A Review on Diabetes Mellitus Type II

International Journal of Pharma Research & Review, Sept 2014; 3(9):23-29 ISSN: 2278-6074
T Pradeep S V et.al, IJPRR 2014; 3(9) 23
Review Article
A Review on Diabetes Mellitus Type II
*T. Pradeep, C. Haranath
Department of Pharmaceutics, Raghavendra Institute of Pharmaceutical Education & Research,
Anantapur, Andhra Pradesh, India.
ABSTRACT
Diabetes mellitus is a worldwide health problem, which is a chronic metabolic disorder leads to defect in
insulin secretion also causes restriction in metabolism of fats, carbohydrates and protein metabolism. The
most effective anti-diabetic d r u g s currently available include insulin and sulphonylureas,
biguanides, meglitinides, thiazolidinediones, alpha- glucosidase inhibitors, incretins, DPP-4
inhibitors, Amylin analogs. Worldwide 382 million people will have Diabetes mellitus. As the disease in
severe conditions causes diabetic complications such as retinopathy, neuropathy, nephropathy,
cardiovascular complications and ulceration. Diabetes mellitus is of several types among them type-1 and
type-2 are major types. Type-2 DM is an incomplete understood chronic disease. It is noninsulin
dependent Diabetes mellitus or adult-onset diabetes. it is characterized by hyperglycemia, means lack of
insulin. The symptoms include excess thirst, frequent urination, and constant hunger. Type-2 Diabetes
mellitus are about 90% cases of diabetes, other 10% belongs to type-1 and gestational diabetes. Currently
available therapies for type II diabetes mellitus are as follows oral insulin secretagogues, sulfonylureas,
repaglinide, nateglinide, biguanides, thiazolidinediones, alpha-glucosidase inhibitors, insulin, pramlintide
and exenatide. The aim of diabetes treatment is to secure a quality of life and lifespan comparable to
those of healthy people and a prerequisite for this is the prevention of onset and progression of vascular
complications. The need for earlier initiation of proactive intervention must be emphasized, as well as the
importance of comprehensive (blood sugar, blood pressure, and lipids) intervention in attaining this goal.
Keywords: Dipeptidyl peptidase-4, insulin, peptide analogues, type 2 diabetes
Received 25 July 2014 Received in revised form 01 August 2014 Accepted 05 August 2014
*Address for correspondence:
T. Pradeep,
Department of Pharmaceutics, Raghavendra Institute of Pharmaceutical Education & Research,
Anantapur, Andhra Pradesh, India.
E-mail: 55.pradeep.deepu@gmail.com
INTRODUCTION
Diabetes mellitus (DM) also known as
simply diabetes, it is a bunch of metabolic
diseases in which there are high blood
sugar levels over a prolonged period. It is
characterized by a hyperglycemic condition
resulting from insufficient action of insulin.
This high blood sugar leads to frequent
urination, increased thirst and increased
hunger. Untreated diabetes can cause many
complications. Diabetes is caused due to
either restriction in secretion of enough
insulin from pancreas or the cells of the
body not responding properly to the insulin
produced [1]. The most effective anti-
diabetic d ru g s currently available include
insulin and sulphonylureas, biguanides,
meglitinides, thiazolidinediones, alpha
glucosidase inhibitors, incretins, DPP-4
inhibitors, amylin analogs worldwide.
