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CME- Diabetes Mellitus Type 2


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CME- Diabetes Mellitus Type 2

  1. 1. CONTINUING MEDICAL EDUCATION ROLE OF HOMOEOPATHY IN DIABETES MELLITUS TYPE 2 & ITS MANAGEMENT “Medicine is the only profession that labours incessantly to destroy the reason for its own existence.” -James Bryce
  2. 2. TABLE OF CONTENTS 1- INTRODUCTION Definition Epidemiology Pathophysiology Signs and symptoms Diagnosis Complications
  5. 5. DIABETES MELLITUS  Diabetes mellitus is a serious degenerative disease known as a silent killer.
  6. 6. WHAT DIABETES MELLITUS IS?  It comprises a group of common metabolic disorder characterized by hyperglycemia due to absolute or relative deficiency of insulin.  INDIA has been dubbed DIABETES CAPITAL OF THE WORLD according to World Health Organization.
  7. 7. CLASSIFICATION Diabetes Mellitus can be classified into 4 types namely : 1. TYPE 1 DIABETES MELLITUS- (IDDM) a) b) 2. Type 1aDM (immune mediated) Type 1bDM (idiopathic) TYPE 2 DIABETES MELLITUS- (NIDDM) This constitutes 95% of Diabetes Mellitus. It is heterogenous group of disorder characterized bya) Insulin resistance b) Impaired insulin secretion c) Increased glucose production 3. 4. GESTATIONAL TYPE OF DIABETES MELLITUS OTHER SPECIFIC TYPES OF DIABETES MELLITUS
  8. 8. EPIDEMIOLOGY In 2011, according to WHO, 171 million people suffered worldwide from diabetes.  In INDIA, presently 19.4 million individuals are affected. This is to go up to 57.2 million by 2025. 
  9. 9. PATHOGENESIS As we all know, in a non-diabetic healthy individual there is a post-prandial rise in serum glucose level which leads to the stimulation of pancreatic beta-cells which further stimulates the insulin secretion in blood. This insulin performs two functions- first being the stimulation of glucose uptake by the peripheral tissues and secondly, the suppression of gluconeogenesis i.e., primary hepatic glucose production. But in type 2 diabetes mellitus, this insulin uptake by peripheral tissues is hampered leading to insulin resistance and the suppression of gluconeogenesis is also hampered leading to increased serum glucose level.
  11. 11. INSULIN Stimulation of glucose suppression of Uptake by peripheral Gluconeogenesis in Tissues Liver
  12. 12. IN TYPE 2 DIABETES MELLITUS INSULIN MEDIATED Stimulation of Glucose uptake by Peripheral tissues Is Hampered Insulin resistance Suppression of Gluconeogenesis in liver is Hampered Increased Serum glucose level Hyperglycemia
  13. 13. HYPERGLYCEMIA Increased catabolism Decreased Anabolism Increased Lipolysis Osmotic diuresis Increased free fatty Acids Dehydration and loss of electrolytes Ketoacidosis Coma (Diabetic coma) DEATH
  14. 14. HOW WILL A DIABETIC PATIENT PRESENT TO US IN OUR CLINICS Symptoms would be present for several years without detection.. Symptoms of type 2 diabetes mellitus can be studies under 3 headings1) Symptoms due to HYPERGLYCEMIAa) Excessive thirst (Polydipsia) b) Excessive urination (Polyuria) c) Excessive eating ( Polyphagia) d) Altered mental status e) Blurred vision
  15. 15. 2) Symptoms due to CALORIE MISUTILIZATION-These are: a) Fatigue b) Unexplained weight loss 3) Symptoms due to IMMUNE DYSFUNCTION –These are: a) poor wound healing b) infections-tuberculosis, candidiasis, skin infection
  16. 16. DIAGNOSIS Revised criteria for diagnosis of Diabetes Mellitus given by National Diabetes Data Group and WHO  Symptom of diabetes + Random blood glucose concentration -------->200mg/dl  Fasting plasma glucose >126mg/dl  2hr.plasma glucose > 200mg/dl during an oral glucose tolerance test.
