This section pertains to the treatment of DM and the various CPGs with regard to DM treatment in Malaysia

2. TREATMENTTREATMENT
 ObjectiveObjective: Maintain blood glucose level within normal range,: Maintain blood glucose level within normal range, withoutwithout
resulting in Hypoglycaemiaresulting in Hypoglycaemia..
 ‘‘Perfect glycemic controlPerfect glycemic control’: glucose levels are always normal (70-130’: glucose levels are always normal (70-130
mg/dl, or 3.9-7.2 mmol/L)mg/dl, or 3.9-7.2 mmol/L)
NON-PHARMACOLOGICAL MEASURESNON-PHARMACOLOGICAL MEASURES
 Weight control, regular exercise – Yoga, Aerobics.Weight control, regular exercise – Yoga, Aerobics.
 Diet modifications – high protein, low carbs-and-fat diet.Diet modifications – high protein, low carbs-and-fat diet.
 Treat underlying causes – obesity, CV diseases, infections, etc.Treat underlying causes – obesity, CV diseases, infections, etc.
 Always carry sweets / sugar / glucose tablets (due to overactivity ofAlways carry sweets / sugar / glucose tablets (due to overactivity of
OHAsOHAs → severe Hypoglycaemia→ severe Hypoglycaemia).).
 Avoid spicy, oily foods.Avoid spicy, oily foods.
 Use Artificial sweeteners (Use Artificial sweeteners (AspartameAspartame).).
 Diabetic footwear is advisable.Diabetic footwear is advisable.
 Protect the eyes (shades, day-night glasses).Protect the eyes (shades, day-night glasses).

3. PHARMACOLOGICAL TREATMENTPHARMACOLOGICAL TREATMENT
 For Type-I DMFor Type-I DM : Insulin: Insulin
 For Type-II DMFor Type-II DM : Oral Hypoglycaemic Agents (OHAs / OADs).: Oral Hypoglycaemic Agents (OHAs / OADs).
INSULININSULIN
 Type-I DM patients requireType-I DM patients require insulinotherapyinsulinotherapy..
 Insulin PumpInsulin Pump,, Insulin penInsulin pen andand Hypodermic needleHypodermic needle..
 Monitoring, Diet Control, Patient education and Compliance areMonitoring, Diet Control, Patient education and Compliance are
vital.vital.
 RiskRisk: Inability to continuously know the blood glucose levels and: Inability to continuously know the blood glucose levels and
adjust insulin infusion appropriately.adjust insulin infusion appropriately.

5. INSULIN PUMPINSULIN PUMP
 Continuous S.C. Insulin InfusionContinuous S.C. Insulin Infusion Therapy;Therapy;
 ComponentsComponents::
-- PumpPump (including controls, processing module, and batteries)(including controls, processing module, and batteries)
-- Disposable reservoir for insulinDisposable reservoir for insulin (inside the pump in newer versions)(inside the pump in newer versions)
-- Disposable infusion setDisposable infusion set (including a(including a cannula for s.c. insertioncannula for s.c. insertion and aand a
tubing systemtubing system to interface the insulin reservoir to the cannula).to interface the insulin reservoir to the cannula).
 Allows theAllows the replacement ofreplacement of slow-acting insulin for basal needsslow-acting insulin for basal needs withwith
aa continuous infusion of rapid-acting insulincontinuous infusion of rapid-acting insulin..
 DosingDosing: 2 ways: 2 ways
-- Bolus or mealtime doseBolus or mealtime dose ((to cover food eatento cover food eaten or toor to correct a high bloodcorrect a high blood
glucose level)glucose level)..
-- Basal or background doseBasal or background dose (pumped continuously at an(pumped continuously at an adjustableadjustable
basal ratebasal rate to deliver insulin neededto deliver insulin needed between meals and at night)between meals and at night)..