There are three major types of diabetes
mellitus among type-2 DM is major. As per
2013; 382 million people have Diabetes
mellitus. Among them 90% cases are type-2
DM [2,3] which is equal to 8.3% of adult
population with equal percentages in both
women and men [4]. The population with
diabetes is expected to rise to 592 million
by 2035. India to become the world’s leader
in the prevalence of T2DM and it already
has a larger number of people with diabetes
than any other country in the world [5]. The
main pathophysiological features of type 2
diabetes are impaired insulin secretion and
increased insulin resistance. The
impairment of pancreatic cell function

notably shows progression over time. DM
Type-2 is a noninsulin dependent diabetes
mellitus or adult onset diabetes. It is a
metabolic disease characterized by
hyperglycemia. It is also caused by insulin
resistance and lack of insulin [6]. Symptoms
include excess thirst, frequent urination,
and constant hunger. Initially Type 2
diabetes is controlled by regular exercise
and dietary changes. If blood sugar levels
are not adequately lowered by these
measures, medications such as
metformin or insulin may be needed. In
those on insulin, there is typically the
requirement to routinely check blood sugar
levels. Since 1960 DM type-2 increased
parallel to obesity. 285 million people
daignosised by DM TYPE-2 as compared to
30 million in 1985 in 2010 [7,8]. High
sugars in blood leads to heart
disease, strokes, diabetic retinopathy where
eyesight is affected, kidney failure which
may require dialysis, and poor blood flow in
the limbs leading to surgery or prolonged
constriction. Sulphonylureas, metiglitinides,
biguanides, thiazolidinedione, Alpha-
glucosidase inhibitors, dipeptidyl
peptidase-4 inhibitor, incretin based
therapies are used as treatments options.
EPIDEMIOLOGY:
Worldwide as per 2010; 285 million people
have type 2 diabetes mellitus about 90% of
diabetes cases belongs to DM type-2 [9].
This is equivalent to about 6% of the
world's adult population [10]. Diabetes is
common both in the developed and
the developing world. It remains
uncommon. However, in the under-
developed world. Type 2 diabetes is
diagnosed frequently as type 1 diabetes in
teenagers in the United States. In 1985
30 million people have diabetes, this
increasing to 135 million in 1995 and
217 million in 2005. This increasing rate is
due to global population aging, a decrease
in exercise, increasing rates of obesity. The
five countries with the greatest number of
people with diabetes as of 2000 are India
having 31.7 million, China 20.8 million, the
United States 17.7 million, Indonesia
8.4 million and Japan 6.8 million [11]. It is
recognized as a global epidemic by
the World Health Organization. In Australia,
the AusDiab study reported that 7.4% of the
population aged 25 or above had diabetes
mellitus (type 2 in 90%) and about 50%
were undiagnosed, which is reported in the
year 2000 [12]. Proportion progressively
increases with age. Hence 20% of people of
age 60 or above have DM type-2.
PATHOPHYSIOLOGY:
Diabetes mellitus type-2 is a dominant form
of diabetes in all cases of diabetes .Diabetes
mellitus type-2 is caused due to insufficient
secretion of insulin from beta-cells and
insulin resistance, insulin resistance is a
condition of a cells which unable to respond
to the insulin hormone, initially it occurs in
muscles, liver and fat tissues [13].
Depending on the test, oral glucose
tolerance test. The essential elements of
NDDM are divided into four groups.
i) Normal glucose tolerance.
ii) Impaired glucose tolerance
iii) Fasting plasma glucose less than 140
mg/dl
iv) Fasting plasma glucose greater than 140
mg/dl.
Insulin suppresses the glucose release in
the liver, insulin releases glucose
inappropriately into blood in order to set
the insulin resistance. The proportion of
insulin resistance compared to beta cell
dysfunction differs in one individual to
another individual, initially having some
insulin resistance and defect in insulin
secretion and others with slight insulin
resistance and initially a lack of insulin
secretion. Mechanism include in DM type-2
is lack of in cretin, raising of breakdown of
lipids within fat cells, increased glucagon
levels in the blood, retention of salts and
water through kidneys is increased,
improper regulation of metabolism by
the central nervous system.
SCREENING AND DIAGNOSIS:
Currently, as 50% of cases of type 2 DM are
undiagnosed, increased detection and
diagnosis are critical. This is an important
objective of the Australian Department of
Health and Ageing National Integrated
Diabetes Program (NIDP), which aims to
improve management of diabetes in general
practice [14]. Most patients with common
symptoms, such as thirst or polyuria, will
have plasma glucose levels ≥ 7.0 mmol/L
(fasting) or ≥ 11.1 mmol/L (random), which
establishes the diagnosis. In this situation,

an oral glucose tolerance test (OGTT) is not
necessary and is, in fact, inappropriate.
