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					Guide to diabetes
Definition

• Diabetes mellitus is a syndrome
  characterised by chronic
  hyperglycaemia and disturbance of
  carbohydrate, fat and protein
  metabolism associated with absolute or
  relative deficiency in in insulin
  secretion and\or insulin action.
Insulin allows glucose (sugar) to enter
body cells to convert it into energy.
Insulin is also needed to synthesize
protein and store fats. In un controlled
diabetes, glucose and lipids (fats)
remain in the blood stream and, with
time damage the body’s vital organs
and contribute to heart disease.
Classification

Diabetes is classified into three main types:
• Type 1 previously called insulin-dependent
  diabetes mellitus (IDDM)
• Type 2 previously called non-insulin-
  dependent diabetes mellitus(NIDDM)
• Gestational Diabetes Mellitus(GDM)
Type 1 Diabetes
Occurrence:
• Autoimmune disease wherein the immune system
  attacks B-cells of pancreas and destroys them. The
  pancreas then produce little or no insulin.
• Scientists do not know exactly what causes the
  body’s immune system to attack the B-cells, but
  they believe that both genetic factors and
  environmental factors and possibly viruses, are
  involved.
Characteristics:
• Often develops in children and young adults, but
  the disorder can appear at any age.
• Symptoms usually develop over a short period,
  although B-cell destruction can begin year earlier.
• If not diagnosed and treated with insulin, a person
  can lapse into a life-threatening diabetic coma,
  also known as diabetic ketoacidosis.
Type 2 diabetes
Occurrence:
• The most common form of diabetes.
• Due to reduce insulin secretion or
  peripheral resistance to action of insulin.
• The result is the same as for Type 1
  diabetes, glucose builds up in the blood and
  the body cannot make efficient use of its
  main source of fuel.
• Often part of a metabolic syndrome
  that includes obesity, elevated blood
  pressure, and high levels of blood
  lipids.
Characteristics:
• Contributes 90 to 95% of total diabetes and one-
  third not been diagnosed.
• This form of diabetes usually develops in adults.
• About 80% of people with Type 2 diabetes are
  overweight.
• Increase in incidence of childhood obesity leads to
  Type 2 diabetes becoming more common in young
  people
Symptoms & Management for
Type 1 and Type 2 Diabetes

Symptoms:
• Increased thirst and urination.
• Constant hunger.
• Weight loss.
• Blurred vision
• Extreme fatigue.
• Slow healing of wounds or sores.
Management:

• Diet
• Exercise
• Insulin for Type 1 and OHAs or insulin in
  Type 2
• Education
• Monitoring blood glucose and therapy
Gestational Diabetes:

Occurrence:
• Develops in pregnancy and disappears after
  delivery, however with increased risk in
  getting later in life
• Insulin resistance due to pregnancy.
• Genetic predisposition.
Management:

• Diet: provide adequate calories which will
  not lead to hyperglycemia or ketonemia.
• Exercise: that does not cause fetal distress,
  contractions or hypertension.
• Insulin: to maintain blood glucose,
  fasting<=95mg/dl (<=5.3 mmol/l); one hour
  post prandially <=120mg/dl(<=6.7 mmol/l).
Diagnosis

 The fasting plasma glucose test in the
 preferred test for diagnosis Type 1 or Type
 2 diabetes. However, a diagnosis of diabetes
 is made by an one of the three positive tests,
 with a second positive on a different day:
• A random Plasma glucose value (taken any
  time of day) of 200mg/dl or more, along
  with the presence of diabetes symptoms.
• A plasma glucose value of 126/mgdL or
  more, after a person has fasted for 8 hours
• An oral glucose tolerance test (OGTT)
  plasma glucose value of 200 mg/dL or more
  in the blood sample, taken 2 hours after a
  person has consumed a drink containing 75
  grams of glucose dissolved in water. This
  test, taken in a laboratory or the doctor’s
  office, measures plasma glucose at timed
  intervals over a 3-hour period.
Gestational Diabetes

 Diagnosed based on plasma glucose values
 measured during the OGTT. Glucose levels
 are normally lower during pregnancy, so the
 threshold values for diagnosis of diabetes in
 pregnancy are lower. If women has two
 plasma glucose values equal to or more than
 any of the following values after a 100gm
 OGTT, she has gestational diabetes:
• 1-hour level of 180 mg/dL
• 2-hour level of 155 mg/dL or 3-hour level
  of 140 mg/dL
• Fasting plasma glucose level of 95mg/dL
People with impaired glucose metabolism, a
state between normal and diabetes are at
risk for developing diabetes, heart attacks,
and strokes. There are two forms of
impaired glucose metabolism.
Impaired Fasting Glucose (IFG):

