Diabetes Mellitus Diagnosis, Treatment And Life Style Changes.

Diabetes Mellitus Diagnosis, Treatment And Life Style Changes

Diagnostic Tests:-

»Oral glucose tolerance

»Urine Glucose

»Fasting blood glucose or casual blood glucose

»Urine and Blood Ketones

»Micro albumin

»Glycosylated Hemoglobin

»Glycosylated Serum Proteins

»Cholesterol.

Diagnosis criteria of DM:-

Pharmacologic Treatment of Diabetes Mellitus:-

Insulin and insulin analog

Types of insulin:-

Rapid-acting insulin:

Lispro (Humalog), aspart (NovoLog), and glulisine (Apidra) insulins

Short-acting insulin:-

Regular insulin (Humulin regular, Novolin regular)

Intermediate-acting insulin:-

Ii is Isophane insulin suspension (neutral protamine Hagedorn; NPH) insulin

Long-acting insulins:-

Glargine (Lantus) and detemir (Levemir) insulins.

ORAL AND NONINSULIN INJECTABLE AGENTS:-

Thiazolidinediones (TZDs):-

»Pioglitazone (Actos)

»Rosiglitazone (Avandia)

Pioglitazone:- is under an constant safety review for the potential increased risk of “bladder cancer”. At this time, the FDA has not resolved an overall associated risk.

Rosiglitazone:- has been associated with increased risk of cardiovascular events (e.g., myocardial infarction, angina) and thus its use has been restricted by the Food and Drug Administration(FDA).

Mechanism of action:- promote glucose acceptance by fat and muscles and stop hepatic glucose output by the stimulation of peroxisome-proliferator-activated receptor-gamma (PPAR-G).

Patient education and other concerns:-

»TZDs as a class cause significant weight gain that is likely associated with fluid retention and fat accumulation. Report unusual shortness of breath, weight gain, swelling of the lower extremities.

»Benefits may not be seen prior to 2 to 4 weeks of use, with maximum effectiveness not seen until 6 to 12 weeks of use.

Biguanides:-

The only available biguanide is metformin (Glucophage, Glucophage XR, Fortamet, Glumetza, Riomet).

Mechanisms of action:-The main starring role of metformin is to prevent hepatic glucose output, thus exerting beneficial effects on fasting blood glucose levels.

The secondary character of metformin is to support glucose uptake by fat and muscles, thereby improving insulin sensitivity. Thirdly, metformin has a negligible role in lessening abdominal absorption of glucose.

Patient education and other concerns:-

»Up to 30% of individuals using metformin are affected by GI effects (e.g., abdominal bloating, nausea, cramping, feeling of fullness, loss of appetite, or diarrhea).

»GI effects are self-limiting over 7 to 14 days. Effects can be minimized by taking the medication with food, starting with a low dose, and slow upward titration of dosage.

»Slight weight loss can be seen initially with this agent, but is not a continued effect.

»Metformin use has been associated with a decrease in vitamin B12 levels. Observing of vitamin B12 levels should be considered.

»Miscellaneous effects include sweating and a metallic taste.

 Alpha-Glucosidase inhibitors:-

Acarbose (Precose)

Miglitol (Glyset)

Mechanism of action: Competitive inhibition of alpha-glucosidases in the intestinal brush border, which leads to a slower absorption of complex carbohydrates.

Patient education and other concerns:-

»Alpha-glucosidase inhibitors cause increased gas formation in the colon, which can result in flatulence.

»The dose should be taken with the first bite of the meal for Effectiveness.

»If hypoglycemia follows within 2hrs. Of dosing, patient should be treated with oral glucose if the patient is conscious or intravenous glucose or glucagon if the patient is unconscious.

»Lactose is also an acceptable alternative in the conscious patient.

»Gastrointestinal side effects will lessen over time, but timing is variable for each patient.

Sulfonylureas:-

Glyburide (DiaBeta, Glynase)

Glipizide (Glucotrol)

Glimepiride (Amaryl)

Mechanisms of action:- stimulates enhanced secretion of insulin from pancreatic β-cells, reduces

hepatic glucose output.

Patient education and other concerns:-

»Hypoglycemia is an adverse effect of insulin secretagogues that warrants significant counseling.

»Sulfonylureas are more likely to cause hypoglycemia, but repaginate and nateglinide are likely to induce hypoglycemia as well, if taken without food.

»Education should include signs and symptoms of hypoglycemia and appropriate treatment.

»Weight increase, secondary to increased insulin secretion, can occur.

Dipeptidyl peptidase-IV (DPP-IV) inhibitors:-

Sitagliptin (Januvia)

Saxagliptin (Onglyza)

Linagliptin (Tradjenta)

Mechanisms of action:- Prevents the inactivation of incretin hormones (e.g., GLP-1) by the enzyme DPP-IV.

GLP-1 workings to motivate insulin exudation and reduction glucagon secretion from the pancreas concluded hyperglycemia; thus preventing the interruption of GLP-1 would allow for improved insulin excretion and reduced hepatic glucose manufacture.

Dopamine agonist:-

Bromocriptine (Cycloset)

 Mechanism of action:- for development in glycemic control is indefinite; however, it is postulated that bromocriptine may disturb circadian rhythms, which may play a role in fatness and insulin confrontation.

