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Diabetes is a disease in which levels of blood glucose, also called blood sugar, are above normal. People with diabetes have problems converting food to energy. Normally, after a meal, the body breaks food down into glucose, which the blood carries to cells throughout the body. Cells use insulin, a hormone made in the pancreas, to help them convert blood glucose into energy.

People develop diabetes because the pancreas does not make enough insulin or because the cells in the muscles, liver, and fat do not use insulin properly, or both. As a result, the amount of glucose in the blood increases while the cells are starved of energy. Over the years, high blood glucose, also called hyperglycemia, damages nerves and blood vessels, which can lead to complications such as heart disease, stroke, kidney disease, blindness, nerve problems, gum infections, and amputation.

Main Types of Diabetes :-

The two main types of diabetes are called type 1 and type 2. A third form of diabetes is called gestational diabetes.

Type 1 diabetes, formerly called juvenile diabetes, is usually first diagnosed in children, teenagers, and young adults. In this form of diabetes, the pancreas no longer makes insulin because the body’s immune system has attacked and destroyed the pancreatic cells specialized to make insulin. These insulin-producing cells are called beta cells.

Type 2 diabetes, formerly called adult-onset diabetes, is the most common form. People can develop type 2 diabetes at any age, even during childhood. This form of diabetes usually begins with insulin resistance, a condition in which muscle, liver, and fat cells do not use insulin properly. As a result, the body needs more insulin to help glucose enter cells to be used for energy. At first, the pancreas keeps up with the added demand by producing more insulin. In time, however, the pancreas loses its ability to secrete enough insulin in response to meals.

Gestational diabetes is diabetes that first occurs during pregnancy. When women are pregnant, their need for insulin appears to increase, and many can develop gestational diabetes during the late stages of pregnancy. Although this form of diabetes usually goes away after the baby is born, a woman who has had it is more likely to develop type 2 diabetes later in life.

Other Types of Diabetes :-

A number of other types of diabetes exist. A person may exhibit characteristics of more than one type. For example, in latent autoimmune diabetes in adults

　 

(LADA), also called type 1.5 diabetes or double diabetes, people show signs of both type 1 and type 2 diabetes. Diagnosis usually occurs after age 30.

Most people with LADA still produce their own insulin when first diagnosed, like those with type 2 diabetes, but within a few years, they must take insulin to control blood glucose levels. In LADA, as in type 1 diabetes, the beta cells of the pancreas stop making insulin because the body’s immune system attacks and destroys them. Some experts believe that LADA is a slowly developing kind of type 1 diabetes.

Other types of diabetes include those caused by

• genetic defects of the beta cell, such as maturity-onset diabetes of the young (MODY) and neonatal diabetes mellitus.
• excess amounts of certain hormones resulting from some medical conditions such as cortisol in Cushing’s syndrome—that work against the action of insulin
• medications that reduce insulin action, such as glucocorticoids, or chemicals that destroy beta cells
• rare autoimmune disorders, such as Stiff-man syndrome, an autoimmune disease of the central nervous system
• genetic syndromes associated with diabetes, such as Down syndrome.

Type 1 and type 2 diabetes

In 1997, to move away from naming the two main types of diabetes based on treatment or the age at onset, an American Diabetes Association expert committee recommended universal adoption of simplified terminology. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) agrees.

Former Name	Preferred Names
Type I juvenile diabetes insulin-dependent diabetes mellitus IDDM	type 1 diabetes
Type II adult-onset diabetes noninsulin-dependent diabetes mellitus NIDDM	type 2 diabetes

 

What is pre-diabetes?

In pre-diabetes, blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. However, many people with pre-diabetes develop type 2 diabetes within 10 years. Experts disagree about the specific blood glucose level they should use to diagnose diabetes, and through the years, that number has changed. Individuals with pre-diabetes have an increased risk of heart disease and stroke. With modest weight loss and moderate physical activity, people with pre-diabetes can delay or prevent type 2 diabetes.

How diabetes and pre-diabetes diagnosed?