8. Advantages of the Insulin pumpAdvantages of the Insulin pump
 OffersOffers relative freedomrelative freedom from a structured meal and exercisefrom a structured meal and exercise
regimenregimen..
 More convenient and discreet than the insulin injection.More convenient and discreet than the insulin injection.
 Deliver moreDeliver more precise amounts of insulinprecise amounts of insulin →→ tighter control overtighter control over
blood sugar and HbA1C levelsblood sugar and HbA1C levels →→ reducing the chance of long-reducing the chance of long-
term complicationsterm complications→→ Long term cost savings relative to multipleLong term cost savings relative to multiple
daily injections.daily injections.
 Modern 'smart' pumps have a ‘Modern 'smart' pumps have a ‘Bolus wizardBolus wizard' - calculates how' - calculates how
much 'bolus' insulin is needed (taking into account the expectedmuch 'bolus' insulin is needed (taking into account the expected
carbohydrate intake and current blood sugar status).carbohydrate intake and current blood sugar status).

9. Disadvantages of the Insulin pumpDisadvantages of the Insulin pump
 Far more expensiveFar more expensive than syringes used for insulin injection.than syringes used for insulin injection.
 Must be worn most of the timeMust be worn most of the time - activities (rough sports and- activities (rough sports and
activities in the water) may damage the pump.activities in the water) may damage the pump.
 Uncomfortable (Uncomfortable (Wearing the pump all the time).Wearing the pump all the time).
 DKADKA (if pump user does not receive sufficient fast acting insulin(if pump user does not receive sufficient fast acting insulin
for many hours).for many hours).
[ Pump battery is discharged / insulin reservoir runs empty / the[ Pump battery is discharged / insulin reservoir runs empty / the
tubing becomes loose and insulin leaks rather than beingtubing becomes loose and insulin leaks rather than being
injected / cannula becomes bent or kinked in the body, preventinginjected / cannula becomes bent or kinked in the body, preventing
delivery]. Therefore pump users typically monitor their blooddelivery]. Therefore pump users typically monitor their blood
sugars more frequently to evaluate the effectiveness of insulinsugars more frequently to evaluate the effectiveness of insulin
delivery.delivery.
 Possibility of insulin pump breakingPossibility of insulin pump breaking andand having to resort back tohaving to resort back to
multiple daily injectionsmultiple daily injections until new pump arrives.until new pump arrives.

10. INSULIN PENSINSULIN PENS
 Insulin injection system for the treatment of diabetes.Insulin injection system for the treatment of diabetes.
 ComponentsComponents:: disposable needlesdisposable needles,, insulin vialinsulin vial and a ‘and a ‘penpen’.’.
 Pen systemsPen systems:: Replaceable cartridgeReplaceable cartridge andand Pre-filledPre-filled..
 Replaceable cartridge penReplaceable cartridge pen reuses the pen portionreuses the pen portion;; vial isvial is
replaced.replaced.
 Pre-filled pen isPre-filled pen is entirely disposableentirely disposable. When the insulin is gone,. When the insulin is gone,
the entire unit is discardedthe entire unit is discarded
 DisadvantagesDisadvantages ::
a] Restricted toa] Restricted to either full or half unit dosingeither full or half unit dosing..
b]b] Can’t mix two different insulinsCan’t mix two different insulins in the same pen.in the same pen.

12. Insulin pens (contd.)Insulin pens (contd.)
 AdvantagesAdvantages::
a]a] More convenientMore convenient andand easier to transporteasier to transport;; discretediscrete..
b]b] Relatively more accurate dosagesRelatively more accurate dosages (compared to injections).(compared to injections).
c] Easier to usec] Easier to use for those with visual or fine motor skillsfor those with visual or fine motor skills
impairments.impairments.
d]d] Less injection painLess injection pain (as polished and coated needles are not(as polished and coated needles are not
‘‘dulled’ by insertion into the insulin vial before a seconddulled’ by insertion into the insulin vial before a second
insertion into the skin)insertion into the skin)

