MANAGEMENT OF DIABETES

It is a chronic metablic disorder charactersied by hyperglycemia with or withour glucosuria resulting from an absolute or relative deficiency of insulin.


The major clinical features of diabetes are:-Non healing ulcers,unexplained weight loss,recurrent respiratory or urinary tract infections,onset of cataract before 50 years,loss of sensations in the periphery,impotence in young males,history of overweight babies and recurrent fetal loss in women,recurrent infections like moniliasis,balanoposthitis and vulvitis,premature onset of stroke,heart disease and valvular occlusions,any vague ill health.

Diabetic patient is adviced to keep a check on his/her lifestyle,take oral anti-diabetic agents and insulin if indicated.

DIET AND LIFESTYLE:-It is the starting point and mainstay treatment in 1 and 2 type diabetes mellitus.It is also helpful in reducing weight in obese patients,to improve glycemic control and to reduce chronic vascular diseases like hyperlipedimia and hypertension.

CALORIE REQUIREMENT:-It is the basic requirement of the body which is about 20-25kcal/kg of desirable body weight.Additional energy required for sedentary persons is 30kcal/kg,for moderate working persons about 40kcal/kg and for people with strenuous lifestyle about 50kcal/kg.We will get 45-60% of total calories from carbohydrates,<35%from fats and 10-15% from proteins.

CARBOHYDRATES:-The major strategies to be followed in carbohydrate uptake are

1.maintain a regular intake of carbohydrate in meals throughout the day.

2.Avoidiing refined carbohydrates

3.Restriction of total intake of carbohydrates.

5.Taking food with low glycemic index.eg:-whole grain food,legumes,fruits,nuts,barley,oats.They cause only a slow gradual rise in blood glucose.



FAT:-Take saturated fat < 10%,monounsaturated fat 10-20%.eg:-- oils made from olive , groundnut .They help to reduce total & LDL cholesterol without reduction in HDL.Polyunsaturated fat <10% helps to reduce total, LDL & HDL cholesterol.w3 fatty acids can be taken once or twice weakly.eg:-mackerals, sardines.



WEIGHT MANAGEMENT:-Reducing energy intake,increasing energy expenditure through physical activity and regular exercise in the form of walking,swimming,cycling for approximately 30 minutes daily improves insulin sensitivity,lipid profile and lowers B.P.Alchohol intake in moderate amounts along with a meal is advisable.Quitting smoking,salt restriction to 6gmm/d-3gm/d in hypertensives is advisable.The patients must intake low calorie,sugar free drinks and foods.Avoid biscuits,cake and take nuts and fruits instead.Eat regular meals avoiding fried and sugary food.Eating plenty of vegetables,whole fruits and limit consumption of animal products like red meat,eggs,liver,high fat diary products.Replace those foods with lean meat,fish,poultry(without skin),low fat diary products.Patients must not overeat in any occasions.

TREATMENT:-Tretement by terapy with insulin secretogogues like suphonylureas,meglitinides and Insulin sensitizers like metformin,thiazolidinediones.

Liver decreases glucose output.Drugs like metformin,thiazolidinediones also do the same action.Pancreas increases insulin secretion and suplhonylureas and meglitinides are used to aid pancreas in insulin secretion.Peripheral glucose uptake is increased by metformin.Alpha gucosidase inhibitors are used to delay glucose absorption.Thaizolidinediones help in increasing insulin sensitivity.

SULPHONYLUREAS:-They are used to treat non-obese patients when lifestyle modification alone doesn’t work.The major limitations are hypoglycemia and weight gain.

METFORMIN:-They are used to treat diabetes in diabetic patients.Their action is synergestic with sulphonylureas and insulin.The major limitations are impaired hepatic/renal function,alcoholic shock and hypoxia.

THAIZOLIDINEDIONES:-Used to treat patients with severe insulin resisitance(abdominal abesity).The major limitations are liver dysfunction,salt and water retention and these drugs are avoided in cardiac failure.

INCRETINS:-Oral glucose ingestion induces the release of GLP-1 which is a gut hormone.It amplify glucose induced insulin release.It suppresses glucagon secretion and improve PP hyperglycemia.It also delays gastric emptying.EXENATIDE is a GLP-1 receptor agonist.S.C.injection twice a day 60 mins before breakfast and dinner is iadvised for type 2 DM patients.Adding Sulphonylureas or metformin further reduces B.glucose.The effects of this drug are weight loss,nausea and hypoglycemia.

PRAMLINTIDE:-Synthetic analogue of islet amyloid polypeptide.It delays gastric emptying,suppress glucagon secretion and decrease appetite.Subcutaneous injection immediately befor meal is done for type 1 and insulin treated type type 2 Diabetes mellitus patients.The effects of this drug are initial weight loss,nausea and hypoglycemia.

INSULIN:-It is advised for patients with type1 Diabetes mellitus,pregnancy induced diabetes,OHA failure,A/C disease atate and surgery.

TYPES OF INSULIN are :-

1.Rapid acting(lispro,aspart)

2.short acting(soluble/regular)

3.Intermediate acting(Lente insulin)

4.Long acting(ultralente)

5.Long acting insulin analogues(glargine,detemir)

ROUTES OF INSULIN DELIVERY:-Insulin is deliverd by means of a syringe/pen.It is delivered subcutaneously to anterior abdominal wall,upper arms,upper thigh,buttocks.

The rate of absorption of insulin depends upon the site,depth,volume,warmth,local message and exercise.Other routes of drug delivery are intra muscular,Intra venous,peritoneal,intrapulmonary.it is also deliverd through continuous S.C or I.V infusion.SIDE EFFECTS of insulin are-hypoglycemia,weight gain,peripheral oedema,insulin antibodies,lipodystrophy,local allergy and phenomena like somogyi,DAWN phenomenon.

The major golas of therapy are maintain glucose level at a range of 90-130,peak post pandrial plasma glucose at <180 and HbA1C<7.

The patient can keep himself completely free from the complications and panic of diabetes by follwing the below mentioned steps.

1.Check HbA1C level 2-4 times/year.

2.Eye check up annually.

3.Foot examination 1-2 times/year by a physician,and daily by the patient.

4.B.P check up quarterly.

5.Lipid profile annually.

6.Educating the patient by giving proper guidance.