A brief description of Diabetes with management guidelines
according to different diabetes foundation and their treatment with drugs and their MOA dose and side effects
12. Clinical Features of DM
3 POLY (Polyuria, Polyphasia,
Polydipsia)
Gen weakness, Fatigue
Weight loss
Bullered Vision
Poor healing wound
Burning feet
Recurrent UTI / frequent superficial
infections
NOTE:- The lack of symptoms is the main reason for the
delayed diagnosis of type 2 DM. Many pts are diagnosed
based on screening or during blood tests taken for other
reasons. A complete medical history should be obtained
with special emphasis on weight, exercise, smoking,
ethanol use, family history of DM, and risk factors for
cardiovascular disease. In a pt with established DM,
14. CRITERIA FOR TESTING FOR PRE-DIABETES AND DIABETES IN
ASYMPTOMATIC INDIVIDUALS
Risk Factors
First-degree relative with diabetes
Physical inactivity
Race/ethnicity (e.g., African American, Latino, Native
American, Asian American, Pacific Islander)
Previously identified IFG, IGT, or a hemoglobin A1c of
5.7-6.4%
History of GDM or delivery of baby >4 kg (>9 lb)
Hypertension (blood pressure >140/90 mmHg)
HDL cholesterol level <0.90 mmol/L (35 mg/dl) and/or a
triglyceride level >2.82 mmol/L (250 mg/dl)
Polycystic ovary syndrome or acanthosis nigricans
History of vascular disease
Note:- Testing should be considered in all adults at age
45 and adults <45 years with BMI >25 kg/m' and one or
more of the following risk factors for diabetes
15. Management of DM
Life Style Modifications (Diet & Habbits)
Exercise
Reduce / Delay complication
Pharmacotherapy (Insulin / + OHA)
Management of Complication
Psychological support
16. LSM
Quit Smoking / any type of Tobacco
Reduce / Stop Alcohal
Low Glycemic Index Diet
High Protein Diet
Low Fat Diet
Low Salt
Never Use Any type of fruit juice
25. OHA & Their Details
BIGUANIDES (METFORMIN)
MOA:- activate an enzyme (AMPK) which helps cells to respond
more effectively to insulin and take in glucose from the blood &
preventing the liver from converting fats and amino-acids into
glucose.
DOSE:- 500-2250mg in divided dose.
ADVANTAGE:- By reducing the liver’s blood glucose raising
effect, metformin helps to lower blood glucose levels through the
day. Rather than stimulating the release of insulin, metformin
increases the body’s sensitivity to insulin and therefore has
benefits for weight management.
SIDE EFFECTS:- As a monotherapy, metformin users are
unlikely to experience hypoglycemia or weight gain. However,
the risk of these side effects increases if the drug is taken
together with insulin or a sulphonylurea.
CONTRAINDICATION:- Lactic acidosis, HF, Renal Impairment,
ALD
26. Sulfonylurea's
Glimepiride, Gilbenclamide, Gilclazide, Glipizide, Glyburide etc.
MOA:- Sulphonylureas bind to a channel of proteins in the pancreas
(ATP-sensitive potassium channel). This triggers a sequence of events
within the cells that leads to an increase in the amount of insulin that is
produced by pancreatic beta cells.
DOSE:- 01-08 mg in divided dose. / 30-120mg
ADVANTAGE:- Sulphonylureas are suitable for people with type 2
diabetes with blood glucose levels that are higher than the
recommended levels (an HbA1c above 6.5%) usually once metformin
has been prescribed. The primary benefit of sulphonylureas is their
effect on increasing insulin secretion and therefore helping to reduce
blood glucose levels.
SIDE EFFECTS:- weight gain , Hypoglycemia, and allergic reaction
during the first six weeks to eight weeks of treatment, resulting in itchy
red skin/skin rashes.
CONTRAINDICATION:- Risk of CVD & Drug to Drug interactions.
27. Thiazolidindiones
Pioglitazone & Rosiglitazone.
MOA:- Targeting the PPAR-gamma receptor, which activates a
number of genes in the body and plays an important role in how
the body metabolizes glucose and how the body stores fat &
help boost insulin sensitivity and preserve the function of insulin
producing cells.
DOSE:- 15-45 mg in divided dose. / 02-08mg
ADVANTAGE:- Decreased blood glucose levels and
preservation of the pancreas’s ability to produce sufficient levels
of also help lower blood pressure and improve lipid metabolism
by increasing levels of HDL cholesterol and reducing levels of
triglycerides and fat tissue.
SIDE EFFECTS:- water retention, weight gain, eyesight
problems, reduced sense of touch, chest pain and infections,
allergic skin reactions.
CONTRAINDICATION:- HF, Hepatic dysfunction, hemodynamic
instability Macular edema Fractures & Anemia.
