Srmc Medical college Nandyal

2. MANAGEMENT
GOALS
 Eliminate symptoms related to hyperglycemia
 Reduce or eliminate the long-term microvascular and macrovascular
complications of DM
 Allow the patient to achieve a normal lifestyle as possible.
 To reach these goals, the physician should identify a target level of
glycaemic control for each patient, provide the patient with the
educational and pharmacologic resources necessary to reach this level
and monitor/treat DM-related complications.
 Symptoms of diabetes usually resolve when the plasma glucose is
<11.1 mmol/L (200 mg/dL)

4. Carbohydrates
Increase in complex
carbohydrate consumption
Ex:
rotis,oats,vegetables,whole
wheat,fructose preferred
over sucrose
Protein
1gm/kg
Class 1 protein –Low fat
milk,egg
white,fish,soy,skinless
chicken
Fats
No Trans Fat
MUFA recommended
Visible fat added while
cooking
Avocado,olive
oil,almonds,cashews

5.  Fitness is a key part of managing type 2 dm.
 All you have to do is get moving
 You can start slowly with a walk around

6. • Figure out how much time per day you can devote to exercise
• Set fitness goals—having clear goals can help you stay motivated
• Build different activities into your daily routine
• Start slowly and allow for recovery time
• Keep track of what you do and stay focused on your goals
 Aerobic Exercise – 5 times / week
 Duration – 30-45 min recommended

7.  Along with your diet and medications, regular physical activity is an
important part of managing diabetes or dealing with prediabetes.
Because when you’re active, your cells become more sensitive to
insulin so it works more effectively. And you just feel better
 Exercise is critical in the treatment and prevention of type 2 diabetes.
Acute exercise activates alternative molecular signals that can bypass
defects in insulin signaling in skeletal muscle, resulting in an insulin-
independent increase in glucose uptake (GLUT4).
 Exersise GLUT4 Blood glucose
5’ amp activated
kinase

8. HBA1C
FBS
PPBS
BP
LDL
HDL
TRIGLYCERIDES
<7% [Ideal: 6.5-7.0%]
80-130 mg/dl
<180 mg/dl
<130/80 mm Hg
<100 mg/dl
Females >50 mg/dl,males> 40 mg/dl
<150 mg/dl

9. GLYCAEMIC INDEX
 Graph describing blood sugar change after a meal.
 The glycemic index (GI) is a number from 0 to 100 assigned to a food, with pure
glucose given the value of 100, which represents the relative rise in the blood glucose
level two hours after consuming that food.
 For Diabetes organizations like the American Diabetes Association, advice people to
follow low GI foods as part of nutritional management of their condition.
 Low GI diets have been shown to reduce insulin resistance.
 They do not spike blood glucose. They improve markers of HbA1c in long run
 low GI foods help in weight management and can significantly reduce total and LDL
cholesterol levels.

10. Instead of this high glycemic index food Eat this lower glycemic index food
White rice Brown rice or Matta rice
Instant oatmeal Steel-cut oats
Cornflakes Bran flakes
Quick oats/pasta Barley
White bread Whole-grain bread
Corn Peas or leafy greens

11.  Gastric inhibitory polypeptide (GIP) and glucagon‐like peptide‐1 (GLP‐1) are the two
primary incretin hormones secreted from the intestine on ingestion of glucose or nutrients to
stimulate insulin secretion from pancreatic β cells

12. Comprehensive care of type 1 and type 2 DM
requires an emphasis on nutrition, exercise, and
monitoring of glycaemic control but also usually
involves glucose-lowering medication(s).

