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Diabetes Mellitus Fifth Stage-Medicine


Diabetes Mellitus Fifth Stage-Medicine Dr. Sarbast Fakhradin MBChB, MSc Diabetes Care & Management * * * * * * Comprehensive diabetes care of type 2 DM Patient ... – PowerPoint PPT presentation

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Title: Diabetes Mellitus Fifth Stage-Medicine

Diabetes MellitusFifth Stage-Medicine
  • Dr. Sarbast Fakhradin
  • MBChB, MSc Diabetes Care Management

Comprehensive diabetes care of type 2 DM
  • Patient education follow up DAFNE DESMOND
  • It is essential that people with diabetes
    understand their disorder and learn to handle all
    aspects of their management educating patients
    about diabetes complications.
  • Carry a diabetic card stating their name and
  • Driving

  • Patient education follow up DAFNE DESMOND
  • Blood glucose monitoring
  • Target Preprandial capillary plasma glucose
    (70-130 mg/dl)
  • Target postprandial capillary plasma glucose (lt
    180 mg/dl)
  • A. Treatment with insulin
  • Regular BG monitoring should be performed by all
    patients to adjust the insulin dose and detect
  • Daily pre-prandial and bedtime measurements are
    usually recommended

  • Treatment with oral hypoglycemic agents
  • BG monitoring is optional in many patients with
    stable type 2 diabetes.
  • Monitoring is most useful in patients taking
    sulphonylureas, during intercurrent illness and
    prescription of corticosteroids, and during
    changes in therapy.
  • Lower limbs feet
  • Blood pressure lt 130/80
  • Smoking alcohol
  • Hypoglycemic episodes.
  • Psychological support
  • Target Lipid profile Cholesterollt 200mg/dl,
  • LDL lt 100
  • TG lt 150
  • HDLgt 40

Lifestyle modification
  • 1. Healthy diet
  • 2. Regular Exercise in the form of walking,
    gardening, swimming or cycling, approximately 30
    minutes daily, as this improves insulin
    sensitivity and the lipid profile and lowers
    blood pressure.
  • 3. Stop smoking
  • 4. Reduce/stop alcohol intake
  • 5. Salt reduce sodium intake to no more than 6
    g daily.

  • The glycaemic index (GI) of a carbohydrate-contain
    ing food is a measure of the change in blood
    glucose following its ingestion. Consumption of
    foods with a low GI is encouraged.
  • All the CHO prescribed should be taken in the
    form of starches and other complex sugars.
  • Fiber- rich foods (e.g barley, oats, legumes,
    beans lentils) has been associated with
    improved blood glucose control lower blood
    lipids in both normal, diabetic hyperlipidemic
  • Low-calorie and sugar-free drinks are useful for
    patients with diabetes. These drinks usually
    contain non-nutritive sweeteners. Many 'diabetic
    foods' contain sorbitol, are expensive and high
    in calories, and may cause gastrointestinal
    side-effects. As a result, these foods are not
    recommended as part of the diabetic diet.

  • Recommended composition of diet for people with
  • CHO 40-65
  • Fat lt 35 ( saturated lt10)
  • Protein 10-15
  • Fruit/Vegetable 5 portions daily

Anti-Diabetic Medications
  • Oral Agents
  • 1. Biguanides (Metformin)
  • 2. Insulin Secretagogues Sulphonylureas
  • 3.Insulin Secretagogues Non-sulphonylureas
  • 4. DPP4 inhibitor (Sitagliptin)
  • 5. a-glucosidase inhibitors (Acarbose)
  • 6. Thiazolidinediones (TZDs) (Pioglitazone)
  • Injections
  • 1. Insulin
  • 2. GLP-1 agonist (Incretin mimetic) Exenatide

Biguanides (Metformin)
  • First drug of choice for obese patients in
    whom strict dieting has failed to control type 2
  • Insulin sensitivity and peripheral glucose uptake
    are increased,
  • Impairs glucose absorption by the gut and
    inhibits hepatic gluconeogenesis
  • It does not increase insulin secretion and seldom
    causes hypoglycaemia.
  • Metformin is given with food.

Biguanides (Metformin)
  • Glucose-lowering effect of metformin is
    synergistic with that of sulphonylureas.
  • Improves lipid profiles reduces risk of CA.
  • SE Dyspepsia, Risk of lactic acidosis
    contraindicated in patients with impaired renal
    or hepatic function, drinking alcohol in excess,
    hypoxia, shock.
  • Not contraindicated in pregnancy.

  • Mainly for people with type 2 diabetes who are
    not overly obese.
  • First Generation Tolbutamide (well tolerated,
    short acting, useful in elderly), Chlorpropamide
    Very long acting (up to 60 hours), avoid in
  • Second generation Glibenclamide, Gliclazide,
    Glimepiride, Glipizide.
  • Glibenclamide is prone to induce severe
    hypoglycaemia (avoid in the elderly)
  • Principally stimulate production of insulin, may
    reduce glucagon levels.

  • SUs can cause hypoglycaemia and their use should
    therefore be closely monitored in the elderly
    in those with nephropathy.
  • Several drugs can potentiate their hypoglycaemic
    effect (e.g. salicylates, phenylbutazone and
    antifungal agents)
  • SE Hypoglycemia, increased appetite and weight
    gain, skin rashes (hypersensitivity) and G.I.
    Disturbances, cholestatic Jaundice, blood
    dyscrasia. Feature of disulfiram- like reaction
    occur in some patients after taking alcohol.
  • Occasionally chlorpropamide can induce (SIADH).

