Management of diabetic mellitus

Management of Diabetes

Bharatha Ambadasu

What is Diabetes?

• Body cannot properly store/use food for fuel• Insulin

• hormone • Produced by beta cells in the pancreas• Allows glucose to move from blood stream into

muscles to be used in energy production

• In diabetes, insulin is produced in insufficient

amounts, or it is produced but cannot be used

properly

Diabetes mellitus (DM)• 5-8% of the population• Large number of individuals are asymptomatic

Classified into:

Type 1 (IDDM) –autoimmune (10%)

• Juvenile onset DM

Type 2 (NIDDM) –genetic (90%)

• Adult onset DM, often obese

Type 3 (MODY) –genetic (1-5%)• Occurs before 25 years of age• No insulin resistance, not obese

Type 4 (gestational)

• Glucose intolerance

Macrovascular Microvascular

Stroke

Heart disease and hypertension

2-4 X increased risk

Foot problems

Diabetic eye disease(retinopathy and cataracts)

Renal disease

Peripheral Neuropathy

Peripheral vascular disease

Diabetes: Complications

Complications

Erectile Dysfunction

Treatment

Unfortunately,

THERE IS NO CURE!

Aims of the treatment

• To alleviate symptomatic hyperglycemia

• Reduce overall blood glucose & minimise fluctuations

• To reduce insulin resistance, hyperglycemia &

dislipidemias

• Avoid hypoglycemia

• (insuln & sulfonylureas)

• Avoid weight gain

• (insulin, sulfonylureas, thiozolidinediones)

• Cardiovascular risk factors should be corrected

Treatment

• PATIENT EDUCATION, understanding, and participation is vital

Treatment

Physical Activity• Regular physical activity helps your body lower blood

glucose levels, promotes weight loss, reduces stress and enhances overall fitness.

Treatment

Diet• What, when and how much you eat

Treatment

Weight Management• Maintaining a healthy weight is especially important

in the management of type 2 diabetes.

Treatment

Lifestyle Management• Learning to reduce stress levels in day-to-day life

can help people with diabetes better manage their disease.

Treatment

Blood Pressure

• High blood pressure can lead to eye disease, heart

disease, stroke and kidney disease, so people with

diabetes should try to maintain a blood pressure at

or below 130/80.

• To do this, you may need to change your eating and

physical activity habits and/or take medication.

Treatment

Medication

• Type 1 diabetes is always treated with insulin. Type

2 diabetes is managed through physical activity and

meal planning and may require medications and/or

insulin to assist your body in making or using insulin

more effectively.

Treatment: Type 1

• Diet + Insulin

Insulin requirement

• Increased during:

• Infections, severe illness, trauma, surgery,

thyrotoxicosis, hyperparathyroidism, acromegaly,

hypokalemia and pregnancy

• Decreased during:

• Dieting, weight loss, exercise, hypothyroidism, renal

insufficiency and old age

Treatment: Type 1 Diabetes Cont…

Insulin regimens:

• Choice of regimen depends on the desired degree of

glycemic control, the patients life style & his/her ability

to adjust the insulin dose

Treatment: Type 1 Diabetes Cont…

i. Three doses of soluble insulin (before the main

meals) plus an intermediate acting insulin at bedtime

ii. A biphasic or intermediate acting insulin twice a day

before morning and evening meals

iii. A single morning dose of a biphasic or intermediate

acting insulin before breakfast

Treatment: Type 2 Diabetes

• 80% are obese• 10% non-obese• 10% unstable: may

look more like a Type 1 Diabetic

• Diet and weight reduction (mild diabetics)

• Diet plus an oral antidiabetic agent

• Insulin (suboptimal doses) with oral antidiabetics

• Insulin

Treatment: Type 2 Diabetes Cont…

<40yrs Most Type I Insulin

Non obese

Obese

Weight maintenance diet

Low energy diet

>40yrs Most Type II

Non obese

Obese

Low energy dietExcersise

Weight maintenance dietSulfonylurea

+Metformin

Or addGlitazones

Alpha glucosidase Inhibitor

PGR Bedtime isophane insulin

Insulin

Insulin

Diet

Sulfonylureas

Metformin

Monotherapy Combined therpy

Low calorie sweetener

• Replace sugar with low calorie sweetener Aspartame

(1 tab of 18mg =sweetness of 1 ts sugar, gives 2

calories)

• Sucralose

Management of MODY

• Any child or young adult who had persistent,

asymptomatic hyperglycemia without progression to

diabetic ketosis or ketoacidosis

• MODY is often referred to as "monogenic diabetes“

• MODY 1 - 6

• Defects are mutations of transcription factor genes

• Changes in diet, physical exercise, oral hypoglycemic

agents, and insulin injections

Management of Gestational diabetes

• Most common medical complication of Pregnancy

• affects 2-3% of pregnancies

• Gestational DM 90%

• Preexisting DM 10%

• To avoid fetal loss at all stages, and in the first trimester

to reduce fetal malformations

Management of Gestational diabetes Cont…

• Human Placental Lactogen (HPL) –”Anti-insulin”

• Estrogen and Progesterone

• Insulinase (Minor role)

• Typically controlled with INSULIN but oral

hypoglycemic agents like glyburide are also showing

promise.

Diabetic Ketoacidosis

Treatment for DKA

• Correct fluid volume deficit

1. 1 liter of isotonic saline over 1 hour

2. 1 liter of hypotonic saline over 6 to 8 hrs

3. 1 liter of hypertonic solution (D5/2NS)

over 8 to 12 hrs.

Drug therapy for DKA Cont…

• Insulin therapy: lower BG by 75-150mg/dl/hr

1. Regular insulin IV bolus dose of 0.1 - 0.2 U/kg

followed by IV drip of 0.1 U/kg/hr.

• Electrolyte replacement

1. Potassium

2. Bicarbonate

Answer these questions

1. A 50year old women has just been diagnosed as a Type 2 diabetic and given a prescription for Metformin. Which one of the following statements is characteristic of this medication?

A. Hypoglycemia

B. Undergoes metabolism to an active compound

C. Many Drug –Drug interactions

D. Increases peripheral glucose uptake & utilisation

E. Pt often gains weight

2. A 64yr old women with a history of Type 2 diabetes is diagnosed with heart failure. Which one of the following drugs would be a poor choice in controlling her diabetes?

A. Exenatide

B. Glyburide

C. Glipizide

D. Pioglitazone

Answer these questions

3. A 75 ys diabetic female on an oral hypoglycemic agent becomes light headed and profuse sweating. Blood glucose is below normal. Which of the following agents are responsible for this?

A. Pioglitazone

B. Glipizide

C. Acarbose

D. Metformin

Answer these questions

4. A 60yr old diabetic male on an oral diabetic agent develops abnormal LFT. Which one of the following agent agent can cause this finding?

A. Glyburide

B. Metformin

C. Troglitazone

D. Acarbose

Answer these questions

THE END!!!!