

Side effects:
Hepatotoxicity weight gain Dyslipidaemia (increases LDL)

Prandial glucose regulators (Meglitinide)

Example:
Repaglinide

Rational:
Fast acting, short duration non-sulfonylurea

Designed to minimize mealtime blood glucose

peaks

Repaglinide
Mechanism of action:
Stimulation of pancreatic insulin

release by closing -cells KATP channels

Very rapid onset of action and short

duration
No hypoglycemic metabolites

Repaglinide
Clinical efficacy:
Improves postprandial glycemia Less effective in decreasing fasting blood

glucose levels and HbA1C

Drawbacks:
Fails to provides a stable 24 hours blood

glucose control

Retinal screening
Leading cause of blindness
Screening by digital retinal photography

Laser therapy & Anti VEGF is effective

hbA1c <7.5 prevents it

Foot care
Annual foot examination for ischaemia,neuropathy,

bony abnormality
Prevention
Frequent washing & drying Foot creams

Trimming nails
Special foot care sandals

BP control
Weight reduction &

physical activity

reduces BP
ARB or ACE considered first

Renal function impairment

In type 1 , mostly many years later
In type 2 micro albuminuria mostly

associated with hypertension

Cardio vascular risk

In type 2, CVD is 2-4 fold risk
Therapy with statins reduces cholestrol

& reduces risk Once daily 10 mg atorvastatin in type 2 diabetes gives primary protection.

Depression
Sufferings affects with self management and need for high

treatment costs 20 mg fluoxetine can be added

(reduces neuropathic pain)

references
Harrison medicine
Tripathi Good man and gillman

Americal diabetes journal

Diabetes mgt guide Dr Vinod Gujral Diabetes mgt in gen practice-Australian DA wikipedia