28. Dipeptidyl Peptidase 4 Inhibitors
Sitagliptin, Vildagliptin, Saxagliptin, Linagliptin, Teneligliptin
etc.
MOA:- They work by blocking the action of DPP-4, an enzyme
which destroys a group of gastrointestinal hormones called
incretins. Incretins help stimulate the production of insulin when it
is needed and reduce the production of glucagon by the liver
when it is not needed It also slow down digestion and decrease
appetite. So by protecting incretins from damage, DPP-4
inhibitors help regulate blood glucose levels.
DOSE:- 50-150 mg in divided dose. / 20-40mg / 0.5-01mg
ADVANTAGE:- DPP-4 inhibitors may be used as a second
or third line medication, lowering blood glucose levels and
people needing to lose weight.
SIDE EFFECTS:- gastrointestinal problems , flu-like
symptoms & skin reactions.
CONTRAINDICATION:- Acute pancreatitis.
29. Sodium-glucose co-transporter-2 Inhibitors
Canagliflozin, Dapagliflozin, Empagliflozin.
MOA:- The kidneys work by filtering glucose out of the blood
and then reabsorbing glucose back into the blood. The proteins
that reabsorb glucose are called sodium-glucose transport
proteins. SGLT2 inhibitors block these proteins which means
less glucose gets reabsorbed back into the blood and gets
passed out of the body via the urine.
DOSE:- 100-1200 mg in divided dose. / 05-40mg / 10-100mg
ADVANTAGE:- By removing glucose from the body, SGLT2
inhibitors can also have benefits for weight loss & No
Hypoglycemia
SIDE EFFECTS:- May increase risk of DKA, UTI &
Dehydration.
CONTRAINDICATION:- CKD Nephropathy,/ <45ml/hr
GFR.
30. Alpha-glycosidase inhibitors
(AGIs).
Voglibose, Acarbose & Meglitol.
MOA:- By blocking AGI enzymes, the medication can
slow down the digestion of carbohydrates in the small
intestine so that glucose from food enters the bloodstream
more slowly, thus reducing the rise in blood glucose levels
after eating
DOSE:- 0.2-0.9 mg in divided dose. / 50-150mg
ADVANTAGE:- Reducing post prandial blood sugar
and therefore helping to lower HbA1c, They also raise post
meal levels of GLP-1, a hormone which helps to delay
digestion and decreases appetite & No Hypoglycemia
SIDE EFFECTS:- GI upset like diarrhea, flatulence.
CONTRAINDICATION:- IBD, Intestinal obstruction
Severe hepatic / renal insufficiency.
31. GLP 1 Analogues
Albiglutide, Exenatide, dulaglutide & Liraglutide.
MOA:- GLP-1 receptor agonists really exert 4 main effects. First, they
stimulate the beta cells of the pancreas to produce insulin in a glucose-
dependent fashion. also suppressing glucagon. The other thing that a
GLP-1 receptor agonist can do is slow gastric emptying. And the other
thing the GLP-1 receptor agonists will do is cause a feedback
mechanism to the central nervous system to actually suppress appetite.
DOSE:- Starting: 30 mg once a week, Maintenance: 30 - 50 mg once a
week, Max: 50 mg once a week
ADVANTAGE:- GLP-1 receptor agonists are an innovative and effective
option to improve blood glucose control, with other potential benefits of
preserving beta-cell function, weight loss, and increasing insulin
sensitivity. Once-weekly formulations may also improve patient
adherence
SIDE EFFECTS:- nausea, vomiting, diarrhea, headache, weakness, or
dizziness.
CONTRAINDICATION:- Acute pancreatitis, Thyroid modularly
32. Insulin's and their doses
First, some basic things to know about insulin:
Approximately 40-50% of the total daily insulin dose is to
replace insulin overnight, when you are fasting and
between meals. This is called background or basal insulin
replacement. The basal or background insulin dose usually
is constant from day to day.
The other 50-60% of the total daily insulin dose is for
carbohydrate coverage (food) and high blood sugar
correction. This is called the bolus insulin replacement.
Bolus – Carbohydrate coverage: The bolus dose for food
coverage is prescribed as an insulin to carbohydrate
ratio. Generally, one unit of rapid-acting insulin will dispose of
12-15 grams of carbohydrate.
Bolus–High blood sugar correction (also known as insulin
sensitivity factor): The bolus dose for high blood sugar
correction is defined as how much one unit of rapid-acting insulin
will drop the blood sugar, Generally, to correct a high blood sugar,
one unit of insulin is needed to drop the blood glucose by 50
mg/dl. This drop in blood sugar can range from 15-100 mg/dl
33. Total Daily Insulin Requirement
The general calculation for the body’s daily insulin requirement is:
I. Total Daily Insulin Requirement(in units of insulin)
= Weight in Pounds ÷ 4
OR if you measure your body weight in kilograms:
Total Daily Insulin Requirement (in units of insulin)
= 0.55 X Total Weight in Kilograms
Example 1: Assume you weigh 160 lbs.
