Diabetes

Dr. Jignesh Vora

Symptoms-1

• Thirst due to increased amount of glu. In urine which lead to dehydration

• Fatigue & lethagy [ carb-glu-glu need insulin to transport it to cells.if glu cant transported to cell then cells starve ,so]

• Urine sugar + [ unutilized glu is excreated in urine]

• Blurred vision [ due to fluctuation of bl sugar]

Symptoms-2

• wt despite of appetite [due to insulin glu is not utilized. so body’s need of energy breakdown protein & fat. So muscle wasting happens which leads to wt.

• Insulin is anabolic hormone that encourages storage of fat & muscle. So when it is wt

• NV due to bl sugar

• T & N due to ischemia and neuropathy

Causes

• Absent or insufficiency of insulin by beta cells of pancreas

• Inability of cells to use insulin.[insulin resistance] by cells of muscles and fat tissues

• Obesity ,Hyglycemic diet

• Lack of exercise , stress

• Hereditary ,genetics

Types

• Type-1 :IDDM [juvenile , autoimmune]• Type-2 :NIDDM• Gestastional diabetes [temporary during

pregnancy]• Secondary DM: Ch.panceratitis, trauma,

surg. removal of pancreas, acromegaly[ incresed GH] , cushings syndrome[ increased cortisol by adrenal gland]

• Rx: steroids, rx of Hiv

Investigations

• FBS [ 8 hrs minimum] desirable < 100 mg/dl if > 126 then repeat again. mg/dl

• When FBS is between 100-126 .It is knas IFG {Impaired fasting glucose}

• RBS :> 200 mg/dl then DM• OGTT-oral glu tolerance test

for gestastionl DM & PCOD [due to insulin resistance]

Investigation

• HBA1c-glycosylaed Hb normal 4-6 % well controlled 6-7 % poor controlled > 8 % 6= 135 7=170 8=205 9=240 10=275 11=310 if pt is anemic then HBA1c is altered

Complications

acute

• Hypoglycemia

• Dehydration

• DKA-diabetic ketoacidosis

• Coma and death

chronic

• Microvascular : eye, brain , kidneys, nerves

• Macrovascular : heart and blood vessels [atherosclerosis-angina-stroke . leg pain-lack of blood-cludication ]

• Diabetic retinopathy

• Diabetic nephropathy

• Diabetic neuropathy

Hypoglycemia

Due to higher dose of insulin or OHAsvigorous exercise,starvation

Symp: dizziness, confusion, wkness, tremors, palpitation

If not treated – coma, seizures, brain death[ < 40 mg/dl]

Rx glycogen inj [im]

DKA-diabetic ketoacidosis

• Insulin decreased – breakdown of protein & fat –ketosis –blood becomes acidic-DKA

• Shock –coma –death

• Symp: nv ,abd pain

• Can be caused due to trauma and stress which require more insulin

retinopathy

• Bl vessels in back of eyes causes leakage of protein and bl in retina and also cause small aneurysms

• Bleeding fm bl vessels-retinal detachment & impaired vision

• Retinopathy is cured by LASER by destroying and prevention of small aneurysms and brittle bl vessels

nephropathy

• Due to leak of protein in urine

• Rx is dialysis , kidney transplantation

• ACEs

• ARBs

neuropathy

• T & N , burning, aching feet and lower limbs due to ischemias

• When nerve damage causes complete sesnsation in feet ,pt may not aware of injury

• Due to poor bl circulation-delayed healing-infection-ulcer-gangrene

• ED• NV• Gastroparesis-delayed emptying of stomach• Wt loss • Diarrhoea• Rx : gabapentin, pregabaline, duloxetine

Rx

• Sulfonylyreas-long acting – once a day increase insulin o/p by panrcreas older rx: chlorpropamide ,tolbutamide newer rx : glipizide , glimepiride ADRs : hypoglycemia

Rx

• Meglitinides increase insulin o/p by pancreas hypoglycemia < sulfonylyreas eg. Repaglinide , nateglinide before meal with Metformin result

Rx

• Biguanides : amount of glu produced by liver

Metformin : does not insulin, so hypoglycemia does not happen.

appetite so prevents wt gain

CI : renal failure

Rx

• Thiozolidinedionessensitivity of cells to insulin

eg. Pioglitazone , rosiglitazone . Once a dayADRs : stroke, heart attack , myopathy

fluid retention-wt gain-swelling-so spirolactone should be added

CI : liver disease, heart failure [ EF < 40%]* Takes 6 wks to bl sugar

and 12 wks for max benefit * # of distal bones of limbsbenefits : HDL , TG

Rx

• ACARBOSE : 25-100 mg thrice a day @beginning of meal

absorption of carb by intestine

HBA1c

ADRs :abd pain,diarrhoea , gas

Rx

• Pramlintide

injectable

PPBS control

in DM-1 with insulin

insulin fluctuation during day

satiety- wt loss

Rx

• Exenatide

* slows release of glu fm liver

* slows stomach emptying

* inj [bf meal ]

ADRs : hypoglycemia

DPP-IV inhibitors

• 2 nd lline drugs

• 1st line of drug is metformin

• GLP-1 is broken down by DPP-IV . So DPP-IV inhibitors stop GLP-1 breakdown

• Eg. Sitagliptin , saxagliptin, linogliptin

• saxagliptin 5mg /day or 2.5 mg;day if GFR is < 50ml / min

• adrs * pancreatitis

Combination therapy

• Glipizide/ glicazide/ glimepiride +metformin

• Pio/ rosi + metformin

• Sitagliptin + metformin

Insulin

• Very short acting: 5-15 min to 30-60• Regular/short acting 30 min to 2-5 hrs• NPH/intermediate 1-2 hrs to 8-14 hrs• Lente/intermediate 1-2.5 hrs to 8-12 hrs• Ultralente/long acting 4-6 hrs to 10-18 hrs• Mode of delivery1 Prefilled pens-300 units2 insulin pumps-minimize hypoglycemia3 Inhaled insulin-disappointed results4 Transdermal patch- disappointed

Inhaled insulin - (Afrezza)

• forvboyh type 1 or type 2 DM

• rapid-acting insulin is taken before each meal, or soon after starting to eat

• Afrezza won't replace the need for injected long-acting insulin for those who need it

• Because it's inhaled, it's absorbed more quickly and in a different way.

• "Afrezza is rapidly absorbed from the cells in the lungs [to the blood stream]

• "From the time you inhale it to the time it

Pancreas transplantation