Diabetes mellitus

Diabetes mellitus as a group of of metabolic disorder characterized by in appropriate hyperglycemia resulting from effect of insulin secretion insulin action or both. Symptoms include poly-urea, polydepsia, weight loss, blurred vision, fatigue, headache and poor wound healing. Chronic  hyperglycemia may lead   organ damage like kidney, heart , blood vessel and nerve.

Classification

 Actually there are three types

• Type 1 ( Insulin dependent)

• Type 2 (Insulin independent)

• Gestational diabetics

Prediabetic

Prediabetic is the condition that may risk to develop the diabetic .

Evolution

• Impaired fasting blood glucose (IFG)= 100 to 125 mg/dl.
• Impaired glucose tolerance (OGT ) O G T T = 100 to 199 mg/dl.
• HbAc1= 5.7% to 6.4%.
  • It is very important  to be alert  from the diabetic. If you take the necessary steps and modify your lifestyle you should free from the risks of diabetics.

Diet of diabetic patient

Very important for all the Diabetic patients. food are calculated by Consuming carbohydrate, fat and protein.

Carbohydrates

• Carbohydrates  consume not exceed 45 to 60% of Total energy intake.
• 70% carbohydrate should be non starchy eg. Broccoli, collards, beans, pluses, etc.
• 30% carbohydrates may be starchy eg. breads rice potatoes etc.

Fat

• Should not consumed exceed 30% of Total energy Intake.
• Saturated fat try to leave.  More mono saturated fat Should be selected  eg. olive oil .
• Trans saturated fat not exceed 10% of total fat consuming eg. Soybean oil, seed oils.

Proteins

For adults without nephropathy protein less than 1 g per kg not more than 20% of Total energy intake.

Food take can a plate method

Standard size dinner can be calculate

• 1/2 of plate non starchy vegetable eg.Broccoli, salad, cabbage, calards etc.
• 1 /4 of plate starchy food eg. bread, rice, potatoes, noodles etc.
• 1/4 of plate by meat eg. 3 oz of cooked meat.
  • I suggest it is better to take a whole meal of a day dividing by 5 times by small small portion.

Exercise

It should be mild or moderate aerobic exercise.  At least 150 min per week.  Daily work and free hand exercise can reduce you insulin resistance to the cell.

Weight control

• Body weight should be less than BMI= 20 to 25 kg/m2.
• Wrist circumference for female < 88 cm and male < 102 cm.
• Who are already overweight and affected diabetes should reduce 10 to 15% of total body weight. Fat of adipose tissue resistance to insulin.
  • If fat reduction, diet and exercise don’t control blood glucose should help the medication.
  • Pre-Diabetics patients should conscious about their diet and lifestyle.

Type 1 diabetic

Characterized by absolute insulin deficiency   auto immune destruction Beta cell Of the islets of Langerhans.

Diagnosis

Symptoms include poly-urea, polydipsia,  weight loss, fatigue etc.

Test result

• FBG= >7 mmol/l

• ABS=>11 mmol/L
• 2 hours after 75g anhydrous ingestion. HbAc1=>6.5%

 

 

Treatment

In early stages treatment may be  immunosuppressive agent like cyclosporine, azathioprine, prednisolone, antithymocyte globulin, etc.

Anti-CD3 monoclonal antibody are very useful preserve B-Cell islets of Langerhans.

Medication

For type 1 diabetes patient  insulin is the main medicine

 I prefer  medication as insulin  Premix  insulin

 70/30  70% of NPH with 30% regular insulin

Dose Adjustment

2 times daily  –  Two third used  Prior  to breakfast  and one portion is evening prior to meal. eg.  21  units in morning and 11units to evening of total 32 units.

Calculation  of  insulin units

 6 unit/ kg per day.

Use long acting  insulin

eg.   Insulin glargine or determir. 5 units per day with meal.

In type 1 Diabetes patient glucagon-like peptide 1  is a very helpful therapy co-administration with insulin. eg.  Exenatide may be used.

Ketoacidosis

Uncontrolled production of ketones bodies.

Causes

Lack of insulin body tried to Utilize fat as a fuel source of energy then form excess Ketone bodies .

Symptoms

• Sweating
• Tachycardia
• Palpitation
• Fatigue
• Loss of concentration
• Confusion
• Hunger, headache first

Diagnosis

Confirm in laboratory test

• Glycosuria and Ketone urea
• Glucose, urea, creatinine, electrolyte, Venous Bicarbonate would be increase
• Distinct glucose test show 22 mmol/l.