 Patient education and other concerns:-

»May cause dizziness and fatigue. Use care when execution tasks that require mental alertness.

»May cause gastrointestinal discomfort, nausea, or vomiting. Take with food to lessen gastrointestinal discomfort.

»Take within 2 hrs after waking in the morning. Dose will be increased weekly until the maximum tolerated dose is achieved.

Incretin mimetics (GLP-1 agonists):-

»Exenatide (Byetta)

»Liraglutide (Victoza)

Mechanisms of action:- Increases glucose dependent insulin secretion, decreases hepatic glucose

output, increases β-cell growth and replication, slows gastric emptying, and enhances satiety.

Patient education and other concerns:-

»Exenatide must be administered within 60 minustes of a meal twice daily. Liraglutide could be dosed independent of meals once daily.

»Management sites include the upper arm, thigh, or abdomen.

»Nausea and vomiting may occur with initiation and dose changes, but is typically a transient effect. Weight loss is a sustained effect unrelated to gastrointestinal effects.

»Report unusual lump or swelling of the neck, difficulty swallowing, or unusual hoarseness with the use of liraglutide

Amylin receptor agonist:-

Pramlintide (Symlin).

Mechanisms of action:-Slows gastric emptying; decreases postprandial glucagon secretion; suppresses appetite.

Patient education and other concerns:-

»When concomitantly given with insulin, could produce severe hypoglycemia within 3hrs of admin.

»Pre- and post-blood glucose monitoring should be used to determine efficacy of agent.

»Management is into abdomen or thigh; injection into upper arm should be avoided due to variable absorption.

»Oral medicines needing quick onset of action (e.g., antibiotics, analgesics) should be administered 1 hr before, or 2 hrs aft er pramlintide.

»Do not mix in similar syringe as insulin.

Obesity and Physical inactivity:-

Obesity:-

»Fatness proven to be a very strong risk factor for diabetes type 2

»Estimates of risk vary from RR of 1.8 to 3.2 in different populations

Physical inactivity:-dormancy it has been obviously exhibited that physical action expands insulin

»danger of diabetes because of physical inertia has been assessed to be as high an RR of 4.31 in several large scale studies.

Nutritional Factors:

There is growing evidence from both epidemiological as well as laboratory studies that.

»Increased dietary intake of saturated fat and

»Decreased intake of fiber can result in

»Lowered insulin sensitivity and impairment of glucose tolerance.

Foetal and Early Childhood Influences:

There has been increasing evidence (Barker’s Hypothesis) that

»Poor maternal nutrition through pregnancy, and

»Malnutrition through early infancy may be associated with insulin resistance, obesity, impaired glucose tolerance, raised blood pressure and occurrence of metabolic syndrome in same person during his/her adult life This underlines value of ensuring adequate nutrition during pregnancy and through primary childhood.

Stress:-

»Whether they can perpetually lead to diabetes is not established

»Similarly, role of mental and social stress contributory factor in diabetes mellitus suggested but remains unproven.

Drugs and Hormones:-

»Phenytoin, diuretics (especially thiazides),

»Beta blockers, corticosteroids and

»Certain contraceptive steroids -In susceptible persons, induce glucose intolerance or even diabetes, but -This usually resolves after withdrawal of drug.

Preventive Strategies for DM:-

Primary prevention:-

»Population Strategy

»Mass Approach

»Targeted Group approach Targeted High Risk Individual Strategy

»Secondary Prevention

»Tertiary Prevention.

Population screening:-

»This would be finished early diagnosis and prompt treatment, mainly by way of screening programmers

»Strategies could be either “population screening” by screening

»Entire population or

»Selected random sample, Which is fruitful only if prevalence of diabetes is very high or

»Else for study or health planning purposes.

Selective screening:-

Choosy screening undertaken in groups of people Known to be at high risk

»As those with family history,

»Obese persons (BMI >25),

»Age more than 40 years in high prevalence populations Women giving history of GDM Persons with history of IGT/IFG, or those with hypertension or dyslipidemia.

Opportunistic Screening:-

Thirdly, it could be an “Opportunistic Screening” employed when high risk individuals come in contact with Doctor

»Obese person,

»Hypertensive, having IHD, having family history, etc.

»Once such a person reports sick

»Similarly, in clinical settings, all opportunities should be utilized to undertake screening for known end organs as ophthalmoscopy, urine testing, etc.

»To identify any evidence of such end organ damages this could have occurred and may have escaped detection till now.

Tertiary Prevention:

The part of Doctors as well as paramedical personnel assumes importance in context of tertiary prevention

»mainly To follow up patient,

»To advocate continuous treatment

»and educate patient about importance of treatment

Educate about:-

»Do not miss anti-diabetic medicines

»Do not miss meals

»Diabetic identification card

»Carry some sugar or lozenges for any hypoglycemic emergency

»Foot care, footwear and regular check

»Early identification of complications

»Regular Physical exercise, Diet

»No Tobacco, Avoid alcohol.

Conclusion:-

If you have any questions and complaints and more information for consult your “Family Doctor” or “Personal “Doctor”.

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