• Fasting plasma glucose level of 110 to 125
  mg/dL, a level higher than normal but less
  than the level indicating a diagnosis of
  diabetes.
Impared Glucose Tolerance (IGT)
 Means that blood glucose during the oral
 glucose tolerance test is higher than normal
 but not high enough for a diagnosis of
 diabetes. IGT is diagnosed when the
 glucose level is 141 to 199 mg/dL, 2 hours
 after a person is given a drink containing 75
 grams of glucose.
OGTT
• OGTT is performed using a 75 or 100 gm oral
  glucose load in the morning after a noncaloric 8-
  hour fast. Water is allowed, but not coffee or
  smoking.
• Test should be performed on an individual without
  underlying illness and/or interfering drugs. OGTT
  is not appropriate for a patient who is
  malnourished, on a restricted carbohydrate diet, or
  with acute and chronic illness.
• Patient should be ambulatory and not to bed rest,
  hospitalized , or immobilized. During the test,
  patient should be resting comfortably.
• Patient should consume an unrestricted diet
  containing at least 150g carbohydrate daily for
  three days before test.
• Just a confirmatory test, not to be done regularly.
Glycated Hemoglobin (HbA1c) Test
 • Indicates blood glucose control over a
   period of approximately 3 months.
 • Normal range varies depending on the
   method the lab uses: usually 4-7%,
   correlating to average blood glucose of 60-
   150 mg/dl (3.3-8.3 mmol/l)
• Should be prescribed by health care
  provider every three months for Type 1
  diabetes and at 3-6 months intervals for
  Type 2, to help determine overall control.
• Patient does not need to be fasting to have
  this blood test performed
Ketone Test

• Ketone is by product of fat metabolism;
  presence of ketone indicates that the body is
  not metabolizing food properly because of
  lack of available insulin or carbohydrate;
  may indicate impeding or established
  diabetic ketoacidosis (DKA), a condition
  that requires immediate medical attention.
Method: Dipstick
When to test:
• When blood glucose level is consistently
  >300 mg/dl (16.7 mmol/l).
• During period of acute illness (illness is a
  stress that can cause and hyperglycemia).
• When symptoms of hyperglycemia
  accompanied by nausea, vomiting and
  abdominal pain are present.
Treatment strategy
Goals Of Treatment
• Control high blood glucose (hyperglycemia)
• Avoid low blood glucose (hypoglycemia).
• Treatment of associated conditions, such as high
  blood pressure, cholesterol disorder and obesity.
• Prevent or retard the progression of complications
  of diabetes such as blindness, kidney failure, heart
  disease, stroke and amputation of legs.
Treatment Plan

1. Management of Blood Glucose:
          Target Blood Glucose values:
 (as recommended by the American Diabetes Association)
Pre-meal blood glucose      80-120 mg/dl
Bedtime blood glucose       100-140 mg/dl
*HbA1c                      Less than 7%
• However, not every person is a candidate for such
  tight blood glucose control. This should not be
  attempted in:
• Frail, elderly person who have already developed
  the complications of diabetes such as blindness
  and end-stage kidney failure.
• Elderly patients having frequent low blood
  glucose episodes.
Management of cholesterol:

           Target Cholesterol Levels
(as recommended by the American diabetes association)


LDL Cholesterol           Less than 100 mg/dl
HDL Cholesterol           Greater than 45 mg/dl
Triglycerides             Less than 200 mg/dl
Management of High Blood Pressure
 • Target blood pressure in diabetic patients
   should be less than systolic 130/ diastolic 85
   mm Hg, as recommended by the American
   diabetes Association.
 • The treatment strategy also involves correct
   nutrition, moderate exercise and proper
   medication.
Nutrition

• Nutrition is an important element in
  diabetes management.
• Diet content should be 10-2-% protein, 60%
  carbohydrates and 20% fats.
Do’s of diabetic diets

• Consistency in diet and meal timings
  according to medicines.
• Multivitamin containing an antioxidant such
  as vitamin ,beta-carotene, vitamins C and E.
• Minimum of 1200 kcal/day for women and
  1500 kcal/day for men.
• Sodium level (salt intake) should be
  maintained between 2.4 and 3.0 gm/day for
  people without hypertension and >2.4
  gm/day for people with mild to moderate
  hypertension.
• Fibre of approximately 20- 35 gm/day from
  a variety of food sources should be
  consumed
Don’ts of diabetic diets

• Avoid alcohol especially if diabetes is not in
  control.
• Avoid in-between meals. Adhere to the time
  and size of the meal decided.
• Avoid fasts and fasting alters body
  metabolism, adversely affecting the diabetic
  state.
Exercise

• Exercise can improve the health and
  outlook of life. Regular and controlled
  exercise not only helps to increase glucose
  utilization but also helps to maintain
  desirable health.
Do’s in exercise
• Check the patients for blood pressure, blood fat
  levels, HbA1c, health of heart, circulatory and
  nervous systems, kidney function, eyes and feet.
• Choose exercises that fit the patient’s health.
• Exercise should be preceded and followed by 5-10
  minutes of slow, continuous, aerobic activities.
• Remember the feet.Advice them to wear the
  comfortable shoes for the sport.
• Watch the low blood sugar, insulin or oral
  diabetes medicine may lead to low blood
  sugar levels.
• Advice the patients to keep a snack handy
  to avoid low blood sugar levels during the
  exercise.
Don’ts in exercise

• Advise not to snack unnecessarily before
  exercise.
• Uncomfortable shoes should not be worn
  while exercising.
• Avoid exercising in extreme cold or heat.
• Exceeding target heart rate of 60 to 80% of
  estimated maximum heart rate.
Oral Hypoglycemic Agents