13. INSULIN GLARGINE (Lantus)INSULIN GLARGINE (Lantus)
 Marketed by Sanofi-Aventis.Marketed by Sanofi-Aventis.
 Long-acting basal insulinLong-acting basal insulin analogue.analogue.
 OD or BDOD or BD ..
 Duration of action isDuration of action is up to 24 hoursup to 24 hours. ‘ Less peaked profile’. ‘ Less peaked profile’
 Moderate control of serum glucose in Type-II DM (along with shortModerate control of serum glucose in Type-II DM (along with short
acting sulfonylurea).acting sulfonylurea).
 In the absence of endogenous insulin (Type I DM or depleted TypeIn the absence of endogenous insulin (Type I DM or depleted Type
II),II), Lantus needs the support of a fast acting insulin taken with food toLantus needs the support of a fast acting insulin taken with food to
reduce the effect of prandially-derived glucosereduce the effect of prandially-derived glucose..
NPH (Neutral Protamine Hagedorn)NPH (Neutral Protamine Hagedorn)
 1936 -1936 - Neutral protamine + Regular InsulinNeutral protamine + Regular Insulin (Hans Christian(Hans Christian
Hagedorn)Hagedorn)
 Suspension ofSuspension of crystalline zinc insulincrystalline zinc insulin ++ polypeptide protamine.polypeptide protamine.
 Via S.C. - Intermediate duration of actionVia S.C. - Intermediate duration of action
(longer than that of regular insulin, but shorter than Ultralente,(longer than that of regular insulin, but shorter than Ultralente,
glargine or detemir).glargine or detemir).

14. ORAL HYPOGLYCAEMIC AGENTSORAL HYPOGLYCAEMIC AGENTS
1]1] Sulfonyl UreasSulfonyl Ureas
a)a) 11stst
GenerationGeneration
 Chlorpropamide 100 – 500 mg odChlorpropamide 100 – 500 mg od
 Tolbutamide 500 – 2500mg bid / tidTolbutamide 500 – 2500mg bid / tid
b)b) 22ndnd
GenerationGeneration
 Glibenclamide 2.5 – 20 mg od / bdGlibenclamide 2.5 – 20 mg od / bd
 Glipizide 2.5 – 20 mg od / bdGlipizide 2.5 – 20 mg od / bd
 Gliclazide 80 – 320 mg od / bdGliclazide 80 – 320 mg od / bd
 Gliclazide MR 30 – 120 mg odGliclazide MR 30 – 120 mg od
 Glipizide XL 5 – 20 mg odGlipizide XL 5 – 20 mg od
c)c) 33rd
GenerationGeneration
 Glimepiride 1 – 8 mg odGlimepiride 1 – 8 mg od

15. OHAs (contd.)OHAs (contd.)
2]2] Non-Sulfonyl UreasNon-Sulfonyl Ureas
a)a) MMetaglinide Analogues ( Repaglinide 1.5 – 10 mg tid).etaglinide Analogues ( Repaglinide 1.5 – 10 mg tid).
b)b) BBiguanides (Metformin 250 – 2500 mg bid / tid)iguanides (Metformin 250 – 2500 mg bid / tid)
c)c) TThiazolidinediones ( Rosiglitazone 2 – 8 mg od / bd;hiazolidinediones ( Rosiglitazone 2 – 8 mg od / bd;
Pioglitazone 15 – 45 mg od)Pioglitazone 15 – 45 mg od)
a)a) αα-glucosidase Inhibitors (Acarbose 25 – 300 mg tid)-glucosidase Inhibitors (Acarbose 25 – 300 mg tid)
*** Never administer OHAs to pregnant ladies; Type-I DM; heart,*** Never administer OHAs to pregnant ladies; Type-I DM; heart,
kidney and renal failure patients***kidney and renal failure patients***

16. OHAs : TYPES & MOAOHAs : TYPES & MOA
 Are used to control DM when diet and lifestyle modifications failAre used to control DM when diet and lifestyle modifications fail
to achieve the desired results.to achieve the desired results.
 Are effective only in case ofAre effective only in case of Type-II DMType-II DM, and in, and in few cases offew cases of
Secondary DMSecondary DM..
 CompriseComprise Insulin ReleasersInsulin Releasers,, Insulin SensitizersInsulin Sensitizers,, αα-glucosidase-glucosidase
InhibitorsInhibitors..
1]1] Insulin ReleasersInsulin Releasers
• Stimulate the pancreatic cells to release Insulin.Stimulate the pancreatic cells to release Insulin.
• Includes Sulfonyl ureas (mostly 2Includes Sulfonyl ureas (mostly 2ndnd
generation) and metaglinidegeneration) and metaglinide
analogues.analogues.
2]2] Insulin SensitizersInsulin Sensitizers
• ↑↑es glucose uptake by peripheral tissues (increase thesees glucose uptake by peripheral tissues (increase these
tissues’ sensitivity to insulin, thus enhancing insulin’s action intissues’ sensitivity to insulin, thus enhancing insulin’s action in
the body).the body).
• Includes Metformin and Glitazones.Includes Metformin and Glitazones.

