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Diabetes Mellitus
Dr. S .K. Maulik
Diabetes Mellitus
• It is a group of metabolic diseases
characterized by hyperglycemia resulting
from defects in insulin secretion, insulin
action, or both
• Two major types : Type 1 and Type 2
• There is either ABSOLUTE or RELATIVE
deficiency of insulin
• In 2010, the number worldwide is
projected to reach 221 million
• In Asia and Africa, diabetes rates could
rise two- to threefold
Criteria for the diagnosis of diabetes mellitus
A. Casual plasma glucose concentration ≥200 mg/dl (11.1 mmol/l), with or without
classic symptoms
Casual is defined as any time of day without regard to time since last meal.
The classic symptoms of diabetes include polyuria, polydipsia, and unexplained
weight loss.
OR
• 2-h post glucose load is ≥ 200 mg/dl (11.1 mmol/l) during an OGTT.
Oral Glucose Tolerance Test should be performed as described by WHO, taking a
glucose load of 75 g glucose dissolved in water
HbA1c
• It measures the amount of glycosylated hemoglobin in blood
• It is not useful for the diagnosis of diabetes mellitus
• It is often used for monitoring long-term glycemic control and reflect glycemia
for the previous 3 months
• Its recommended level for a good glycemic is less than 6.5%.
Therapeutic aims
• Glycemic control
• Treatment of conditions associated with DM
– Obesity
– Hypertension
– Dyslipidemia
– Ischemic heart disease
• Detection / treatment of DM related complications
– renal
– cardiovascular
– retinal and
– neuropathic
Therapeutic strategies
• Pharmacologic management of
Type 2 DM includes both oral glucose
lowering agents or/ plus insulin
(As Type 2 DM is a progressive disorder, it ultimately
requires multiple therapeutic agents and often insulin)
Recap of Drugs
Oral Glucose Lowering Agents, also called
Oral Hypoglycemic Agents
Sulfonylureas Meglitinides
1st. Generation: Rapaglinide (0.25 - 4 mg tid/ qid)
Chlorpromamide (100-500 mg od) Nateglinide
2nd. Generation:
Gliblenclamide (5-15 mg bid ac)
Glimepiride (1-6 mg od)
Insulin Secretagogues (Sulfonylureas)
1. Thiazides,
2. Hydantoins
3. Oral contraceptives
4. Corticosteroids
Insulin Secretagogues (meglitinides)
3. The initial starting dose is 500 mg OD/ BID, upto 1000 mg BID
• ADR: diarrhea, anorexia, nausea, and loss of appetite
The major ADR of metformin is lactic acidosis
Initial Intervention
1. Diabetes Education
2. Medical Nutrition, Weight Control, Exercise
If NOT CONTROLLED
3. Consider Monotherapy (Metformin, if OBESE)
L
E
V
E
L
Time in hours
Identify A , B & C
ADRs of insulin
• Hypoglycemia
• Lypodystrophy at the site of injection (atrophy or hypertrophy)
• Insulin allergy
Otherwise, use
NPH Insulin
NPH Insulin
2
An intermediate- or long-
acting insulin at bedtime
PLUS a short- acting
insulin before each meal Regular Insulin
Regular Insulin
NPH Insulin
Dinner
Lunch
Break Fast
Bed Time
Monitoring therapy
1. Finger prick blood glucose testing
Reagent strips and measuring instrument
– Before each meal, before bed
– Before meal blood glucose should be 70 – 120 mg/dl
– After food level should be <180 mg/dl
5. HbA1C measurement
– Useful for measure of the degree of glycemia in the past 4-6 weeks
– Good control if < 6 %
• Self-monitoring of blood glucose (individualized
frequency)
A. _______
C.________
B._______
Diabetic Ketoacidosis
• Altered sensorium, high blood sugar, urinary
ketones
• It is an emergency and the treatment is:
• Large IV fluid:
• Isotonic saline: 1.0 L in 1st 30 min.,1.0 L in next 2hrs.,
& 0.5L q 4 hr. (depends on degree of dehydration)
• Continue until BG is ~ 180 mg/ dl.
• Then switch to 10% dextrose
• Adjust infusion rate according to CVP and urine output
Treatment of DKA (contd.)
1. Regular insulin:
• 6.0 iu stat iv and 0.1 iu/kg/h iv till BG 180mg/dl
• BG level should be monitored every hour
• If BG does not fall in 2h., and infusion lines are OK,
double the insulin dose