13. TYPE I DIABETES MELLITUS
 The goal is to design and implement insulin regimens that mimic
physiologic insulin secretion.
 Because individuals with type 1 DM partially or completely lack
endogenous insulin production, administration of basal insulin is
essential for regulating glycogen breakdown, gluconeogenesis,
lipolysis, and ketogenesis.
 Intensive insulin therapy has the goal of achieving near-normal
glycemia.
 This approach requires multiple resources, including thorough and
continuing patient education, comprehensive recording of plasma
glucose measurements and nutrition intake by the patient, and a
variable insulin regimen that matches carbohydrate intake and insulin
dose

15.  Route-Inhalation Insulin
 Used for Post-prandial hyperglycemia with long acting insulin
 Side Effects- cough , increased risk of lung cancer
 C/I: Bronchial Asthma/Copd
 Comes in Colour Cartridges – Blue 4U
Green 8U
Yellow 12U

17. Abdomen
Anterior
Thigh
Upper
buttock
Upper
Arm
 Most common site is abdomen
 Maximum absorption is seen in ABDOMEN Except GLARGINE
 All are given by S/C route
 ASPART and REGULAR INSULIN can be given by IV route
 REGULAR INSULIN is D.O.C for DKA, HYPERKALEMIA

18. Hypo glycemia - Regular Insulin f/b ultra short actin
insulin
Lipodystrophy-due to injecting at same site (advice to
rotate the site of injection)
Lipo hypertrophy at same site due to blockage of hormone
sensitive lipase
Hypokalemia

20. DAWN
PHENOMENON
Night dose
insulin to be
increased
SOMOGYI
EFFECT
Night dose
insulin should
be decreased in
somogyi

24. INSULIN
Triple Drugs
HBA1C > 7
Add Long acting /
ultra long acting
Complicatons
(or)HBA1C >9
2/3 regular Insulin
+ 1/3 Long acting
Galgine at night or
Degludac(alternate
day)
Step up by 4 u or
Step Down by 2 u

25.  MANAGEMENT
 DOC for Diabetic Dyslipidemia  Saroglitazar
 It is Dual Peroxisome Proliferator-activated Receptor-{ppar alpha and gamma agonist}
• Non Atherosclerotic Vascular
Disease Saroglitazar
• Atherosclerotic Vascular
Disease Saroglitazar + STATIN
AGE<40
yrs
• Non Atherosclerotic Vascular
Disease/Atherosclerotic Vascular
DiseaseSaroglitazar + STATIN
AGE>40
yrs

26.  If no ASVD target LDL to be achieved is < 100 mg/dl
 If there is ASVD target LDL < 70 mg/dl
 Statins Used Atorvastatin[40-80mg] and Rosuvastatin [20-40 mg]

27. START
INSULIN
HBA1C>9%
Present with
Diabetes
Complications
Type 1 DM
 APART FROM ABOVE CONDITIONS OHA’S CAN BE STARTED

28.  Metformin is the only drug in its class
 It reduces hepatic glucose production and improves peripheral glucose utilization
slightly
 It activates AMP-dependent protein kinase and enters cells through organic cation
transporters
 Metformin reduces fasting plasma glucose (FPG) and insulin levels, improves the lipid
profile, and promotes modest weight loss
 Metformin is effective as monotherapy and can be used in combination with other oral
agents or with insulin
 Long-term use is associated with reduced micro and macrovascular complications
 DOSAGE- 1gm Max Dose as a single drug 3 gm Max dose per day

29. ADVANTAGES
Combats Insulin Resistance
Potency of HBA1C Reduction 1-2%
Weight loss
No Hypoglycemic Risk
DISADVANTAGES
Renal Excretion unchanged (C/I if GFR
< 40 ml/min)
It Causes Lactic Acidosis
Vit B12 Deficiency

30. ABSOLUTE CONTRAINDICATIONS (INCREASED RISK
OF LACTIC ACIDOSIS)
 Elderly
Chronic alcoholic
Renal failure

31. •GLP1 Agonist
•SGLT2 Inhibitors
Any ASVD
Risk present
•SGLT2 Inhibitors2nd line
•GLP 1 Agonist2nd line
•DPP4 Inhibitorsless potent
•THIAZOLIDINEDIONEMore side effects
NO RISK

32.  SODIUM DEPENDENT GLUT2 Inhibitors in PCT of Kidney
 DAPAGLIFLOZIN(5mg or 10mg)
 EMPAGLIFLOZIN(10mg or 25mg )
 CANAGLIFLOZIN(100mg or 300mg)
ADVANTAGS
Weight loss
Decrease Systolic BP
Potency 1-1.2%
Cardioprotective Mostly To
EMPAGLIFLOZIN
SIDE EFFECTS
UTI_Especially to CANDIDA
Increased risk of Osteoporosis
Increases risk of Ketosis
Increases LDL