However, as a large proportion of people
with type 2 diabetes have no symptoms,
screening is necessary. Screening may also
detect IFG and IGT, with the potential for
preventing progression to type 2 diabetes
and other adverse effects. While more data
on the cost effectiveness of different
methods of screening are needed, the
current consensus is that the appropriate
initial test is measurement of fasting plasma
glucose (FPG) level. While measurement of
random plasma glucose level may be more
convenient, it has limited ability to correctly
classify individuals. Measurement of
glycosylated hemoglobin (HbA1c) is
theoretically an attractive alternative.
However, as standardizing the different
assay methods remains an issue, cut-off
levels for screening and diagnosis are not
available. If FPG level on initial screening is
in the range 5.5–6.9 mmol/L, it should be
followed up with an OGTT [14,15]. If FPG
level is < 5.5 mmol/L, FPG testing should be
repeated every 3 years. If either IFG or IGT
is diagnosed (FPG level of 6.1–6.9 mmol/L
or 2 h plasma glucose level after OGTT of
7.8–11.0 mmol/L, respectively), testing for
diabetes by OGTT should be repeated
annually. About 25%–35% of people with
IFG also have IGT, and vice versa, but many
people have one condition without the
other. While those with both IFG and IGT
are at greatest risk of progressing to
diabetes, those with one but not the other
still have an increased risk of both future
diabetes and cardiovascular disease.
Screening should be offered to people with
any one of:
Age > 55 years (or 35 years if
Aboriginal or Torres Strait Islander,
Pacific Islander, Indian or Chinese);
Known IGT or IFG;
Ischemic cardiovascular disease;
Prior gestational diabetes; or
Polycystic ovary syndrome combined
with obesity.
Screening should also be offered to people
aged 45-54 years with one or more of the
following:
Obesity (body mass index
≥ 30 kg/m2);
A first-degree relative with type
2 diabetes; or
Hypertension
SYMPTOMS:
The symptoms of DM type-2 are polyuria
(frequent urination), polydipsia (increased
thirst), polyphagia (increased hunger) and
weight loss [16]. Other symptoms that are
commonly include vision, itchiness,
peripheral neuropathy, recurrent vaginal
infections and fatigue. However, there are
no symptoms during the first few years and
are diagnosed on routine testing. People
with type 2 diabetes mellitus may rarely
present with hyperosmolar hyperglycemic
state (a condition of very high blood sugar
associated with a consciousness and low
blood pressure). Other symptoms like
Dry mouth
Nausea and sometimes vomiting
Numbness or tingling of the hands or feet
Frequent infections of the skin, urinary
tract, or vagina
Sores that are slow to heal
Rarely, a person may be diagnosed with
type 2 diabetes after falling into a diabetic
coma.
The expected life of DM type-2 is 10 years,
the complications include in DM type-2 are
the risk of cardiovascular disease, including
ischemic heart disease and stroke; lower
limb amputations, and increased rates of
hospitalizations. In the developed world,
type 2 diabetes is the largest cause of
nontraumatic blindness and kidney failure
[17]. Other complications such as increased
risk of cognitive dysfunction and dementia
through disease processes such as
Alzheimer's disease and vascular dementia
[18]. Other complications include
acanthosis Nigerians, sexual dysfunction,
and frequent infections.
CLASSIFICATION OF DIABETES
MELLITUS:
1. Insulin dependent diabetes mellitus
(IDDM)
2. Non Insulin dependent diabetes mellitus
(NIDDM)
3. Maturity onset diabetes of youth (MODY)
4. Gestational Diabetes.
CLASIFICATION OF ANTI-DIABETIC
DRUGS
Insulin
Secretagogues

Sulfonyl urea’s E.g.:
Generation I: Tolbutamide,
Chlorpropamide, Tolazamide.
Generation II: Glibenclamide, Glipizide,
Gliclazide, Gliquidone.
Generation III: Glimepiride.