Meglitinides - prandial glucose regulators
  • Repaglinide, Nateglinide
  • Stimulates insulin release (rapid and short
  • Better control of postprandial hyperglycaemia
  • Take before meals.
  • It is less likely to cause hypoglycaemia than

Alpha-glucosidase inhibitors (Acarbose)
  • Carbohydrate digestion in the small intestine is
    slowed down by selectively inhibiting
  • Glucose is not absorbed into the bloodstream so
  • SE Bloating, flatulence, diarrhoea and abdominal
    pain, especially upon initial treatment.

Thiazolidinediones (pioglitazone)
  • Bind and activate peroxisome proliferator-activate
    d receptor-? (PPAR? agonists).
  • Reduced insulin resistance and decreased insulin
  • insulin concentrations are not increased
    hypoglycemia is not a problem.
  • Fat redistribute from the abdominal stores and
    into subcutaneous depots. However, body weight
    and total body fat are increased.
  • Pioglitazone may reduce myocardial infarctions
    and strokes (improvement in endothelial
    function), but increase the risk of HF?

Thiazolidinediones (pioglitazone)
  • SE sodium and fluid retention, which is
    aggravated if they are combined with insulin,
    upper limb fractures.
  • TZDs must be avoided in patients with cardiac
    failure, hepatic impairment or severe renal
  • Increase LDL (non-atherogenic form?), increased
    HDL, lowered FFA, lowered triglycerides.

Oral hypoglycaemics
? Insulin resistance
? Glucose output ? Insulin resistance
Mechanisms of glucose-stimulated insulin secretion
  • Incretin-based therapies
  • The secretion of insulin in response to a rise in
    blood glucose is greater when glucose is given by
    mouth than by intravenous infusion. In part this
    is caused by secretion of gut hormones, or
    incretins (Glucagon-like peptide (GLP-1), which
    potentiate glucose-induced insulin secretion.
  • GLP-1 suppresses glucagon secretion, delays
    gastric emptying, reduces appetite and encourages
    weight loss.

  • Incretin-based therapies (Cont.)
  • They improve postprandial glucose excursions and
    early satiety
  • GLP-1 is rapidly degraded by the enzyme,
    dipeptidyl peptidase 4, inhibitors of this enzyme
    can be used to prolong its biological effect.
  • The DPP-4 inhibitors or gliptins (sitagliptin,
    vildagliptin and saxagliptin) are oral agents
    which act in this manner.

  • Incretin-based therapies (Cont.)
  • Exenatide Liraglutide (SC injection) are
    Synthetic GLP-1 receptor antagonists with longer
    therapeutic action. They induce weight loss in
    most patients. SE pancreatitis GI disturbance.
  • Incretin-based therapies are most useful in obese
    patients and can be used in combination with
    other oral anti-diabetic agents.

  • Insulin are either bovine or porcine, human
    insulin produced by recombinant DNA technology
    protein engineering technique.
  • In most countries, the insulin concentration in
    available formulations has been standardised at
    100 U/mL.
  • Plastic Syringe or pen injector.
  • Insulin is usually given by the SC route, IV or
    IM routes.
  • Rotation of injection sites is recommended to
    reduce insulin injection site damage.

Insulin (Cont.)
  • It is removed mainly by the liver and also the
    kidneys plasma insulin concentrations are
    elevated in patients with liver disease or renal
  • Absorption from the abdomen is faster than from
    thighs or upper arms and may be preferred for
    short- acting preparation.
  • Insulin absorption may be influenced by insulin
    formulation, injection site, depth and volume of
    injection, skin temperature (warming), local
    massage and exercise.

Types of insulin
  • Rapid-acting insulin it begins to work about 5
    minutes after injection, peaks in around 1 hour,
    and continue to work for 2-4 hours (Lispro,
  • Regular or Short-acting insulin reach the
    bloodstream within 30 minutes after injection. It
    will peak anywhere from 2-3 hours after injection
    and will stay effective for around 3-6 hours.
  • Intermediate-acting insulin (NPH) - reach the
    bloodstream within 2-4 hours after injection. It
    will stay effective for around 12-18 hours.
  • Long-acting insulin (Glargin) this type of
    insulin will reach the bloodstream within 6-10
    hours after injection and will stay effective for
    20-27 hours.
  • Premixed insulin

  • Side-effects
  • Hypoglycaemia
  • Weight gain
  • Peripheral oedema (insulin treatment causes salt
    and water retention in the short term)
  • Insulin antibodies (animal insulins)
  • Local allergy (rare)
  • Lipodystrophy at injection sites

Insulin dosing regimens
  • Most people require two or more injections of
    insulin daily.
  • Once-daily injections rarely achieve satisfactory
    glycaemic control are reserved either for some
    elderly patients or for those who retain
    substantial endogenous insulin secretion have a
    low insulin requirement.
  • Twice- daily mixtures of short- and intermediate
    acting insulin is a commonly used regimen.
  • Basal-Bolus A regimen of multiple injection of
    short- acting insulin before the main meals, with
    an appropriate dose of single daily intermediate-
    or long acting insulin.
  • The dose of the insulin preparations is adjusted
    according to frequent monitoring of blood glucose
    levels. Blood glucose monitory should be
    intensified during intercurrent illness other
    stressful conditions (Sick Day rule)

  • Combined oral anti-diabetic therapy and insulin
  • In patients with type 2 diabetes who are
    requiring increasing doses of oral anti-diabetic
    drugs, the introduction of a single dose of an
    intermediate- (e.g. isophane) or long-acting
    insulin analogue, administered at bedtime, may
    improve glycaemic control and delay the
    development of overt pancreatic ß-cell failure.
  • Insulin Pump
  • Transplantation
  • Surgery

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