17. SULFONYLUREASSULFONYLUREAS
 First widely used OHAs; for Type-II DM only.First widely used OHAs; for Type-II DM only.
 Limit glucose productionLimit glucose production in liver.in liver.
 ↓↓es Lipolysises Lipolysis (prevents DKA to an extent) and(prevents DKA to an extent) and InsulinInsulin
clearanceclearance by the liver.by the liver.
 Bind strongly to Plasma ProteinsBind strongly to Plasma Proteins..
 Side effectsSide effects:: Hypoglycaemia;Hypoglycaemia;
Unintentional weight gainUnintentional weight gain (due to edema);(due to edema);
Abdominal upset, Headache,Abdominal upset, Headache,
Hypersensitivity;Hypersensitivity;
TeratogenicTeratogenic ((Contraindicated in pregnancyContraindicated in pregnancy))..

18. NON - SULFONYL UREASNON - SULFONYL UREAS
1] MEGLITINIDES / GLINIDESMEGLITINIDES / GLINIDES
 For Type-II DM;For Type-II DM;
 Can beCan be taken with meals to boost insulin responsetaken with meals to boost insulin response..
 MOA similar to Sulfonylureas, but different binding siteMOA similar to Sulfonylureas, but different binding site..
 Egs.Egs. : Nateglinide 120 mg TID (max. dose 60 mg/day).: Nateglinide 120 mg TID (max. dose 60 mg/day).
Repaglinide (max. dose 16 mg/day); 0 to 30 minutes p.cRepaglinide (max. dose 16 mg/day); 0 to 30 minutes p.c
Mitiglinide.Mitiglinide.
 If a meal is skipped, the medication must be skipped.If a meal is skipped, the medication must be skipped.
 ADRsADRs : weight gain and hypoglycemia.: weight gain and hypoglycemia.

19. 2] BIGUANIDESBIGUANIDES
 Insulin sensitizersInsulin sensitizers
 Egs.Egs. ::
• Metformin (Glucophage)Metformin (Glucophage) : widely used to treat Type-II DM combined: widely used to treat Type-II DM combined
with obesitywith obesity
• Phenformin and BuforminPhenformin and Buformin : withdrawn from markets (toxic effects): withdrawn from markets (toxic effects)
• ProguanilProguanil (an antimalarial drug).(an antimalarial drug).
 Side effectsSide effects : Diarrhoea, Dyspepsia, Abdominal pain, Bloated: Diarrhoea, Dyspepsia, Abdominal pain, Bloated
sensation,sensation, Lactic AcidosisLactic Acidosis..
 Should NOT be used in any conditions that can cause lactic acidShould NOT be used in any conditions that can cause lactic acid
accumulation (CCF, recent MI, Liver cirrhosis, severe infection etc.).accumulation (CCF, recent MI, Liver cirrhosis, severe infection etc.).

20. 3] THIAZOLIDINEDIONES (TZDs) / GLITAZONESTHIAZOLIDINEDIONES (TZDs) / GLITAZONES
 Activate PPARsActivate PPARs;; Decrease Insulin resistanceDecrease Insulin resistance;; Better use of glucoseBetter use of glucose
by the cellsby the cells
 Egs.Egs. : i): i) RosiglitazoneRosiglitazone ii)ii) PioglitazonePioglitazone
iii)iii) TroglitazoneTroglitazone withdrawn (drug-induced hepatitis).withdrawn (drug-induced hepatitis).
 Side effectsSide effects ::
• Edema & weight gainEdema & weight gain (can lead to HF).(can lead to HF).
• Pioglitazone – Significant protection fromPioglitazone – Significant protection from micro and macro vascularmicro and macro vascular
diseases and plaque progressiondiseases and plaque progression..
• Rosiglitazone –Rosiglitazone – Increased risk of Heart attacks and CHDsIncreased risk of Heart attacks and CHDs..
 WHAT ARE PPARs?WHAT ARE PPARs?