  17. 17. FASTING PLASMA GLUCOSE is the most reliable and convenient test for diagnosing diabetes mellitus in patients who are asymptomatic because- a) Epidemiology studies have proved that type 2 diabetes mellitus may be present up to a decade before diagnosing.  b) As many as 50% individuals with type 2 diabetes mellitus have one or more complications at the time of diagnosis. 
  18. 18. WE SHOULD MAKE A PARAMETER ON WHO SHOULD BE TESTED FOR DIABETES MELLITUS a) those who have family history of diabetes (i.e. Parent or sibling).  b) persons suffering from obesity (BMI >27kg/m2).  c) those with age over 45 years.  d) previous identified impaired fasting glucose or impaired glucose tolerance.  e) women with history of gestational diabetes mellitus or delivery of baby over 4 kgs. 
  19. 19.  f) Those with hypertension ( B.P.>140/90 mmhg)  g) Lab findings of high density lipid cholesterol level <35 mg/dl and triglyceride level >250 mg/dl  h) Women with polycystic ovarian disease.
  20. 20. COMPLICATIONS o o The commonly seen acute complication are diabetic ketoacidosis, hyperosmolar non-ketoacidosis and hypoglycaemia. Diabetic Ketoacidosis is more commonly characterized by breathing which is deep and rapid as the body attempt to correct the blood acidity. Breath smells like nail polish remover due to ketones escaping into the breath. Next encountered acute complication is Hyperosmolar non-ketotic state which is more commonly seen in type 2 DM. In hyperglycemic individual (>300 mg/dl), water is osmotically drawn out of cells into the blood. The kidneys begin to spill more glucose in urine leading to increased water loss. This eventully leads to dehydration and electrolyte imbalance.
  21. 21.  The third most commonly seen acute complication is hypoglycemia or abnormally low blood glucose. It usually occurs due to too much or incorrectly timed insulin, too much or incorrectly timed exercise or fasting in diabetics. Patient become agitated, sweaty, unconscious or even comatosed. Seizures, brain damage or even death may occur.
  22. 22. o o Now the chronic complication which arise due to microvascular and macrovascular disturbance, affects the blood supply to vital organs due to atherosclerosis. The organs most commonly affected due to microvascular changes are eyes causing retinopathy, brain causing neuropathy and kidney causing naphropathy.
  23. 23.  In Diabetic retinopathy, growth of friable and poor quality new blood vessels in the retina and macular oedema leads to diminished vision and ultimately blindness can occur.  In Diabetic neuropathy, hyperglycemia causes increased levels of glucose in nerves therefore resulting in demylenation. Patient present with symptoms such as decreased sensation, tinglimg, muscle weakness.  Diabetic nephropathy is defined as the presence of persistent proteinuria (>0.5g/24 hours). Symptoms include oedema of the whole body especially around eyes and legs, frothy urine and weight gain due to fluid accumulation.
  24. 24. MACROVASCULAR CHANGES may lead to cardiovascular disease like coronary artery disease and myocardial infarction. Diabetic cardiomyopathy leads to diastolic dysfunction and eventually heart failure.  Coronary artery disease may lead to angina and myocardial infarction.  Peripheral vascular disease contribute to intermittent claudication as well as diabetic foot caused due to sensory neuropathy. 
  25. 25. Due to vascular damage numbness and insensitivity may occur leading to easy injuries and even when patient has cuts or sores he is unaware of it, injuries heal slowly leading to infection.  Patient become more susceptible to infections such as urinary, vaginal and skin. 
  26. 26. AS A CLINICIAN WHAT SHOULD BE OUR AIM IN CLINICAL PRACTICE?? The aim of any health care professional while treating a case of diabetes should always be to control ABC. A is the level of Hba1c which should be less than 7.5%. B is the blood pressure below 140/90 mm hg. C is the total cholesterol below 200 mg/dl.
