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Insulin Resistance A Challenge In Diabetes Management
- 1. Insulin Resistance A Challenge In Diabetes Management By: www.seas9.com
- 2. CONTENTS • Prevalence of diabetes • What is Diabetes • Insulin secretion • Insulin receptors • Insulin resistance • Complications of diabetes • Management By: www.seas9.com
- 3. PREVALENCE OF DIABETES • 177 million people world wide. • May be doubled by 2030 WHO/ Country and Regional Data By: www.seas9.com
- 4. 4 million deaths every year are attributed to complications of diabetes WHO 2003 Prevalence of Diabetes By: www.seas9.com
- 5. GLOBAL EPIDEMICS OF DIABETES 171,000,000 366,000,000 2000 2030 WHO 2003 By: www.seas9.com
- 6. GLOBAL PROJECTION OF DIABETES AS (% POPULATION) 0 10 20 30 40 50 60 70 1994 2000 2010 Africa Asia North America South America Europe World WHO 2003 By: www.seas9.com
- 7. TOP TEN COUNTRIES 1- India 2- China 3- USA 4- Indonesia 5- Russia 6- Japan 7- Pakistan 8- UAE 9- Brazil 10- Italy WHO 2003 By: www.seas9.com
- 8. COUNTRIES WITH LARGEST NO. OF PERSONS WITH DIABETES Country Prevalence of diabetes (%) Number persons (millions) Prevalence of diabetes (%) Number persons (millions) India 3.8 19.4 5.5 31.5 China 2.0 16.0 2.4 20.7 USA 7.8 13.8 7.8 17.5 Indonesia 4.1 4.5 6.7 8.5 Estimates 1995 Estimates 2000 WHO 2003 By: www.seas9.com
- 9. RECENT STUDIES OF THE PREVALENCE OF KNOWN AND PREVIOUSLY UNDIAGNOSED DIABETES IN SELECTED POPULATION. Study Country Prevalence of previously undiagnosed diabetes (%) Prevalence of known diabetes (%) Ratio of previously undiagnosed to known diabetes Levitt et al, 1993 98 South Africa 3.1 3.3 1:1 Mooy et al, 1995 99 The Netherlands 4.8 3.6 1:1 Park et al, 1995 100 South Korea 5.1 3.9 4:3 Elbagir et al, 1996 101 Sudan 2.2 1.3 2:1 Oilveira et al, 1996 102 Brazil 2.0 5.1 1:2 Shera et al, 1999 108 Pakistan 7.1 4.0 2:1 Harris et al, 1998 105 USA 2.7 5.1 1:2 By: www.seas9.com
- 10. CAUSES OF DEATH IN NIDDM PATIENTS FROM WHO CAUSE OF DEATH PERCENTAGE OF PATIENTS Ischemic heart disease 34 % Kidney disease 11 % Stroke 9 % Other cardiovascular disease 7 % By: www.seas9.com
- 11. PAKISTAN BURDEN OF DIABETES 5217000 13853000 0 2000000 4000000 6000000 8000000 10000000 12000000 14000000 2000 2030 WHO/Country and regional data By: www.seas9.com
- 12. Pakistan –burden of diabetes Nutritional 6% Injuries 11% Cardio-vascular/ Diabetes 11% Reproductive health 12% Communicable disease 38% Other Non- communicable disease 19% Neuro psychological 3% Ministry of Health By: www.seas9.com
- 14. WORD ORIGIN Diabetes mellitus comes from the Greek word Diabetes which means siphon (dia means through and bainein is to go) and mellitus which means honey sweet By: www.seas9.com
- 15. HISTORY Diabetes is one of the oldest disease known. In the 17th century, diabetes was known as the “pissing evil” because affected people passed out abnormally large quantities of urine. By: www.seas9.com
- 16. DIABETES MELLITUS Diabetes Mellitus is a chronic disorder characterized by the impaired metabolism of glucose and other energy- yielding fuels. CECIL TEXT BOOK OF MEDICINE 2nd EDITION page 1424 By: www.seas9.com
- 17. Classification of Diabetes Mellitus Type 1 (IDDM) Type 2 (NIDDM) Impaired Glucose Tolerance Gestational DM By: www.seas9.com
- 18. INSULIN • Is the only anabolic hormone and it has profound effects on the metabolism of carbohydrate, fat and protein. • Overall effect is to reduce blood levels of glucose and aminoacids and fats. By: www.seas9.com
- 19. INSULIN RELEASE MECHANISM H i g h High Intake of Carbohydrate Diet Rapid Increase of Glucose Level Activation of Beta Islet Cells Insulin Release By: www.seas9.com
- 20. FACTORS INFLUENCING INSULIN SECRETION Increase secretion Decrease secretion Glucose Fasting (except in diabetes) Amino acid Epinephrine (adrenaline) Fatty acid Norepinephrine (non adrenaline) Intestinal hormones Somastatin Glucagon Low blood potassium Cortisol Sympathetic nerve impulse Parasympathetic nerve impulses (vagus) drugs Drugs By: www.seas9.com
- 21. INSULIN RECEPTORS • Insulin receptors are protein in nature • Located on target cells such as blood cells,fat cells,liver cells and muscle cells • Insulin receptors have four sub units • Two outside of the cell membrane called Alpha sub units • Two inside of the membrane called Beta sub units By: www.seas9.com
- 22. INSULIN RESISTANCE • Insulin resistance may be due to any of the three general causes • An abnormal insulin molecule • An excessive amount of circulating antagonist • Target tissue defects.(most common cause of insulin resistance) (The last is the most common in type 2 diabetes ) By: www.seas9.com