21. 4] αα-GLUCOSIDASE INHIBITORS-GLUCOSIDASE INHIBITORS
 PancreaticPancreatic αα–Amylase–Amylase αα–Glucosidase–Glucosidase
 Egs.Egs.:: AcarboseAcarbose,, MiglitolMiglitol andand VogliboseVoglibose (lesser side effects and(lesser side effects and
cheaper).cheaper).
 Taken at start of mealsTaken at start of meals for maximal effect.for maximal effect.
 Side effectsSide effects::
• Flatulence and Diarrhoea (bacteria digest the Carbohydrates inFlatulence and Diarrhoea (bacteria digest the Carbohydrates in
colon).colon).
• HypoglycaemiaHypoglycaemia

22. PEPTIDE ANALOGUESPEPTIDE ANALOGUES
A] Incretin MimeticsIncretin Mimetics
 IncretinsIncretins :: Insulin Secretagogues (drugs that stimulateInsulin Secretagogues (drugs that stimulate
secretion of Insulin).secretion of Insulin).
 Egs.Egs.: i): i) Glucagon-Like Peptide-1Glucagon-Like Peptide-1 ((GLP-1GLP-1))
ii)ii) Gastric Inhibitory PeptideGastric Inhibitory Peptide ((Glucose-dependentGlucose-dependent
Insulinotropic PeptideInsulinotropic Peptide // GIPGIP).).
 GLP-I and GIPGLP-I and GIP →→ Stimulates insulin releaseStimulates insulin release
Inhibits Glucagon releaseInhibits Glucagon release
↓↓
Elevated Blood Glucose is loweredElevated Blood Glucose is lowered
 GLP-I and GIP are rapidly inactivated byGLP-I and GIP are rapidly inactivated by DipeptidylDipeptidyl
peptidase-4peptidase-4..
[NOTE:[NOTE: DPP-4DPP-4 enzyme inhibits GLP-I;enzyme inhibits GLP-I;
DPP-4 Inhibitors block DPP-4]DPP-4 Inhibitors block DPP-4]

23. B] Glucagon-like peptide (GLP) analogues and agonistsGlucagon-like peptide (GLP) analogues and agonists
 Bind to a membrane GLP receptorBind to a membrane GLP receptor→→ Insulin release increased.Insulin release increased.
 Endogenous GLP has a half life of only a few minutesEndogenous GLP has a half life of only a few minutes..
 Exenatide / Exendin-4 (Byetta)Exenatide / Exendin-4 (Byetta)::
• First GLP-1 agonist approved for the treatment of Type-II DM.First GLP-1 agonist approved for the treatment of Type-II DM.
• Dose is 5Dose is 5μμg BD by Insulin pen increased to 10g BD by Insulin pen increased to 10μμg BD after 4g BD after 4
weeksweeks..
• Increased resistance to degradation by DPP-4Increased resistance to degradation by DPP-4→→ extended Half-extended Half-
lifelife..
 Liraglutide (Victoza)Liraglutide (Victoza)::
• a OD dose; developed by Novo Nordisk.a OD dose; developed by Novo Nordisk.
• Approved by FDA in June 2010.Approved by FDA in June 2010.
 Side effectsSide effects: decrease in gastric motility, nausea, weight loss.: decrease in gastric motility, nausea, weight loss.

24. Peptide analogues (contd.)Peptide analogues (contd.)
C] Gastric inhibitory peptide (GIP) analogsGastric inhibitory peptide (GIP) analogs
None are FDA approvedNone are FDA approved
D] Dipeptidyl peptidase-4 (DPP-4) inhibitors / DPP-4 inhibitorsDipeptidyl peptidase-4 (DPP-4) inhibitors / DPP-4 inhibitors
 Inhibit degradation of GLP-I by DPP-4Inhibit degradation of GLP-I by DPP-4 →→ increase bloodincrease blood
concentration of the incretin GLP-1.concentration of the incretin GLP-1.
 ExamplesExamples:: Vildagliptin, SitagliptinVildagliptin, Sitagliptin..
 IS GIP REALLY BENEFICIAL????IS GIP REALLY BENEFICIAL????