• OHAs are primarily used in type 2 diabetes
  adjunct to nutrition therapy and exercise.
• Oral agents are broadly classified as
  follows:
First generation sulfonylureas
Generic name     Dosage        Duration of   Side effect of class
                 range per day action
Chlorpropomide   100-500 mg    6-2 hrs       Prolonged
                                             hypoglycemia,
                                             cholestatic
                                             jaundice,
                                             Hypersensitivity;
                                             alcohol flush
Tolbutamide      500-3000 mg 6-2 hrs         Hypoglycemia,
                                             hypersensitivity
Tolazamide       100-1000 mg 12-24 hrs       Hypoglycemia,
                                             hypersensitivity
Aceohexamide     500-1500 mg 12-24 hrs       Hypoglycemia,
                                             hypersensitivity
Second generation sulfonylureas
Generic name    Dosage   Duration   Side effects
               range per    of        Of class
                  day     action
  Glipiside   2.5-40 mg 12-24 hrs Hypoglycemia,
                                  hypersensitivity
Glibenclamide 5-20 mg   12-24 hrs Hypoglycemia,
                                  hypersensitivity
Glymeperide 1.8 mg        24 hrs Hypoglycemia,
                                  hypersensitivity
  Gliclazide  40-240 mg 12-24 hrs Hypoglycemia,
                                  hypersensitivity
Agents enhancing effects of insulin
Generic name    Dosage    Duratio Side effects of class
                Range      n of
                Per day   action
  Metformin    500-2500   6-8 hrs   Gi upset; diarrhea;
  (Obimet)        mg                possible resumption
                                    of ovulation in
                                    premenopausal
                                    anovolvutary
                                    patients; acidosis (if
                                    renal, liver, heart
                                    impairment present).
Agents enhancing effects of insulin
  Generic       Dosage    Duration Side effects of class
   name         Range     of action
                per day
Rosiglitazone   4-8 mg    Very long Renal and liver
                                    function studies
                                    should be done to
                                    monitor liver
                                    dysfunction, salt
                                    and water retention,
                                    edema, congestive
                                    heart failure.
Agents enhancing effects of insulin
Generic name    Dosage     Duration    Side effects of class
               range per   of action
                  day
Pioglitazone   15-45 mg    Very long Renal and liver
                                     function studies
                                     should be done to
                                     monitor liver
                                     dysfunction, salt and
                                     water retention,
                                     edema, congestive
                                     heart failure
Other Oral agents
Generic name Dosage range Duration     Side effects of class
               per day    of action
 Repaglinide   1.5-16 mg    2-6 hrs   Hypoglycaemia,
(NovoNorm)                            arthralgia, leukopenia

 Acarbose      25-300 mg    < hrs     Diarrhoea,abdominal
                                      discomfort, flatulence
  Miglitol     25-300 mg    <4 hrs    Diarrhoea, abdominal
                                      discomfort, use not
                                      recommended when
                                      significant renal
                                      dysfunction present
          Incidence of HOA failure

Primary failure:
About one third of of Type 2 patients fail to
respond to sulphonylurea treatment within
one month of initiation of therapy.
Secondary failure:

• Of the patients that initially achieve
  satisfactory glycaemic control, about 5 to
  10% go on to develop secondary failure
  each year, so that after 10 years only about
  half of the patients continue to have
  satisfactory response.
Secondary failure: (continued)

• From the data of the UKPD study, it
  appears by the sixth year,approximately
  50% of the patients randomized to
  sulphonylurea needed supplemental insulin
  to maintain adequate glycemic control.
Diagnosis OHA failure:
• It is a condition in which an individual does not
  respond adequately/ satisfactorily with OHAs.
• Clinically, following parameters can be of great
  relevance in diagnosing OHA failure:
  1. Inadequate improvement in the classical signs
  and symptoms of diabetes viz., polydypsia,
  polyuria, polyphagia and fatigue.
2.Weight loss accompanied by rising blood
  glucose and recurring infections.
3.Inadequate/deteriorating blood glucose
  control. The objective to the pursued on this
  front is:
   Fasting blood glucose   <140 mg/100 ml
   PP blood glucose        <180 mg/100 ml
4.High and increasing number of tablets with
  inadequate control; especially exceeding
  two to two and a half tablets in case of
  commonly used OHA.
Dose at which review is essential
Oral hypoglycemic Agent Mg per day   No of tablets

Glibenclamide (Glyburide)   10             2


Gipzide                     10             2

Glyclazide                  120           1.5
Dose at which review is essential

• Poor performance with the above doses
  indicates the necessity to review the
  entire therapy and the therapeutic
  alternative to be considered at this
  point of time is initiation of insulin
  therapy
In case of Type 2 diabetes, there
are 2 possibilities:

• Stop HOA treatment and start insulin
  therapy (substitution) or
• Continue OHA treatment and add
  insulin therapy (supplement)
Oral antidiabetics are contraindicated in
Type 1 diabetes and in Type 2 diabetes
undergoing surgery, serve infections, liver
and kidney disease, and gestational
diabetes.
Insulin

 Insulin are always used in patients with
 Type 1 diabetes and may be required in
 patients with Type 2 diabetes or gestational
 diabetes.
 Insulin can be broadly classified on the
 basis of species, action profile and strength.
Sources of insulin: human, porcine
and Bovine
Species   Structural difference        Immunogenecit
                                       y

Human     Identical to physiological   Least
          insulin

Porcine   Differs in one amino acid    Negligible
          from Human insulin

Bovine    Differs in three amino   More
          acids from Human insulin
 Action profile of insulin:
    Type            Onset             Peak           duration

Rapid-acting          ½ hrs            1-3 hrs          8 hrs
Human
Actrapid
Indication
1. For dose titration, quick glycemic control
2. Emergencies like diabetic ketoacidosis (DKA),
   hyperosmolar non-ketotic state (HONK)
3. Stressful conditions like surgery, labour,myocardial infraction
    Type           Onset            Peak          Duration

