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Diabetes Mellitus
A group of metabolic diseases
characterized by elevated levels
of glucose in the blood resulting
from defects in insulin secretion,
insulin action, insulin receptors
or any combination of conditions.
Diabetes Mellitus
COMPLICATIONS OF INSULIN
THERAPY
3. INSULIN DYSTROPHY
A localized reaction in the form
of lipoatrophy or lipohypertrophy
Diabetes Mellitus
Lipoatrophy- loss of
subcutaneous fat usually
caused by the utilization of
animal insulin
Diabetes Mellitus
Lipohypertrophy-
development of fibrofatty
masses, usually caused by
repeated use of injection site
Diabetes Mellitus
4. INSULIN RESISTANCE
Most commonly caused by
OBESITY
Defined as daily insulin requirement
of more than 200 units
Management- Steroids and use of
more concentrated insulin
Diabetes Mellitus
5. MORNING HYPERGLYCEMIA
Elevated blood sugar upon arising in
the morning
Caused by insufficient level of insulin
DAWN phenomenon
SOMOGYI effect
INSULIN WANING
Diabetes Mellitus
DAWN PHENOMENON
Relatively normal blood glucose until
about 3 am, when the glucose level
begins to RISE
Results from the nightly surges of
GROWTH HORMONE secretion
Management: Bedtime injection of
NPH
Diabetes Mellitus
SOMOGYI EFFECT
Normal or elevated blood
glucose at bedtime, decrease
blood glucose at 2-3 am due to
hypoglycemic levels and a
subsequent increase in blood
glucose (rebound hypergycemia)
Diabetes Mellitus
SOMOGYI EFFECT
Nocturnal hypoglycemia
followed by rebound
hyperglycemia
Diabetes Mellitus
SOMOGYI EFFECT
Due to the production of
counter regulatory
hormones- glucagon. cortisol
and epinephrine
Management- decrease
evening dose of NPH or
increase bedtime snack
Diabetes Mellitus
INSULIN WANING
Progressive rise in blood glucose
from bedtime to morning
Seen when the NPH evening dose
is administered before dinner
Management: Move the insulin
injection to bedtime
Diabetes Mellitus
ORAL HYPOGLYCEMIC
AGENTS
These may be effective when
used in TYPE 2 DM that cannot
be treated with diet and exercise
These are NEVER used in
pregnancy!
Diabetes Mellitus
ORAL HYPOGLYCEMIC AGENTS
There are several agents:
Sulfonylureas
Biguanides
Alpha-glucosidase inhibitors
Thiazolidinediones
Meglitinides
Diabetes Mellitus
SULFONYLUREAS
MOA- stimulates the beta
cells of the pancreas to
secrete insulin
Classified as to generations-
first and second generations
Diabetes Mellitus
SULFONYLUREAS
FIRST GENERATION-
Acetoheximide, Chlorpropamide,
Tolazamide and Tolbutamide
SECOND GENERATION- Glipizide,
Glyburide, Glibenclamide,
Glimepiride
Diabetes Mellitus: Sulfonylureas
The most common side –effects
of these medications are Gastro-
intestinal upset and
dermatologic reactions.
HYPOGLYCEMIA is also a
very important side-effect
Diabetes Mellitus: Sulfonylureas
Chlorpropamide has a very long
duration of action. This also
produces a disulfiram-like reaction
when taken with alcohol
Second generation drugs have
shorter duration with metabolism in
the kidney and liver and are the
choice for elderly patients
Diabetes Mellitus
BIGUANIDES
MOA- Facilitate the action of
insulin on the peripheral
receptors
These can only be used in the
presence of insulin
Diabetes Mellitus
BIGUANIDES= “formin”
They have no effect on the
beta cells of the pancreas
Metformin (Glucophage) and
Phenformin are examples
Diabetes Mellitus: Biguanides
The most important side effect
is LACTIC ACIDOSIS!
These are not given to patient
with renal impairment
Diabetes Mellitus: Biguanides