- 23. SOME FEATURES OF INSULIN RESISTANCE (METABOLIC SYNDROME) • Hyperinsulinaemia • Type 2 diabetes or impaired glucose tolerance • Hypertension • Low HDL cholesterol; elevated triglycerides • Central (visceral) obesity • Microalbuminuria • Increased fibrinogen • Increased plasminogen activator inhibitor-1 • Elevated plasma uric acid By: www.seas9.com
- 24. FACTORS INVOLVED IN INSULIN RESISTANCE • Genetic predispostion • Obesity • Lack of physical activity. • Urbanized lifestyle. • Hypertension • Advancing age • Pregnancy • Diabetogenic drugs e.g thiazide diauretics, corticosterides. By: www.seas9.com
- 25. INSULIN RESISTANCE • Impaired insulin action. • The insulin dose-response curve for augmenting glucose uptake in peripheral tissues is shifted to the right (representing decrease in insulin sensitivity. • Maximal response is reduced. • Inhibition of hepatic glucose production and lipolysis also reduce sensitivity of insulin By: www.seas9.com
- 26. HYPERGLYCEMIA INSULIN RESISTANCE INSULIN SECRETION ELEVATIONS OF CIRCULATING GLUCOSE INITIAE A VICIOUS CYCLE IN WHICH HYPERGLYCEMIA BEGITS MORE SEVERE HYPERGLYCEMIA CECIL TEXT BOOK OF MEDICINE 2nd EDITION page 1431 By: www.seas9.com
- 27. INSULIN RESISTANCE • Insulin receptors are rarely abnormal in type 2 patients. • Post receptor pathways plays a far greater role in insulin resistance. • Reduce capacity of GLUT 4 to the cell surface in muscle. • Adiponectin (Acrp 30) a fat derived hormone; circulates at levels that correlate inversely with both adiposity and degree of insulin resistance. • Hyperglycemia per se impairs the B-cells response to glucose and promotes insulin resistance. By: www.seas9.com
- 28. Impaired Glucose tolerance Type 2 diabetes Defective Blunted Insulin resistance Insulin secretion Hyperinsulinemia Proposed sequence of events leading to the development of type 2 Diabetes: insulin resulting from genetic influence, central obesity, inactive or combination of these factors leads over time to progressive Loss of B-cell’s capacity to compensate for this defect. CECIL TEXT BOOK OF MEDICINE 2nd EDITION page 1432By: www.seas9.com
- 29. Direct effects Insulin resistance Hyperinsulinemia Hypertension VLDL HDL Glucose Tolerance Coronary Artery disease Metabolic syndrome. Insulin resistance may account for a clustering of cardiovascular Risk factor, including hypertension, dyslepidemia, glucose intolerance CECIL TEXT BOOK OF MEDICINE 2nd EDITION page 1451By: www.seas9.com
- 30. COMPLICATIONS OF DIABETES Microvascular/neurop athic • Retinopathy • Nephropathy • Peripheral neuropathy • Autonomic neuropathy • Foot disease Macrovascular • Coronary circulation • Cerebral circulation • Peripheral circulation CMDT 2004 page 1172 By: www.seas9.com
- 32. MACROVASCULAR COMPLICATIONS Major risk of atheroma effecting large vessels • Myocardial infarction • Stroke • Peripheral vascular disease By: www.seas9.com
- 33. MANAGEMENT OF DM DIETDIET EXERCISEEXERCISE DRUG THERAPYDRUG THERAPY By: www.seas9.com
- 34. Maintain Good Glycemic Control Avoid the Acute Complications of Hyperglycemia Avoid Dangerous Complications of Hypoglycemia Prevent or Delay Long Term Complications in Diabetes DIABETIC PATIENT DIABETIC PATIENT MANAGEMENT OF DM By: www.seas9.com
- 35. DRUGS FOR NIDDM Sulfonylureas Biguanades Glucosidase Inhibitor Glibenclamide Glipizide Gliclazide Glimepride Metformin Acarbose By: www.seas9.com
- 36. Medication classification How they work First generation Sulphonylurea and 2nd generation Sulphonylurea They lowers the blood Glucose by stimulating the pancreas to release more insulin Biguanides Improves insulin action in the body and lowers blood glucose by decreasing the amount of glucose released by liver. Sulphonylurea and Biguanide combination Stimulate the pancreas to release more insulin, improves insulin action in the body and lowers the amount of glucose released by liver. Thiozolidineione Improves insulin’s action in the body and lowers the amount of glucose by the liver. Alpha-glucosidase inhibitor Lowers blood glucose by delaying glucose absorption in small intestine. This medication blocks certain enzymes to slow down digestion of some starches. Meglitinide Lowers the blood glucose by stimulating pancreas to release more insulin. However, it is necessary to take before meals otherwise insulin that is blocked and will not lower blood glucose. Medi Health DME : Oral Diabetes By: www.seas9.com