Intermediate        2.5 hrs         7-15 hrs        24 hrs
Acting lente
Human
Monotard
Indication
 1. OHA Failure
 2. Pregnant diabetes
 3. Chronic infections in Type 2 diabetes e.g Tuberculosis
    Type           Onset            Peak          Duration

Intermediate        1.5 hrs         4-2 hrs         24 hrs
Acting NPH
Human
Insultard
Indication
 1. OHA Failure
 2. Pregnant diabetes
 3. Chronic infections in Type 2 diabetes e.g Tuberculosis
      Type              Onset           Peak         Duration

Pre-mixed (30/70        ½ hrs          2-8 hrs         24 hrs
regular/NPH)
Human Mixtard
Indication
 1. OHA Failure
 2. Pregnant diabetes
 3. Chronic infections in Type 2 diabetes e.g Tuberculosis
 4. Any other indications where a mixture of rapid and
intermediate acting insulin is desired in the ratio of 30:70
       Type            Onset         Peak        Duration

Pre-mixed 50/50         ½ hrs       2-8 hrs       24 hrs
regular/NPH
Human Mixtard 50

Indication
1. Patients with modern lifestyles on two large daily meals
2. Patients with high post prandial blood glucose levels
Amounts of insulin
• Insulin regimen should be individualized
  depending on lifestyle, activity level and eating
  pattern.
• Continuous treatment and monitoring are the main
  stay.
• Efforts should be taken to keep blood glucose as
  close to the target range (72 mg/dl before a meal,
  180 or less two hours after a meal).
Insulin Initiation

Substitutions
• Stop OHA tablets.
• Start with Intermediate insulin 0.2 units /kg
  body weight before breakfast or at bed time
  (upto a maximum of 20 units).
• Increases by 2-6 units every 3-4 days if
  necessary.
Note:

• If post prandial blood glucose levels are too
  high add Rapid action insulin. Alternatively,
  Pre-mixed insulin could be used. If the dose
  exceeds 30-40 units, divide the dose into
  daily injections 2/3rd before breakfast and
  1/3rd before dinner.
Supplement

• Continue with OHA tablet with out any
  change in dose.
• Start with 0.1 to 0.2 units of
  intermediate insulin per Kg body
  weight before breakfast or bed time.
Supplement: (continued)

• Increase dose by 2-4 units every 3-4
  days if necessary
• If more than 30-36 I.U. is required for
  adequate control ( i.e FGB<140
  mg/100ml), consider stopping OHA
  and continue on insulin
Suggested Guidelines For Fine
Tuning Split Mix Regimens

• Response to insulin treatment may be
  different in different patients may require
  adjustment to the insulin regimen. The table
  given below depicts a simple way to adjust
  the dose.
Adjustment to morning injections
                      Before Lunch          Before Dinner

If persistent      Increase fast acting   Increase
hyperglycaemia (or (soluble) insulin in   intermediate acting
glycosuria) occur the morning             insulin in the
                   injection by 2IU       morning injection
                                          by 2 IU
If hypoglycaemia    Decrease fast         Decrease
occurs with out     acting (soluble)      intermediate acting
explanation         insulin next          insulin next
                    morning by 2 IU       morning by 2 IU
 Adjustment to evening injection
                      Before Lunch            Before Dinner
If persistent      Increase fast acting    Increase intermediate
hyperglycaemia     (soluble) insulin in    acting insulin in the
(or glycosuria)    the evening injection   evening injection by
occur              by 2IU                  2 IU (after excluding
                                           nocturnal
                                           hypoglycaemia
If hypoglycaemia   Decrease fast acting    Decrease
occurs without     (soluble) insulin       intermediate acting
explanation        evening injection by    insulin in the evening
                   2 IU                    injection by 2 IU
Mixing Insulin

• NPH and short-acting insulin formulations
  when mixed may be used immediately or
  stored up to 2 weeks.
• Mixing of regular and lente is not
  recommended unless injected immediately
  after preparation; binding action of regular
  and lente begins immediately and effect of
  regular may be blunted.
Insulin Administration
• Choose a syringe compatible with the insulin
  strength (i.e.40 I.U. insulin)
• For cloudy insulin (suspension) invert the vial a
  few times until the suspension has been mixed
  well.
• Draw air into syringe corresponding to the
  prescribed dose of insulin and slowly inject air
  into vial held vertically at eye level, then draw up
  insulin
Insulin Administration: continued
• Inject excess amount of insulin back into the vial
  held vertically at eye level and pull out the needle.
• Lift up the skin at the injection site in a broad fold
  and insert needle at an angle of 45 into the sub-
  cutaneous tissue, inject insulin slowly.
• In order not to injure the tissue beneath the skin
  rotate the injection site in the chosen area.
Delivery Devises

Needle and Syringe
• A common way of administering insulin is
  with a needle and syringe.
• Syringes come in a range of capacities (1ml,
  0.5ml, or0.3ml) and different strengths.
• Most suitable size can be selected to deliver
  the insulin dosage as per the requirement.
• Needles also come in different gauges and
  lengths, and have very fine points and
  special coatings to make them relatively
  pain-free although some people find them
  daunting and not very convenient.
Insulin Pens (NovoPen 3)