  27. 27. RESEARCH
  28. 28. RESEARCHES RELATED TO DIET AND SUPPLEMENT Bitter gourd (Karela) Taken as juice or powdered seeds Most beneficial in treatment of Diabetes Mellitus. Active principle- Insulin like principle called plant insulin which is similar to Insulin and help in lowering blood and urine sugar level.
  29. 29. FRENCH BEAN POD TEA Excellent substitute to insulin 1 cup of tea = 1 unit of insulin Active principle- Silica and hormone substances analogous to insulin found in skin of pods of greens beans.
  30. 30. SOLANUM MELONGENA (BRINJAL) Rich in Phenol Regulate carbohydrate metabolism Gives time to insulin to break carbohydrate Control Blood Sugar
  31. 31. CUCUMBERS Active principle- Hormone needed by cells of pancreas for producing insulin. Helps control Diabetes Mellitus
  32. 32. SCOPE OF HOMOEOPATHY IN DIABETES MELLITUS Diabetes mellitus a chronic miasmatic state Pre/potential Diabetics Confirmed Diabetics Stress related Chronic Type1 Type2 Psoric Tubercular Psorasycosis Advanced Stages Acute Psoric
  33. 33. As classified by Dr.K.P. Majumdar, we usually receive three categories of patients of Diabetes mellitus in our clinical practice. A) PRE OR POTENTIAL DIABETICSThese are patients in which blood sugar rise on STRESS and may come down to a normal level once the stress is removed or it may remain at slight higher level of normal. These are PSORIC DIABETES. Exercise, diet and counselling will help to keep these under normal state and no medication may be required.
  34. 34. B) CONFIRMED DIABETICS These patient with either Type1 or Type2 diabetes. Here we need to determine the cause of his disease. Cases with type1 are a resultant of destruction of beta cells of pancreas from the beginning. The predisposition to destruction is due to hereditary miasmatic influence of TUBERCULAR or PSEUDOPSORIC miasmatic state. The scope of homoeopathic treatment is very much limited here as the lacking in one of the vital secretion of the body necessary for preservation of health.
  35. 35. Homoeopathic treatment is very helpful in cases with Type2 until cellular destruction has taken place. The condition is REVERSIBLE and can be successfully managed by homoeopathic drugs.
  36. 36. C) ADVANCED STAGES of COMPLICATION of DiabetesThe acute complication of metabolic disturbances are PSORIC in nature, while chronic complication have SYPHILITIC background or mixed miasmatic disease with strong syphilitic nature. Homoeopathic treatment is partially helpful in such cases as may not be achieved.
  37. 37. HOMOEOPATHIC APPROACH IN CASE OF DIABETES Now let us see what should be our approach as homoeopaths in treating a case of Diabetes mellitus. 1) If a case of Diabetes mellitus come to us for treatment, our first duty is to decide whether the case is curable or not. This may generally be assessed from the aetio-pathology of the condition, the family history, the age of onset, the severity of present condition, the assessment of renal function and the presence of complication. But the final prognosis of course depends on observing the effect of the well indicated medicine
  38. 38. 2) In Non-insulin Dependent Diabetes Mellitus the situation is all together different. In such cases oral hypoglycaemic drugs may be stopped from the very beginning of homoeopathic treatment. Because, homoeopathic constitutional medicine may perform the function of oral hypoglycaemic drugs may be correcting the miasmatic dyscrasia, checking destruction of cells as also by stimulating cells to act much more efficiently. This , at the same time, may help in reducing obesity supported by adequate exercise and dietetic control. Thus the insulin resistant state or the defect in insulin receptor may be corrected and the patient may be completely
  39. 39. SELECTION OF MEDICINE Our principle is to select constitutional medicine covering the totality of symptoms of the patient including the miasmatic background. We are to take care of the fundamental cause and the disease process and not the ultimate of the disease. The environmental causes must at the same time be taken proper care of.