The following tests are used for diagnosis:

A fasting plasma glucose (FPG) test measures blood glucose in a person who has not eaten anything for at least 8 hours. This test is used to detect diabetes and pre-diabetes.

Procedure :-

To prepare, you must not eat for at least eight hours before the test. The next morning, a healthcare provider takes a single sample of your blood and sends it to a lab for analysis. Fasting blood glucose tests done in the morning, rather than the afternoon, appear to be more accurate in diagnosing diabetes. So be sure to schedule your test for first thing in the morning.

• An oral glucose tolerance test (OGTT) measures blood glucose after a person fasts at least 8 hours and 2 hours after the person drinks a glucose-containing beverage. This test can be used to diagnose diabetes and pre-diabetes.

Procedure :-

1. A zero time (baseline) blood sample is drawn.

2. The patient is then given a measured dose (below) of glucose solution to drink within a 5 minute time frame.

3. Blood is drawn at intervals for measurement of glucose (blood sugar), and sometimes insulin levels. The intervals and number of samples vary according to the purpose of the test. For simple diabetes screening, the most important sample is the 2 hour sample and the 0 and 2 hour samples may be the only ones collected. Sometimes other laboratory continuous to collect blood up to 3 hours depending on the requesting physician

The WHO recommendation is for a 75g oral dose in all adults: the dose is adjusted for weight only in children. The dose should be drunk within 5 minutes.

 

• A random plasma glucose test, also called a casual plasma glucose test, measures blood glucose without regard to when the person being tested last ate. This test, along with an assessment of symptoms, is used to diagnose diabetes but not pre-diabetes.

Procedure :-

A healthcare provider will take a single sample of your blood and send it to a lab to be analyzed.

Test Results :-

A random blood glucose level of 200 mg/dL (which means 200 miligrams of glucose for each deciliter - or 1/10th liter - of blood) or higher with diabetes symptoms means it's likely you have diabetes. The doctor will confirm the diagnosis with an additional test, often a fasting plasma glucose test, or fasting blood glucose test. Your doctor may confirm all abnormal tests with a second test before diagnosing diabetes.

Test results indicating that a person has diabetes should be confirmed with a second test on a different day.

Etiology :-

Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused by too little insulin, resistance to insulin, or both.

To understand diabetes, it is important to first understand the normal process by which food is broken down and used by the body for energy. Several things happen when food is digested:

· A sugar called glucose enters the bloodstream. Glucose is a source of fuel for the body.

· An organ called the pancreas makes insulin. The role of insulin is to move glucose from the bloodstream into muscle, fat, and liver cells, where it can be used as fuel.

People with diabetes have high blood sugar. This is because:

· Their pancreas does not make enough insulin

· Their muscle, fat, and liver cells do not respond to insulin normally

· Both of the above

There are many risk factors for type 2 diabetes, including:

· Age over 45 years

· A parent, brother, or sister with diabetes

· Gestational diabetes or delivering a baby weighing more than 9 pounds

· Heart disease

· High blood cholesterol level

· Obesity

· Not getting enough exercise

· Polycystic ovary disease (in women)

· Previous impaired glucose tolerance

· Some ethnic groups (particularly African Americans, Native Americans, Asians, Pacific Islanders, and Hispanic Americans)

　

Pathophysiology :-

The pathophysiology of diabetes mellitus (all types) is related to the hormone insulin, which is secreted by the beta cells of the pancreas. This hormone is responsible for maintaining glucose level in the blood. It allows the body cells to use glucose as a main energy source. However, in a diabetic person, due to abnormal insulin metabolism, the body cells and tissues do not make use of glucose from the blood, resulting in an elevated level of blood glucose or hyperglycemia. Over a period of time, high glucose level in the bloodstream can lead to severe complications, such as eye disorders, cardiovascular diseases, kidney damage and nerve problems.

In Type 1 diabetes, the pancreas cannot synthesize enough amount of insulin hormone as required by the body. The pathophysiology of Type 1 diabetes mellitus suggests that it is an autoimmune disease, in which the body's own immune system generates secretion of substances that attack the beta cells of the pancreas. Consequently, the pancreas secretes little or no insulin. Type 1 diabetes is more common among children and young adults (around 20 years). Since it is common among young individuals and insulin hormone is used for treatment.

