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History
Specific symptoms
Glycosuria Polyuria Polydipsia Polyphagia Weight loss Nocturia
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:
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.
STEPS OF MANAGEMENT
1. 2. 3.
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
min / week )
Insulin
Rapid acting(peak at 1 -2hr)
o Lispro o Aspart o Glulisine
Regular{soluble}
insulin
Intermediate (peak at 12-24 hr)
MorningBlood Glucose
EveningBlood Glucose
Schedule
High Ok high
Ok High High
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
Biguanides
Mode of action
Antihyperglycemic
It does not stimulate pancreas to secrete insulin
Somatostatin.
Biguanides
Mode of action:
Decreases the intestinal absorption of
CHO
Increases glucose uptake (GLUT 4) Increases glucose utilization
(glycogensynthase)
Increases glycolysis via anaerobic
Biguanides
Pharmacokinetics:
Metformin is well absorbed from small
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
SULFONYLUREAS
discovered during the 2nd. World war
SUs are drugs that used orally to
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:
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
SULFONYLUREAS
Adverse Reactions :
SUs may induce hypoglycemia especially in
functions
SULFONYLUREAS
Contraindications :
Type 1 DM
Glucosidase Inhibititor
Acarbose
Indicated for type 2 diabetes
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
releasers)
Thiazolidenedione
Drawbacks:
They are not effective alone in case of severe insulin
Side effects:
Hepatotoxicity weight gain Dyslipidaemia (increases LDL)
Rational:
Fast acting, short duration non-sulfonylurea
peaks
Repaglinide
Mechanism of action:
Stimulation of pancreatic insulin
duration
No hypoglycemic metabolites
Repaglinide
Clinical efficacy:
Improves postprandial glycemia Less effective in decreasing fasting blood
Drawbacks:
Fails to provides a stable 24 hours blood
glucose control
Retinal screening
Leading cause of blindness
Screening by digital retinal photography
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
& reduces risk Once daily 10 mg atorvastatin in type 2 diabetes gives primary protection.
Depression
Sufferings affects with self management and need for high
references
Harrison medicine
Tripathi Good man and gillman