Meglitanides E.g.: Repaglinide (Prandin),
Nateglinide.
Sensitizers:
Biguanides
E.g.: Metformin (Glucophage), Buformin.
Thiazolidinediones
E.g.: Rosiglitazone (Avavdia), Pioglitazone.
Alpha Glycosidase inhibitor E.g.: Acarbose
(Glucobay), Miglitol, Voglibose.
Peptide analogues:
I. Incretin mimetics
Glucagon like peptides (GLP) analogs and
agonist E.g. Exenatide
Gastric inhibitory peptide (GIP) analogs
II. DPP-4inhibitors E.g.: Vildagliptin
(Galvus)
III. Amylin analogs E.g.: Pramlinitide
New antidiabetic drugs: Exenatide (Byetta),
Sitagliptin (Januvia).
Combinations: Glibomet (metformin +
glibenclamide), Avandamet (rosiglitazone +
metformin), Competact (pioglitazone +
metformin), Janumet (sitagliptin +
metformin).
PREVENTION:
DMtype-2 is prevented by proper nutrition
and regular exercise [19,20]. Taking green
leafy vegetables in diet is the evidence in
reduction of DM type-2 [21], prevent taking
of sugar drinks [22]. People with impaired
glucose tolerance, either diet and exercise
or with combination with metformin and
acarbose reduces the risk of increasing
diabetes mellitus type-2 [23], regular
exercise and diet is more important than
taking drugs.
TREATMENT OF DM TYPE-2:
ORAL HYPOGLYCEMIC DRUGS:
Sulfonylureas: Sulfonylurea’s include
tolbutamide, glibenclamide,
chlorpropamide, glipizide, acetohexamide,
gliclazide and tolazamide.
Biguanides: Phenformin and metformin.
Miscellaneous: Acarbose and guar gum.
NEW DRUGS:
These include insulin sensitizers, drugs
which reduce insulin resistance by
interaction with the PPAR- (peroxisome
proliferators activated receptor-) a nuclear
receptor which regulates genes involved in
lipid metabolism. The effect on insulin
sensitivity may result from decreased
production of nonesterified fatty acids.
They have the capacity to potentiate the
effect of endogenous insulin. One of these,
troglitazone, which belongs to the
thiazolidinedione group, is used in Type II
diabetes mellitus. Repaglinide, a benzoic
acid derivation which stimulates insulin
production at meal times has been used in
type II diabetes mellitus patients.
DPP-4 inhibitors:
It belongs to the class oral hypoglycemic
which blocks DPP-4. It is used to treat DM
type-2. Incretin-based therapy is either
delivered orally (dipeptidyl peptidase-4
[DPP- 4]) inhibitors or injected
subcutaneously (glucagon-like peptide-1
[GLP-1] mimetics and analogues).
Dipeptidyl peptidase-4 inhibitors are
effective either as a single or in combination
in lowering blood glucose level; it increases
incretin levels i.e., GLP-1 and GIP. There are
3 DPP-4 inhibitors currently available
(sitagliptin, saxagliptin and vildagliptin),
First agent is sitagliptin. New agents in DPP-
4 Inhibitors are Teneligliptin and Alogliptin.
DPP-4 inhibitors are effective in the
treatment of patients with type 2 diabetes.
Incretin mimetics:
Incretin mimetics are used to treat DM
type-2, Incretin mimetic agents like
Exenatide and Iraglutide are used to treat
DM type-2. Major incretins that affect
glucose metabolism are GLP-1: glucagon-
like peptide-1 and GIP: glucose-dependent
insulinotropic polypeptide. These therapies
have a unique mechanism of action that
addresses glucose appearance as well as
glucose disappearance. In cretin is a natural
harmone prepared with in the body,
Incretin tells to the body to release insulin
after a meal.
Thiazolidinediones:
The thiazolidinediones also known as
glitazones, it activates PPARs (peroxisome
proliferator-activated receptors). It is a
class of medications that are used in the
treatment of diabetes mellitus type 2. They
were introduced in the late 1990s.
Thiazolidinediones are group of nuclear
receptors.