Treatment of  ketoacidosis

• Expand fluid volume ( 0.9% sodium chloride)
• Infusion insulin
• Prevent hyperkalemia

Type 2 diabetes

 Insulin independence, basically cells are resistant to insulin, maximum time it is  genetic.

Glycemic management of type 2 diabetes patient

Prevent further of major organs damage it should be strictly glycemic control. It would be better by controlling bellow HbAc1=6.5%.

Treatment goal should be

• If  HbAc1  range is  6.5% to 7.5 %.
• Metformin is the first choice if no contraindication, try two to three months as mono therapy. If  not glycemic control then second  medicine would be added. Choice of second medicine would be better of sulphonylureas  group. eg. glacazid.
• If HbAc1 range is 7.62% to 9% Medicine should be added with metformin as double or triple therapy. If second (Sulphonyl urease) or third(Thiazolidinediones) or DPP4 inhibitor drug are contraindicated to reduce HbAc1 < 8.5 % then insulin is added.
• If triple therapy failed to reduce hyperglycemia insulin is directly administrate alone or with anti-hyper glycemic agent.

Diabetics mellitus treated by best antihyperglycemic agent

Biguanides

Metformin

It is first line therapy.  It is very effective and  safest.  If  patient are not  acute cardiac  failure, acute renal disease, acute liver damage record  metformin should the first choice.

Dose  adjustment

500 mg daily a week initiate the dose. Then 500 mg twice daily. Then increase if needed. Maximum dose is 3g per day. Modified  release preparation are available  and dose is one per day.

Adverse effect

• Abdominal discomfort is the main adverse effect
• Bolting is another
• Diarrhea may be occurs

 Contraindication

•  Should not prescribed for patients who have renal impairment eGFR < 45 ml per minute/1.73 m2.
• Should stop In  anyone  with an eGFR less than 30 ml per minute/1.73 m2.
• Should be considered as cardiac failure serial pulmonary insufficiency.

Sulphonyl urease

Gliclazide

It is the best medicine of this group and most beneficial.

Dose  adjustment

• Initiate  with low dose for 2 weeks.
• 1 to 2 times daily 30 minute  before to  meal.
• Modified release drugs are available 30 mg modified release drug are equivalent to 80 mg.

Adverse effect

• Hypoglycemia is common complain
• Weight gain
• Hyponatremia
  • All of   studies medicine of this group is best choice.

Thiazolidinediones

Very effective antihyperglycemic but have a lots of contraindication to use.

Pioglitazone

It is very effective drugs  of this group. significant beneficial on macro-vascular morbidity and mortality. This types of medicine are third line therapy.

Dose  adjustment

Initiate 15 mg maximum 45 mg per day in ones with or without meal for 6 months therapy. Should stop after reduce HbAc1 =0.5%.

Adverse effect

• weight gain
• Edema
• Bone fracture
• Heart failure

Contraindication

• Should not treat it hypertensive And heart failure patient
• Caution should be   taken for postmenopausal women
• Caution should be taken co-administration with insulin it may cause edema.
  • My suggestion is  avoid this groups of medicine if possible.

Dipeptidylpeptidase-4 inhibitor

It is third line therapy and Newly added for this treatment purpose. Insulin resistance patient treated with thiazolinedione or alone. Co-administered with metformin.

 Sitagliptin

It is the most  potent and effective drug of this group.

Dose  adjustment

100 mg par  day with a single dose.

Adverse effect

• Gastrointestinal discomfort
• Upper respiratory tract infection.
• Liver dysfunction

Contraindication

 should not used pancreatitis patient.

Long term diabetes complications

Cardiovascular disease

• Myocardial infarction
• Hypertension
• Dyslipidemia
• Atherosclerosis
• Peripheral vascular disease
• Atherosclerosis cramping pain & reversible muscle pain.

Retinopathy

• Prevent should light control blood glucose and blood pressure.
• Early detected site may be saved by laser photo coagulation in advance case surgery required.
• Pregnancy may worse, moderate to sever retinopathy.

 Nephropathy

In diabetic renal disease the kidney become  enlarged, GFR initially increase then decrease and progress reduction of GFR. GFR diagnosis by albumin creatinine ratio.

protienurea

GRF -Male equal or greater than 2.5 mg per mmol  and female 3.5 mmol.

Macroalbuminia

GRF =>30 mg/mmol at end stage 200 mg/mmol.

Medication

Should tight control of hyperglycemia and blood pressure. Drug may be treated- ACE  inhibitor ( Enalapril)  and  ARBs ( olmesartan) are preferred by class.