25. AMYLIN ANALOGUESAMYLIN ANALOGUES
 Amylin agonist analoguesAmylin agonist analogues slow gastric emptying andand suppress
glucagon..
 Have all the incretins actions except stimulation of insulinHave all the incretins actions except stimulation of insulin
secretion.secretion.
 PramlintidePramlintide - only clinically available amylin analogue (2007).- only clinically available amylin analogue (2007).
via S.C. inj.via S.C. inj.
adverse effect – Nausea.adverse effect – Nausea.
TREATMENT FOR COMPLICATIONSTREATMENT FOR COMPLICATIONS
Diabetic retinopathyDiabetic retinopathy::
i) 3 treatments are laser surgery, triamcinolone inj. into the eyei) 3 treatments are laser surgery, triamcinolone inj. into the eye
and vitrectomy.and vitrectomy.
ii) Can’t cure; Monitoring is essential.ii) Can’t cure; Monitoring is essential.
iii) Avoid tobacco use, correct HTN.iii) Avoid tobacco use, correct HTN.

26. Diabetic NephropathyDiabetic Nephropathy::
i) ACEIs (to reduce proteinuria, slow progression of disease) +i) ACEIs (to reduce proteinuria, slow progression of disease) +
ARBs.ARBs.
ii) Antibiotics (for UTIs). iii) C-peptide (By-product of insulinii) Antibiotics (for UTIs). iii) C-peptide (By-product of insulin
production; prevents diabetic nephropathy).production; prevents diabetic nephropathy).
iv) Dialysis (end-stage renal disease).iv) Dialysis (end-stage renal disease).
v) Blood glucose monitoring.v) Blood glucose monitoring.
vi) Avoid Common NSAIDs, Ivi) Avoid Common NSAIDs, I22-containing contrast medium.-containing contrast medium.
Diabetic NeuropathyDiabetic Neuropathy ::
i) Treat the nerve pain with Gabapentin (Neurontin), Phenytoini) Treat the nerve pain with Gabapentin (Neurontin), Phenytoin
(Dilantin), CBZ (Tegretol), Desipramine (Norpraminine),(Dilantin), CBZ (Tegretol), Desipramine (Norpraminine),
Amitriptyline (Elavil), topically-released Capsaicin.Amitriptyline (Elavil), topically-released Capsaicin.

33. DIET CONTROLDIET CONTROL
1]1] Nutritious dietNutritious diet : need not be totally different from normal diet.: need not be totally different from normal diet.
 Goals of Nutrition TxGoals of Nutrition Tx ::
• Maintain near-normal blood glucose levels;Maintain near-normal blood glucose levels;
• Achieve optimum serum lipid levels;Achieve optimum serum lipid levels;
• Adequate calories.Adequate calories.
• Prevent, delay or treat complications.Prevent, delay or treat complications.
 Glycaemic Index (GI):Glycaemic Index (GI):
• Indicates theIndicates the ↑ in blood sugar post-eating, against the ↑ in blood↑ in blood sugar post-eating, against the ↑ in blood
sugar after consuming an equivalent amount of glucosesugar after consuming an equivalent amount of glucose..
• Useful in planning diet for diabetics.Useful in planning diet for diabetics.
• High GIHigh GI : Cereals (wheat, rice); veggies (potato, carrot) 65 – 75%: Cereals (wheat, rice); veggies (potato, carrot) 65 – 75%
• Intermediate GIIntermediate GI : fruits 45 – 55%: fruits 45 – 55%
• Low GILow GI : Legumes & lentils 30 – 40%; beneficial for diabetics.: Legumes & lentils 30 – 40%; beneficial for diabetics.
 Fats & OilsFats & Oils ::
• Avoid butter, ghee, coconut & palm oil; use mustard, corn,Avoid butter, ghee, coconut & palm oil; use mustard, corn,
sunflower, groundnut and gingelly oil.sunflower, groundnut and gingelly oil.