TOTAL DAILY INSULIN DOSE = 160 lb ÷ 4 = 40 units of
insulin/day
Or Assume your weight is 70Kg
TOTAL DAILY INSULIN DOSE = 0.55 x 70 Kg = 38.5 units of
insulin/day
Note: If your body is very resistant to insulin, you may require a
higher dose. If your body is sensitive to insulin, you may require
a lower insulin dose.
34. Basal/background insulin dose:
Basal/background Insulin Dose = 40-50 % of Total Daily
Insulin Dose
Example: Assume you weigh 160 pounds
Your total daily insulin dose (TDI) = 160 lbs ÷ 4 = 40 units.
In this example: Basal/background insulin dose
= 50% of TDI (40 units) = 20 units
The carbohydrate coverage ratio: 500 ÷ Total Daily Insulin
Dose
= 1 unit insulin covers so many grams of carbohydrate.
This can be calculated using the Rule of “500”: Carbohydrate
Bolus Calculation
Example: Assume your total daily insulin dose (TDI)
= 160 lbs ÷ 4 = 40 units
In this example: Carbohydrate coverage ratio
= 500 ÷ TDI (40 units) = 1unit insulin/ 12 g CHO
35. The high blood sugar correction factor:
Correction Factor = 1800 ÷Total Daily Insulin Dose = 1 unit of insulin
will reduce the blood sugar so many mg/dl
This can be calculated using the Rule of “1800”.
Example:
Assume your total daily insulin dose(TDI) = 160 lbs ÷ 04 = 40 units
In this example:
Correction Factor = 1800 ÷ TDI (40units)
= 01 unit insulin will drop reduce the blood sugar level by 45 mg/dl
Note:- While the calculation is 1 unit will drop the blood sugar 45 mg/dl, to
make it easier most people will round up or round down the number so
the suggested correction factor may be 1 unit of rapid acting insulin will
drop the blood sugar 40-50 mg/dl.
Please keep in mind, the estimated insulin regimen is an initial “best
guess” and the dose may need to be modified to keep your blood sugar
on target.
Also, there are many variations of insulin therapy. You will need to work
out your specific insulin requirements and dose regimen with your
medical provider and diabetes team.
36. Calculation of insulin's dose by examples
Example 1: Carbohydrate coverage at a meal
CHO insulin dose = Total grams of CHO in the meal ÷ grams of
CHO disposed by 1 unit of insulin.
For Example #1, assume:
You are going to eat 60 grams of carbohydrate for lunch
Your Insulin: CHO ratio is 1:10. To get the CHO insulin dose,
plug the numbers into the formula:
CHO insulin dose = Total grams of CHO in the meal (60 g) ÷
grams of CHO disposed by 1 unit of insulin (10) = 6 iu
You will need 6 units of rapid acting insulin to cover the
carbohydrate.
37. Example #2:High blood sugar correction dose
High blood sugar correction dose = Difference between actual
blood sugar and target blood sugar
Correction factor = Actual blood sugar minus target blood
sugar
For Example #2, assume:
1 unit will drop your blood sugar 50 mg/dl and the high blood
sugar correction factor is 50.
Pre-meal blood sugar target is 120 mg/dl & Your actual blood
sugar before lunch is 220 mg/dl.
So 220 minus 120 mg/dl = 100 mg/dl
To get the high blood sugar correction insulin dose, plug the
numbers into this formula:
Correction dose = Difference between actual and target blood
glucose (100mg/dl) ÷ correction factor (50) = 2 units of rapid
acting insulin
So, you will need an additional 2 units of rapid acting insulin
to “correct” the blood sugar down to a target of 120 mg/dl.
38. Example #3: Total mealtime
dose Finally, to get the total mealtime insulin dose, add the CHO
insulin dose together with the high blood sugar correction insulin
dose:
CHO Insulin Dose + High Blood Sugar Correction Dose = Total
Meal Insulin Dose
For Example #3, assume:
The carbohydrate coverage dose is 6 units of rapid acting insulin
& high blood sugar correction dose is 2 units of rapid acting
insulin. so, add the two doses together to calculate your total
meal dose.
Carbohydrate coverage dose (6 units)
+ high sugar correction dose (2 units)
= 8 units total meal dose.
The total lunch insulin dose is 8 units of rapid acting insulin.
39. Complications of DM
ACUTE COMPLICATION CHRONIC COMPLICATION
Hypo-Glycemia Vascular complication
Non-Vascular
Complication
Diabetic Keto-Acidosis
Micro-
Vascular
Macro-
Vascular
PE& ED
Non-ketotic Hyper-osmoler
Diabetic Coma
Nephro-pathy CVA Nocturnal Diarrhoea
Retino-pathy
PVD /
DVT
Skin Menisfestation
Neuro-Pathy CAD Recurrent UTI