Alpha glucosidase inhibitors:
Oral anti-diabetic drugs used to the
treatment of overweight patients with
NIDDM. These are the drugs which inhibit
the enzymes involved in the breakdown of
carbohydrates in the intestine. It decreases
the impact of carbohydrates on blood sugar.
Acarbose inhibits the enzymes like
glycoside hydrolases and pancreatic alpha-
amylase. Acarbose and miglitol slows down
the digestion of complex carbohydrates.
They will not initiate pancreases to release
more insulin. These medicines can use
alone or with another agents or with
insulin. Voglibose is also used to treat DM
type-2. It lowers the post-prandial blood
glucose levels. Voglibose is a new drug.
Medicinal plants used to treat DM are
Prinsepia utilis Royle, Ricinus communis L,
Aloe vera, Crataeva nurvala Buch, Hyssopus
officinalis, Trigonella foenum-graecum L,
Matricaria chamomilla, Gymnema sylvestre,
Eugenia caryophyllus, Ajugaiva L, Tribulus
terrestris, Anacardium occidentale linn,
Bougainvillea glabra, Ferula asafoetida,
Ficus bengalensis, Curcuma longa,
Hippophea rhamnoide L, Aerva lanata,
Laurus nobilis, Momordica balsamina L,
Psidium guajava L, Syzygium cumini etc.
MANAGEMENT:
Self management of sugars in the blood is
necessary, due to self monitoring of sugars
in blood, it minimizes the risk factors,
minimizing risk factors like
hypertension, high cholesterol, and micro-
albuminuria, improves a person's life
expectance. Basement for controlling
diabetes is proper nutrition and regular
exercises, harder exercises gives better
results [24], aerobic exercises decreases the
HbA1c and improved insulin sensitivity.
Strength training is useful and the
combination of both types of exercise may
be most effective. Diabetic diet helps in
reducing weight loss [25]. Consuming
limited is necessary in controlling DM.
Appropriate education is necessary to the
people with DM type-2 to control the blood
sugar levels [26]. If there is no results in six
weeks, even though following changes in a
life style, considering medication is better.
MEDICATION:
There are many anti-diabetic drugs
available in the market for the treatment of
DM. Metformin is recommended as first line
treatment, second oral agent of other class
is preferred if metformin is not sufficient.
Metformin is not used in the patients having
severe kidney and liver problems. Insulin
parentrals are also available in the market.
This insulin can be used either with oral
agents or used single. Primarily, most of
people do not use insulin, if insulin is used,
long acting diabetic agent is necessary at
night and oral agents should be continued.
Later doses are increased for effective
reduction of blood sugars. At night, if the
insulin is not sufficient, for better control
take insulin twice per day.
glargine and detemir which are long acting
insulin are equally safe and effective, insulin
is used as a choice of treatment in pregnant
people. Now a day’s People Preferring to
surgery to treat DM without using any
medication [27]. Surgery is an effective
measure of treatment for obese people to
get weight loss [28], surgery is
recommended in people who are unable to
get weight loss and who are unable to
control blood sugars even though taking in
control measures [29].
CONCLUSION
Oral hypoglycemic agents have a very
crucial clinical focus on treating DM TYPE-2.
Many complications arise if the disease is
not treated early and with the suitable anti-
diabetic agents. These complications
include diabetic retinopathy, nephropathy,
and neuropathy. Other cardiovascular risk
factors must also be addressed in patients
with type 2 diabetes. Formerly existing
agents such as sulfonylurea’s, biguanides,
TZDs, alpha‐Glucosidase inhibitors, and
short‐acting insulin secretagogues, and
combination therapies had a better focus on
disease treatment. Sitagliptin, Exenatide,
and vildagliptin offer a different effective
and new approach in management of type 2
diabetes. The clinical benefits of all
pharmacological agents become more
complete when accompanied with
non‐pharmacological treatments.
ACKNOWLEDGMENT
I would like to express my sincere thanks to
Mr. Haranath. C, for his suggestions and
guidance.

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