34.  FibresFibres ::
• ↓↓ post-prandial blood glucose levels.post-prandial blood glucose levels.
• Fruits & veggies (soluble fibres) – lower the blood cholesterolFruits & veggies (soluble fibres) – lower the blood cholesterol
levels.levels.
• Fibres intake : 20 – 35 gms /day.Fibres intake : 20 – 35 gms /day.
 Artificial SweetenersArtificial Sweeteners ::
• Aspartame and Saccharine.Aspartame and Saccharine.
• Low calorie and non-calorie types are useful; shouldn’t exceedLow calorie and non-calorie types are useful; shouldn’t exceed
daily intake.daily intake.
 AlcoholAlcohol ::
• ↑↑es B.P., triglyceride levels; weakens the heart muscles →es B.P., triglyceride levels; weakens the heart muscles →
cardiomyopathy.cardiomyopathy.
• Affects liver and peripehral nerves.Affects liver and peripehral nerves.
• ↑↑ in calorie and no nutritive value (‘Empty calories’).in calorie and no nutritive value (‘Empty calories’).
• Best to avoid alcohol.Best to avoid alcohol.

35. 2]2] ExerciseExercise ::
 Can vary based on age, sex, type of diabetes, diabetic complicationsCan vary based on age, sex, type of diabetes, diabetic complications
and con-current diseases.and con-current diseases.
 ↓↓es Blood glucose levels, B.P. and cholesterol levels; strengthenses Blood glucose levels, B.P. and cholesterol levels; strengthens
the heart and muscle tone; ↑es metabolism.the heart and muscle tone; ↑es metabolism.
 45 mins. – 1 hour45 mins. – 1 hour is sufficient; ‘warm up’ and ‘cool down’ phases areis sufficient; ‘warm up’ and ‘cool down’ phases are
vital.vital.
 Choose longer route while walking; use steps instead of elevator.Choose longer route while walking; use steps instead of elevator.
 Park vehicle at a distance and walk.Park vehicle at a distance and walk.
 YogaYoga : improves blood circulation, pancreatic activity; stimulates: improves blood circulation, pancreatic activity; stimulates
insulin secretion and food digestion.insulin secretion and food digestion.
3]3] Foot care for DiabeticsFoot care for Diabetics ::
 Wash the feet daily w/ ordinary soap and lukewarm water.Wash the feet daily w/ ordinary soap and lukewarm water.
 Dry feet w/ soft towels (focus on areas b/n toes also).Dry feet w/ soft towels (focus on areas b/n toes also).
 Trim the nails straight regularly (in case of poor eyesight, askTrim the nails straight regularly (in case of poor eyesight, ask
relatives or family to do it).relatives or family to do it).
 Wear shoes and footwear that fit well.Wear shoes and footwear that fit well.
 Never soak the leg for too long in water.Never soak the leg for too long in water.

36. Foot care for Diabetics (contd.)Foot care for Diabetics (contd.)
 Never walk barefoot and never expose the toes.Never walk barefoot and never expose the toes.
 Never try to self-treat in case of injury.Never try to self-treat in case of injury.
 Monitor the feet for blisters.Monitor the feet for blisters.
4]4] Eye care for DiabeticsEye care for Diabetics ::
 Wash the eyes regularly; use soft towel.Wash the eyes regularly; use soft towel.
 Use sunglasses (while outside).Use sunglasses (while outside).
 Utmost safety and surety while using contact lenses.Utmost safety and surety while using contact lenses.
PRECAUTIONS FOR DIABETICSPRECAUTIONS FOR DIABETICS
 Always carryAlways carry diabetic identity carddiabetic identity card..
 Carry sugar, glucose,Carry sugar, glucose, candycandy..
 Drink plenty of water to avoid dehydration.Drink plenty of water to avoid dehydration.
 Avoid strenuous exercise (for patients w/ eye bleeds).Avoid strenuous exercise (for patients w/ eye bleeds).
 Stop exercising if chest pain or discomfort develops.Stop exercising if chest pain or discomfort develops.