• Easiest and the most convenient way of
  administrating insulin.
• Accurate even at extremely low dosage.
• NovoPen 3 reduces the insulin
  administration to mere two step procedure:
  Dial the dose and inject.
Advantages:
• Combination of insulin pens and Penfills
  completely eliminates the need to handle
  syringes and vials.
• No need to mix and measure and therefore
  improves dosage accuracy.
• NovoPen 3 is compact enough to fit easily
  into a purse or pocket and convenient to
  carry anywhere.
• Launch of single penfills has further
  enhanced convenience to buy and has also
  offered economy to the patient by avoiding
  huge investment at one single time.
Disposable Pens (NovoLet):

• Premixed, prefilled and ready to use
   disposable insulin delivery devices.
• Patients just have to dial dose, inject and
   dispose the pen after use of 300 units of
   insulin.
NovoLets useful in initiating insulin therapy
in
• OHA inadequacy and failure
• Pre and post operative conditions
• Gestational diabetes mellitus
NovoLets are available in all the varieties of
insulin viz.
Mixtard 30 NovoLet, Mixtard 50 NovoLet,
Actrapid NovoLet, Insulatard NovoLet
Storage of Insulin
• Refrigerate unopened insulin (will be good until
  the expiration date on the vial).
• The vial of insulin is used within 30 days of
  opening, may be stored at room temperature (>2
  degree Celsius and <30 degree Celsius); insulin ac
  activity decreases after 30 days at room
  temperature.
• Unlike other medications insulin requires a special
  storage and transportation arrangement.
• Needs to be stored between 2 degree
  Celsius to 8 degree Celsius without
  dampness and direct exposure to
  sunlight.
• In transportation it is to be dispatched
  with coolants and thermocol boxes.
• Neutral insulin should be a clear solution
  whereas premixed and intermediate
  insulin are suspensions.
• Magnus Novo Nordisk offer complete
  range of insulin with C4 (Complete care
  cool chain) guarantee.
Diabetes Treatment Chart

       Define individual Aims of therapy
                                         Very symptomatic
                                         Severe
                  Diet and Exercise
                                         hypoglyceamia
Glycemic goals                           Ketosis Pregnancy
Monotherapy                      Glycemic goals
Repaglinide                      achived
Sulphonylurea
Biguanide Alpha-
glucosidase inhibitor
Thiazolidinedione
Insulin
Traditional Medicines

Due to chronic nature of the disease, patients
 try various therapies available in the market,
 which are clinically not proven. The basis
 of the usage of these medicines is “no side-
 effects” but then “efficacy” is always a
 question mark. Some of the traditional
 medicines used in the treatment are:
• Better substances like Neem leaves, Bittergourd,
  Methi etc.
• Ayurvedic drugs viz. Vijasar, Bittergourd, Jamoon
  Seeds and Nisha Amlakki are used commonly.
  However their clinical results have not been either
  conclusive or not published.
• Spirulina (fresh water algae) that grows in water
  tanks is used, but not significant effect seen on
  blood sugar.
Precautions

• It is essential to provide the efficacy and
  safety of traditional medicines in wide
  variety of patents and to look for long term
  safety and efficacy in human beings.
• Any system of medicine that claims that it
  has cure or relief for Diabetes has to under
  go the clinical safety tests before it is
  accepted.
• Scientific proof and clinical study
  should authenticate any such claims in
  magazines and newspapers.
Drugs that may alter the
glycemic control of sulfonylureas

A. Enhance hypoglycemic effect (decrease
 blood glucose)
     Alcohol (acute use)   Methyldopa

     Allopurinol           Monoamine Oxidase
                           (MAO) inhibitors
     Androgens             Phenobarbital
     Anticoagulants        Phenylbutazone

     Chloramphenicol       Probenecid
Clofibrate                Salicylates

Fenfluramine              Sulfinpyrazone

Flucanazole               Sulfonamides

Gemfibrozil               Ticuclic antidepressants

Histamine H2 antagonists Urinary acidifiers
Decrease hypoglycemic
effect(increase blood glucose)

   Beta-blockers    Rifampin

   Cholestyramine   Urinary alkalinizers

   Diazoxide        Diuretics
 Drugs that interact with insulin
• Enhance hypoglycemic effect (decrease blood
  glucose)
    Angiotensin-converting      MAO inhibitors
    enzyme (ACE)inhibitors
    Alcohol                     Mebendazole

    Anabolic steroids           Octreotide

    Beta-blockers(delay recovery Pentamidine
    from hypoglycemia)
    Calcium                      Phenylbutazone
Chloroquine         Pyridoxine

Clofibrate          Salicylates

Fenfluramine        Sulfinpyrazone

Guanethidine        Sulfonamides

Lithium carbonate   Tetracyclines
       Decrease hypoglycemic effect
           (increase blood glucose)
Acetazolamide          Empinephrine