  40. 40. POTENCY & REPETITION OF DOSES In non-insulin dependent cases without any organic destruction anywhere in the system, centesimal potency may also safely be used in medium high potency like 200th. But as repeated stimuli are necessary to stimulate the beta cells without causing further destruction, it is better to use 50 millesimal scale which can gradually be increased to successive higher potencies. Even if there is any aggravation in this scale, it can easily controlled by further dilution and increasing the duration in between the doses.
  41. 41. NEW OBSERVATION NOTED IN TREATING DIABETES MELLITUS It has been observed that after the administration of a well selected medicine, the patient as a whole feels much better and all the outward symptoms are nicely ameliorated but the blood sugar level steadily increases to an alarming level of 300 to 400 mg% or even more. If it is observed only in the beginning of treatment, then the prognosis may finally turn to be favourable, but if the condition of hyperglycaemia goes on persisting to an increasing severity, the prognosis is undoubtedly grave and the patient should be considered as incurable. Palliation should be the method of choice in such cases.
  42. 42. PREVENTION OF DIABETES MELLITUS It may be difficult or impossible to cure an advanced cases of Diabetes but its prevention is not so difficult if we know when and how to do it. a) Constitutional treatment of Diabetic parents: Antimiasmatic constitutional treatment of diabetic father, mother or both of them will undoubtedly help to eradicate the miasmatic dyscrasia responsible for Diabetes to a great extent, if not completely cured.
  43. 43. b) Constitutional treatment of potential diabetes: Children are born of diabetic parents or in other cases where a predisposition to diabetes is suspected, constitutional treatment will undoubtedly in eradicating the tendency and there will be less chance of developing overt diabetes in future. c) Treatment of latent diabetes: Patient with impaired glucose tolerance only but no active clinical symptoms of diabetes must be treated constitutionally to avoid developing overt diabetes.
  44. 44. RETROSPECTIVE STUDY ON DIABETES MELLITUS TYPE- 2 ( It was done on 5000 cases of BAKSON COLLEGE OPD from year 2008-2009.)
  45. 45. 5000 Cases 48 cases of DIABETES MELLITUS 50% CASES CASES Initial stages of diabetes mellitus 50% Later stages of Diabetes mellitus with
  46. 46. STUDY WAS DONE IN TWO PARTS:A) 1st study- cases of initial stages, where presenting complaint was related to diabetes mellitus. B) 2nd study- cases of later stages and with complication.
  47. 47. A) FIR ST STU D Y 24 C ASES IN ITIAL STAGES 20% CASE 80% CASES Si ngl e medi ci ne More than one medi ci ne 25% cases 75%cases w i th patents w i thout patents
  48. 48. Conclusion of 1st study 45% cases cases are improved result 9% cases are are standstill 40% have no
  49. 49. B) SECOND STUDY 24 cases In late stages, with complication 20% cases Single medicine 80% cases more than one medicine few with patents without patents few
  51. 51. CONCLUSION OF 2ND STUDY 55% CASES CASES Improved no 10% CASES Standstill 35% Have result
  52. 52. MEDICINE WHICH ARE FREQUENTLY USED:1) 2) 3) 4) 5) Syzygium Jambolanum Uranium nitrate B-20 Drops Arsenic album Acid phos
  53. 53. HOMOEOPATHIC THERAPEUTICS OF DIABETES MELLITUS Some of the important homoeopathic medicines are listed below…. Mother tinctureSyzygium jambolanum Gymnema sylvestre Cephalandra indica Rhus aromatica
  54. 54. Constitutional drugsCalcarea carb Phosphorus Lycopodium OTHER DRUGS Acidum lacticum Insulinum Pancreatinum Uranium nitricum
  55. 55. MOTHER TINCTURE SYZYGIUM JAMBOLINUM Most useful remedy in diabetes mellitus. No other remedy causes in so marked degree the diminution and disappearance of sugar in the urine.  Great thirst, weakness, large amount of urine.  Specific gravity of urine-high.  Diabetic ulceration.  Skin covered with small red papules which itch intensely. 