37. DM UpdatesDM Updates

38.  The US FDA has announced the approval of a drug calledThe US FDA has announced the approval of a drug called
FarxigaFarxiga ((DapaglifozinDapaglifozin) to help treat adults with type 2 DM.) to help treat adults with type 2 DM.
The tablets,The tablets, in combination with diet and exercisein combination with diet and exercise, are said to, are said to
improve control of blood sugar levels.improve control of blood sugar levels.
 Farxiga, aFarxiga, a sodium-glucose co-transporter 2 inhibitorsodium-glucose co-transporter 2 inhibitor (SGLT2),(SGLT2),
works byworks by preventing the kidney from reabsorbing glucosepreventing the kidney from reabsorbing glucose. This. This
increases the excretion of glucoseincreases the excretion of glucose andand reduces blood sugarreduces blood sugar
levelslevels..
 According to the US FDA, 16 clinical trials involving more thanAccording to the US FDA, 16 clinical trials involving more than
9,400 patients with type 2 diabetes assessed the safety and9,400 patients with type 2 diabetes assessed the safety and
effectiveness of the drug.effectiveness of the drug.
 These trials demonstrated that Farxiga wasThese trials demonstrated that Farxiga was able to improveable to improve
HbA1c levels in type 2 diabetic patientsHbA1c levels in type 2 diabetic patients..
 The FDA says as well as being assessed as aThe FDA says as well as being assessed as a stand-alonestand-alone
therapytherapy, the drug has also been tested in, the drug has also been tested in combinationcombination withwith
other treatments for type 2 diabetes, including insulin,other treatments for type 2 diabetes, including insulin,
pioglitazone, metformin, glimepiride, and sitagliptin.pioglitazone, metformin, glimepiride, and sitagliptin.

39.  BUTBUT…..…..
 Clinical trials have found that Farxiga isClinical trials have found that Farxiga is not suitable fornot suitable for
individuals with type 1 diabetes, diabetic ketoacidosis, patientsindividuals with type 1 diabetes, diabetic ketoacidosis, patients
with moderate or severe kidney deterioration, end-stage kidneywith moderate or severe kidney deterioration, end-stage kidney
disease, or patients receiving dialysisdisease, or patients receiving dialysis..
 Clinical trials revealed that among users of Farxiga, there wereClinical trials revealed that among users of Farxiga, there were
an increased number ofan increased number of bladder cancerbladder cancerss diagnosed.diagnosed.
 Therefore, the FDA recommendsTherefore, the FDA recommends that patients with bladderthat patients with bladder
cancer do not use the drugcancer do not use the drug, and that patients with a history of, and that patients with a history of
the disease should consult their physician prior to using it.the disease should consult their physician prior to using it.
 DehydrationDehydration was found to be a side effect of the drug. The FDAwas found to be a side effect of the drug. The FDA
notes that elderly patients withnotes that elderly patients with impaired kidney function andimpaired kidney function and
patients using diuretics seemed to be more susceptible to thispatients using diuretics seemed to be more susceptible to this..
 The most common side effects from Farxiga in clinical trialsThe most common side effects from Farxiga in clinical trials
werewere fungal infectionsfungal infections andand urinary tract infectionsurinary tract infections..

40.  The FDA have asked forThe FDA have asked for six post-marketing studiesix post-marketing studies to bes to be
performed. These include aperformed. These include a cardiovascular outcomes trialcardiovascular outcomes trial
((CVOTCVOT) in order to analyze how Farxiga affects patients with) in order to analyze how Farxiga affects patients with
high risk of heart disease, and a double-blind randomized andhigh risk of heart disease, and a double-blind randomized and
controlled analysis of the risk of bladder cancer for patients whocontrolled analysis of the risk of bladder cancer for patients who
are a part of the CVOT trial.are a part of the CVOT trial.
(http://www.medicalnewstoday.com/articles/270986.php)(http://www.medicalnewstoday.com/articles/270986.php)
9 Jan 20149 Jan 2014
 INSULIN IMPLANTINSULIN IMPLANT
(http://www.dailymail.co.uk/health/article-2545180/The-end-diabetes-jabs-
New-insulin-implant-controls-blood-glucose-levels-without-injections.html?
ITO=1490&ns_mchannel=rss&ns_campaign=1490)

42. THE ENDTHE END