AIDS antivirals        Estrogens

Asparaginase           Enthacrynic acid

Calcitonin             Isoniacid

Contraceptives, oral   Lithium carbonate

Conticosteroids        Morphine sulfate
Cyclophosphamide   Niacin

Dextrothyroxine    Phenothiazine

Diazoxide          Nicotine

Diatiazem          Thiazide diuretics

Dobutamine         Thyroid hormone
Low Blood Sugar (Hypoglycemia)
• A common problem in diabetic patients
  whether on oral antidiabetics Or insulin.
• Hypoglycemia can be longer & serious with
  some oral antidiabetics because of their
  longer duration of action and unpredictable
  pharmacokinetics.
Symptoms of Hypoglycemia:
•   Sweating        • Frequent hunger
•   Palpitations    • Feeling of “passing out”
•   Shakiness       • Decreased
•   Blurry vision     “concentrating ability”
•   Headache        • Inappropriate behavior
                    • Loss of conciousness
Treatment of Hypoglycemia:
• Check blood glucose to exclude other reasons.
• If glucose meter not readily available, then
  presume hypoglycemia and institute testament
  immediately.
• Provide glucose tablets, fruit juices,candy,etc.
• If the patient becomes unconscious, a Glucagon
  injection (GlucaGen Hypokit) Should be
  administered.
• Recheck blood glucose after 30 minutes.
• Hypoglycemia can be recurrent on
  administration of long acting insulin or
  drugs such as Glyburide, Glipizide
  especially if patients also have kidney
  disease.
• Patients are generally monitored in the
  hospital for 24 48 hours for any recurrent
  hypoglycemia.
Diabetic ketoacidosis

Symptoms:
• Anorexia, nausea, vomiting
• Thirst, Polyuria
• Weakness
• Abdominal pain
• Visual disturbance
• Weight loss
Signs:
•   Elevated blood glucose (>250mg/dl)
•   Ketonuria/Ketonemia
•   Plasma bicarbonate <15meq/L
•   Dehydration
•   Warm dry skin
•   Tachycardia
•   Rapid/deep breathing, acetone odour
•   Somnolence, coma
Treatment:
• Replacement of fluid loss to correct dehydration &
  hyperosmolarity
• Replacement of electrolysis with potassium
  containing saline
• Correction of hyperglycemia by insulin and fluid
  replacement
• Ketosis and acidosis are simultaneously corrected
  by above measures
• Identification and correction of precipitatory
  causes.
Complications: Long Term

• Diabetes is the silent killer as it affects
  almost all the organs of the body and
  usually leads to a host of complications if
  not controlled aggressively.
Kidney Disease

Symptoms:
• Hypertension, edema, proteinuria and renal
  insufficiency
Diagnosis:

• Urinary microalbumin excretion testing
• Spot urine sample testing
Treatment:
• Tight control of blood glucose in most diabetic
  patients.
• Dietary protein restrictions.
• Excessive urinary microalbumin excretion should
  be treated with an ACE-inhibitor agent (provided
  there are no contraindications) even if their blood
  pressure is not elevated. This helps to control
  intraglomerular hypertension.
• High blood pressure should be aggressively
  treated in diabetic patients and target blood
  pressure should be less than 130/85mg Hg.
Monitoring:

• Urinary albumin excretion test on a yearly
  basis
Eye Disease

• Symptoms:
• Diminished visual activity; frequent change
  in power of lens, painful eye
Diagnosis:

• Check visual acuity with Snellens chart,
  seperately for each eye
• Dilate pupils
• Examine fundi by ophthalmoscope
• Microaneurysms, retinal hemorrhages,hard
  exudates from eye.
Treatment:

• Aggressive control of blood glucose and
  blood pressure in most diabetic patients.
• Laser photocoagulation surgery for diabetic
  macular edema or proliferative retinopathy.
• Vitrectomy surgery for vitreous hemorrhage
  or severe progressive neovascularization.
Monitoring:

• Yearly eye examination of the diabetic
  patient by an ophthalmologist
Foot Problem

Symptoms:
• Tingling, pins & needle sensation, burning
  sensation, numbness or pain.
Diagnosis:

• Carefully inspect the feet (whole foot, nails)
• Check peripheral pulses
• Examine for neuropathy i.e touch and
  vibration
  Treatment:
• Best treatment is regular care of the feet.
• Tight blood glucose control is crucial.
• The mode of treatment depends upon
   – the degree of lesions,
   – neuropathic & vascular assessment
   – and X-ray.
• Treatment can range from bed rest, antibiotics
  according to culture and sensitivity, plaster, special
  shoes to ampulation.
Mentoring:

• A podiatrist should be visited for regular
  foot checking.
Erectile Dysfunction

• Erectile dysfunction is the most common
  male sexual dysfunction in diabetes.
Treatment options for diabetic
erectile dysfunction
General measures
• Improving diabetic control
• Reduce alcohol intake
• Withdraw causative drugs
Nonhormonal therapy
• Alpha-2-adgrenergic blocking agents (yohimbine
  hydrochloride)
• Type-specific phosphodiesterase inhibitors
  (sildenafil citrate)
Noninvasive Therapy:
• Vacuum erection devices
• Intracavernosal injection of vasoactive
  agents (mixture of papaverine,
  phentolamine, prostaglandin E1)
Invasive therapy:
• Penile prosthesis (malleable versus
  inflatable device)
• Microvascular arterial bypass surgery
Heart Disease

• Symptoms:
• Augina symptoms: chest, arm, and/or jaw
  pain (discomfort), Shortness of breath, cold
  clammy sweat
• Myocardial infraction (ML)- “silent”ML
  more common.
Diagnosis:

• Examine blood pressure
• Electrocardiogram monitoring particularly
  ambulatory
• ECG monitoring for silent ischemia
• Stress testing for coronary heart disease
• Echocardiography (with Doppler)
• Testing of cholesterol
Treatment