  56. 56. GYMNEMA SYLVESTRE Sugar killer excellent medicine for diabetes mellitus.  Burning all over the body.  Diabetic carbuncle.  Sexual power is loss  CEPHALENDRA INDICA Profuse urination, weakness and exhaustion after urination. Sugar in urine with dryness of mouth with great thirst.
  57. 57. CONSTITUTIONAL DRUG CALCAREA CARB           Excessive hunger Profuse perspiration Excessive urination Emaciation Obesity Chilly patient They have distended abdomen with thin hands & legs Apprehensive Fearful Fat, fair,flabby,sourness,craves for eggs ,sluggish
  58. 58. PHOSPHORUS          Sudden emaciation Hunger soon after eating Increased thirst Great emaciation, gradual weakness and prostration Chilly patient Patient is tall, stooped shoulder ,slender, sickly face, earthy, sunken and pale Craving for cold food and water which is vomited out as soon as it become warm Lively, cheerful, mixes with all Desire to be magnetized
  59. 59. LYCOPODIUM CLAVATUM           Burning in general and urine in particular Emaciation Excessive appetite Increased urine during night Wounds refuse to heal Adapted to old person or children, premature old age, weak body but sharp mind, intellectually keen but weak muscular power Red sand in urine Predominantly right sided medicine All complaint <4-8 p.m. Weeps when thanked
  60. 60. ACIDUM LACTICUMGastro-hepatic variety of diabetes.  Copious urination, light yellow and saccharine urine.  Thirst, nausea, debility, vocarious appetite.  Costive bowels, dry skin, dry tongue  Gastralgia 
  61. 61. ACIDUM PHOSPHORICUM Of nervous origin.  Useful in early stages.  Urine milky in colour, containing sugar in urine.  Mental symptoms- grief, anxiety, indifferent, apathetic.  Physical symptoms- great debility, bruised feeling in muscle, unquenchable thirst, loss of appetite. 
  62. 62. INSULINUM Small doses given by mouth, as larger doses and hypodermic injections has no effect on ordinary diabetes. (dr. Cartier)  Baker advises to give Insulinum in 3x and 30x for good result. 
  63. 63. PANCREATINUM Deficient secretion and affection of pancreas, can be given for symptoms like diarrhoea containing undigested food particles, indigestion, pain in stomach or upper abdomen after one hour of eating.
  64. 64. URANIUM NITRICUM Diabetes with assimilative derangements.  Polyuria, dryness of mouth, and skin.  Exhaustion 
  65. 65. SOME OTHER DRUGS WHICH IS FREQUENTLY OR RARELY USED               Lactic acid Oxalic acid Arsenic album Natrum muriaticum Sulphur Argentum nitricum Adrenalin Lac defloratum Thyroidinum Medorrhinum Tuberculinum B.gaertner B.morgan proteus
  66. 66.  DIET AND REGIMEN  Low caloric and high residual diet should be taken.  The standard caloric requirement is 30 K.Cal. Per kg of body  Our aim should be to stop weight loss in patient who are progressively emaciating and to encourage weight loss in patient who are becoming progressively obese.
  68. 68. General Management Personal cleanliness  To avoid mental worries and anxiety  To avoid alcohol  Foot care  Moderation in all sphere of life  Adaptability  Regular check-up of blood sugar  Regular urine examination 
  69. 69. BIBILIOGRAPHY BOOKS  Harrison’s Principle of Internal Medicine  Davidson’s Principle and Practice of Medicine  Boerick William,Homoeopathic Materia Medica  Kent J.T., Lectures on Homoeopathic Materia Medica  Khan L.M, Pleasure of Prescribing  Vijayankar Praful, Predictive Homoeopathy  Dev. S.N., Scope of Homoeopathy  Monograph on Diabetes mellitus (CCRH)
  70. 70. BIBILIOGRAPHY... ARTICLES British Journal of Homoeopathy  American Journal  Quarterly CCRH Journal. WEBSITE  www.similia .com  www.wikipedia .com
  71. 71. Any Query ??