34. MOA
ATP SENSITIVE K+
CHANNEL
INHIBITOR
INUSULIN
RELEASING
POTENCY
DURATION OF
ACTION
SULFONYLUREAS
MORE POTENT
LONG ACTING
MAINTENANCE OF
TYPE 2 DM
MAXIMUM
REDUCTION IN
HBA1C
SULFONYLUREAS>
BIGUANIDES
MEGLITINIDES
LESS POTENT
SHORT ACTING
POST PRANDIAL
HYPERGLYCEMIA IN
TYPE 2 DM

35. SULFONYLUREAS
•Hypoglycemia(Higher
Risk)
•Weight Gain(Higher
Risk) Due To
Inhibition Of Hormone
Sensitive Lipase
•Preferred In Thin
Patients
MEGLITINIDES
•Hypoglycemia(Weight
gain)

36. SULFONYLUREAS
Metabolized by liver excreted by
kidney
Renal failure, liver failure
MEGLITINIDES
Metabolized by liver excreted by
kidney
Can be used in renal, liver failure
with dose adjustment

37.  1ST Generation – not preferred because of low potency and their side effects
 2nd Generation –GLYBURIDE,GLMIPERIDE,GLICLAZIDE,GLIPIZIDE
GLICLAZIDE only
sulfonylurea approved
•It inhibits platelet
aggregation
•Anti oxidant action is
present (prevents
endothelial damage)
•Cardioprotective
•Prevents weight gain
•80mg can step up
to320mg
•Safe in renal failure
GLIPIZIDE
•Less potent
•Lesser risk of
Hypoglycemia
•Preferred in Renal
failure And elderly
patients
GLYBURIDE a.k.a
GLIBENCLAMIDE
•Most potent
concentrated in Beta
cells Longer Acting
•Potent inhibitor of
ATP sensitive K+
channels
•Blunts myocardial
response to ischemia

38.  HBA1C reduction potential 0.5%
 NATEGLINIDE,REPAGLINIDE
 Used for post prandial hyperglycemia

39.  It is DPP4 inhibitor prolongs physiological t 1/2 of GLP-1 and GIP
•Weight neutral drug
•No hypoglycemia
•Cardio neutral drug{no
cardio toxicity or benfit}
Advantages
•cost
•Potency {0.5-0.75%}
•pancreatitis
Disadvantages

41. Stimulates
PPAR ALPHA

42. EXENATIDE,LIXISENATI
DE
• B.d,o.d dosing respectively
LIRAGLUTIDE
ALBIGLUTIDE,DULAGLU
TIDE,SEMAGLUTIDE

43.  Oral semaglutide was developed
 Increases gap junction between intestinal epithilial cells thus increases intestinal
absorption

44. Advantages
• Potency 1-1.2%
• Premotes weight loss(acts on satity Center)
• Supress glucagon
• Inhibits gastric emptying
• No risk of hypo glycemia
• Cardiovascular benfits
Side effects
• Acute Pancreatitis
• Nausea,vomiting
• Medullary thyroid cancer

45.  PRIMLINTIDE
 Given s/c
 M.O.A- Decrease glucagon,slows gastric emptying,improves satity
 Approved for both type 1 and type 2
 Can be used with insuin by decreasing of insulin dose by 50 %
 Amylin has acidic ph should not combine with insulin in same syringe
 Dose : 15 mg prior to meals (TID before meals)
 Mainly Post prandial glucose control and weight loss
 Side effects – nausea,vomiting
 Contraindications-Gastroparesis

49. Avoid Hypoglycemia Avoid Weight Gain
Minimize Cost of
Therapy
Metformin
DPP4
i
TZD
s
Insulin
DPP4
i
SU
s
Metformin
Metformin
GLP1R
A
GLP1R
A
Cost Effective
SGLT2
SGLT2

51.  Colesevelam - Bile Acid Sequestrant
 Telmisartan – Only ARB acting on PPAR Gamma
 Bromocriptine-decrease insulin resistance
 Hcq