• Antiplatelet / anticoagulants:
• Start Aspirin 80 to 325mg/d if not
  contraindicated Manage warfarin to
  international normalised ratio 2 to 3.5 for
  post ML-patients not able to take aspirin
ACE inhibitors in post-ML patients:
• Start early post-ML in stable high risk
  patients (anterior ML, previous ML, Killip
  class II
• Continue indefinitely for all with LV
  dysfunction
• Use as needed to manage blood pressure or
  symptoms in all other patients
Beta-blockers:

• Start in high risk post-ML patients
  (arrhythymia, LV dysfunction, inducible
  ischemia) at 5 to 28 days with continuation
  for six months minimum
• Use as needed to manage angina, rhythym,
  or blood pressure in all other patients
Pregnancy and Diabetes
Insulin treated diabetes

Planned Pregnancy
• Good glycemic control be obtained before
  conception. In some situations intensive
  stabilization pre-pregnancy may be
  necessary
• Good glycemic control before and
  throughout pregnancy reduces the risk of
  complications for the mother and foetus.
• For pre-pregnancy stabilization use at least
  a twice daily mixtures of short and
  intermediate acting insulin.
• Reinforce education on diet and insulin self
  adjustment.
Preconception goal for glycemic
control
• Premeal glucose 70 to 100 mg/100 ml (3.8
  to 5.5 mmol/l)
• 1 to 2 hour post meal glucose at or below
  150 mg/100ml(< 8.3 mmol/ol)
• Serial H BA1c levels to be maintained at the
  normal or near normal value.
Other Assesments

• Asses for any diabetic complications
  (hypertension, ischemic heart disease,
  nephropathy, neuropathy, retinopathy and
  severe gastroenteropathy).
• Obsteric assessment
• Thyroid function test as per local practice
Optimal Target Index for Glycemic
Control During Pregnancy with diabetes
  • Blood Glucose Goals in Diabetic Pregnancy

  Fasting               60-90 mg/100 ml (3.3-5.0 mmol/l)

  Premeal               60-105 mg/100 ml(3.3-5.0 mmol/l)

  1 hour postprandial   100-120 mg/100ml(5.5-6.7 mmol/l)

  2 a.m 6 a.m Hours     60-120 mg/100 ml(3.3-6.7 mmol/l)
Oral hypoglycemic treated diabetes
• Oral hypoglycemic drugs should be
  discontinued and human insulin therapy
  instituted.
• Planning for pregnancy; preconceptions
  goals for glycemic control; other
  assessment; and Optimal Target Index for
  glycemic control during pregnancy with
  diabetes.
Gestational diabetes

• Gestational diabetes mellitus develops in
  approximately 2-5% of pregnant women.
  GDM are at increased risk for the
  development of Type 2 diabetes later in life
  and their infants are at risk for macrosomia.
Screening, diagnosis and
treatement

• All pregnant women should be screened for
  glucose intolerance between 24th and 28th
  week
                       Diagnosed GDM



                Diet; monitor glycemia, foetus


Fasting blood glucose < 105      Fasting blood glucose > 105
mg/100ml (<5.8 mmol/l) and       mg/100ml (>5.8 mmol/l) and 2-
2-hour postprandial <120         hour postprandial >120 mg/100
mg/100 ml (< 6.7 mmol/l)         ml (>6.7 mmol/l)



Continue diet and monitor                 Initiate Human Insulin
  glycemia and foetus                       treatment; monitor
                                           glycemia and foetus
• Diabetes is frequently associated with
  infections as seen in clinical practice, but
  not clearly proved. Defects in both cell
  mediated immunity and polymorphonuclear
  functions have seen experimentally shown,
  but their exact role in human beings is yet to
  be clearly shown.
• A decreased perfusion due to abnormality in
  microvascular circulation and neuropathy
  may worsen the prognosis as infection sets
  in.
• The entire immune system is altered to
  defense against microbial invasion, certain
  defects may be more directly associated
  with certain infections in diabetes.
Skin infections

• Due to compromised host defense and high
  blood sugars, microbes withy low virulence
  easily cause infections of the damaged skin.
• Staphylococcus aurous infection causing
  boils, carbuncles and abscesses are the most
  common skin infections.
Diagnosis:

• Confirmation is by biopsy of the affected
  area

Treatment:
• Board-spectrum antibiotics, antifungul
  agents
Tuberculosis

• Tuberculosis is common with diabetes in
  India.
Diagnosis:
• Chest X-ray
• Sputum and urine examination
• Hematology
Symptoms:

•   Weight loss
•   Fever with chills
•   Weakness
•   Excessive urination
Treatment:

• Antitubercular therapy of INH, Rifampicin,
  Ethambutol and Pyrazinamide.
• Rifampicin and INH interact with OHAs
  and therefore choose insulin to initiate
  antidiabetic treatment.
Surgery

• During surgery utmost care is required from
  the family physician in co-ordination with
  anesthetist to achieve proper glycemic
  control and avoid complications. The
  management differs as per the current
  treatment and status of diabetes. Broadly
  surgery management in diabetics is
  undertaken in following three phases:
Pre-operative Management
• In patients managed on diet, assess for metabolic
  control with proper diet. If uncontrolled, admit
  patient 1-2 days before operation and initiate
  Human Actrapid.
• In patients managed on oral anti-diabetics, shift to
  shorter acting sulphonylurea. Biguanide should be
  stopped one week before and the patient should be
  shifted to insulin for stabilisation
• In patients on insulin, shift from
  intermediate acting insulin to short acting
  insulin (Human Actrapid)
• Frequent monitoring is required.
• If optimal control is not achieved with
  subcutaneous Human Actrapid, considered
  intervevous infusion.
Peri-operative (during surgery)
Management
• In patients only managed on diet institute insulin if
  hyperglycemia develops & persists post
  operatively.
• In patients managed on oral medication, avoid
  breakfast and no medication on day of treatment.
  Treats as non diabetic if blood glucose is<126
  mg/dl.
• If blood glucose increase more than 126mg/dl then
  initiate insulin (human Actrapid)
• In major surgery set up Human Actrapid insulin
  infusion.
• In patients managed on insulin,set up i.V,
  infusion (10% Dextrose 500ml + I.U.
  Human Actrapid+10 mmol KCL) and
  regimen adjust as per patient’s requirement.
• Monitor patient frequently (1-2 times every
  hour) during operation.
Post-operative (after surgery)
Management

• In diet treated diabetics, return to pre-
  operative dietary management incase of
  minor surgery. In major surgery, treat with
  Human Actrpid (8-12 units) t.d.s before
  each meal. Further titrate the dose as per the
  requirement.
• In patients managed on oral medication
  recommence sulphonylureas with first meal
  in case of minor surgery. In major surgery,
  treat with Human Actrapid (8-12 units)
  t.d.s. before each meal. Further titrate the
  dose as per the requirement.
• In patients managed on insulin, continue the
  infusion at the same rate until oral feeding
  commences. If infusion is prolonged (24 hrs),
  check electrolytes daily (Na/K).
• Initiate Human Actrapid (equivalent to pre-
  operative dose) with oral feeding
• After 2-3 days, restabilise on suitable regimen for
  the patients.
• Measure Ketone bodies and blood glucose
  frequently
• Being sick can make the blood glucose level
  go up very high.
• It can also cause serious conditions that can
  put up the patient in a coma.
What Happens When the Patient
is Sick
• Patient when sick is under stress leading to release
  of hormones, which raises blood glucose levels,
  and interferes with the glucose-lowering effects of
  insulin.
• Easy to lose control of the diabetes leading to
  ketoacidosis and diabetic coma particularly in
  people with Type 1 diabetes.
• People with Type 2 diabetes, especially older
  people, can develop a similar condition called
  hyperosmolar hyperglycemic nonketotic coma.
Diabetes Medicines

• Type 1 diabetes, it is advisable to take extra
  insulin to bring down the higher blood sugar
  levels.
• Type 2 diabetes, may be able to take pills,
  or may need to use insulin for a short time.
Food

• Eating and drinking can be a big problem.
  But it is important to stick to the normal
  meal plan.
• Easy to run low on fluids when one is
  vomiting or has fever or diarrhea. Extra
  fluids will also helps get rid of the extra
  sugar (and possibly ketones) in the blood.
Medicines to Watch Out For
• Advice to check the label of over- the-counter
  medicines before buying them to see if they have
  sugar. Small doses of medicines with sugar are
  usually okey.
• Many medicines when taken for short-term
  illnesses can affect blood sugar levels, even if they
  don’t contain sugar. For example, aspirin In large
  doses can lower blood sugar levels
• Some antibiotics lower blood sugar levels in
  people with Type 2 diabetes who take
  diabetes pills.
• Decongestant and some products for
  treating colds raise blood sugar levels.
Monitoring Glucose level
• Regular / frequent monitoring required
Travel

• Before a long trip, medical examination is
  necessary to make sure diabetes is in good
  control.
Packing Tips
  Whether traveling by car, plane, boat, bike, or foot,
  the patient will want keep this “carry-on” bag with
  him at all times. Pack this bag with:
• All the insulin and syringes needed for the trip
  blood and urine testing supplies (include extra
  batteries for the glucose meter)
• All Oral medications (an extra supply is a good
  idea)
• Other medications or medical supplies, such as
  glucagon, antidiarrhea medication, antibiotic
  ointment, antiemetic drugs
• ID and Diabetes identity card
• A well-wrapped, air-tight snack pack of crackers
  or cheese, peanut butter, fruit, a juice box, and
  some form of sugar (hard candy or glucose tablets)
  to treat low blood glucose.
Insulin During Travel
• Insulin stored in very hot or very cold temperature
  may lose strength. Don’t store insulin in the glove
  compartment or trunk of the car
• Insulin used in India are of the strength 40 and 100
  I.U.
• In foreign countries, insulin may come as I.U.40
  or I.u.80. If the patient needs to use these insulin,
  one must buy new syringes to match the new
  insulin to avoid mistake in the insulin dose.
Crossing Time Zones
  If one takes insulin shots and will be crossing the
   time zones, remember:
• Eastward travel means a shorter day, less insulin
   may be needed.
• Westward travel means a longer day, so more
   insulin may be needed.
• To keep track of shots and meals through
   changing time zones, advice the patient to keep his
   watch on his home time zone until the morning
   after he arrives.
After Arrival
• After a long flight, it is advisable to take it easy
  for a few days. Test the blood sugar often.
• If one takes insulin, plan the activities so that one
  can adjust insulin dose and meals.
• Ask for a list of ingredients for unfamiliar foods.
  Some foods may upset the stomach and hurt the
  diabetes control.
• Always advice to wear comfortable shoes and
  never go barefoot. Check the feet every day.

				
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