 

In case of Type 2 diabetes mellitus, there is normal production of insulin hormone but the body cells are resistant to insulin. Since the body cells and tissues are non responsive to insulin, glucose remains in the bloodstream. It is commonly manifested by middle-aged adults (above 40 years). As insulin is not necessary for treatment of Type 2 diabetes, it is known as Non-insulin Dependent Diabetes Mellitus (NIIDM) or Adult Onset Diabetes.

Gestational diabetes, on the other hand, occurs among pregnant women. It is caused due to fluctuations of the hormonal level during pregnancy. Usually, the blood glucose level returns to normal after the baby is born.

Early and correct detection of the type of diabetes is necessary to prevent severe health effects. After diagnosis, a physician may prescribe appropriate

 

medication for treatment of diabetes, which could include insulin injections or oral insulin medicines, depending upon the type of diabetes mellitus. In addition, healthy lifestyle modifications, especially diet and exercise are recommended for the effective management of symptoms and long-term effects. Since diabetes is a global health issue, studies regarding the pathophysiology of diabetes mellitus are currently in progress in order to minimize its associated health effects.

　

Symptoms :-

High blood levels of glucose can cause several problems, including:

· Blurry vision

· Excessive thirst

· Fatigue

· Frequent urination

· Hunger

· Weight loss

However, because type 2 diabetes develops slowly, some people with high blood sugar experience no symptoms at all.

Symptoms of type 1 diabetes:

· Fatigue

· Increased thirst

· Increased urination

· Nausea

· Vomiting

· Weight loss in spite of increased appetite

Patients with type 1 diabetes usually develop symptoms over a short period of time. The condition is often diagnosed in an emergency setting.

Symptoms of type 2 diabetes:

· Blurred vision

· Fatigue

· Increased appetite

· Increased thirst

· Increased urination

Treatment :-

The immediate goals are to treat diabetic ketoacidosis and high blood glucose levels. Because type 1 diabetes can start suddenly and have severe symptoms, people who are newly diagnosed may need to go to the hospital.

The long-term goals of treatment are to:

· Prolong life

· Reduce symptoms

· Prevent diabetes-related complications such as blindness, heart disease, kidney failure, and amputation of limbs

These goals are accomplished through:

· Blood pressure and cholesterol control

· Careful self testing of blood glucose levels

· Education

· Exercise

· Foot care

· Meal planning and weight control

· Medication or insulin use

There is no cure for diabetes. Treatment involves medicines, diet, and exercise to control blood sugar and prevent symptoms.

 

LEARN THESE SKILLS :-

Basic diabetes management skills will help prevent the need for emergency care. These skills include:

· How to recognize and treat low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia)

· What to eat and when

· How to take insulin or oral medication

· How to test and record blood glucose

· How to test urine for ketones (type 1 diabetes only)

· How to adjust insulin or food intake when changing exercise and eating habits

· How to handle sick days

· Where to buy diabetes supplies and how to store them

After you learn the basics of diabetes care, learn how the disease can cause long-term health problems and the best ways to prevent these problems. Review and update your knowledge, because new research and improved ways to treat diabetes are constantly being developed.

 

SELF-TESTING :-

If you have diabetes, your doctor may tell you to regularly check your blood sugar levels at home. There are a number of devices available, and they use only a drop of blood. Self-monitoring tells you how well diet, medication, and

　

exercise are working together to control your diabetes. It can help your doctor prevent complications.

The American Diabetes Association recommends keeping blood sugar levels in the range of:

· 80 - 120 mg/dL before meals

· 100 - 140 mg/dL at bedtime

Your doctor may adjust this depending on your circumstances.

 

WHAT TO EAT :-

You should work closely with your health care provider to learn how much fat, protein, and carbohydrates you need in your diet. A registered dietician can help you plan your dietary needs.

People with type 1 diabetes should eat at about the same times each day and try to be consistent with the types of food they choose. This helps to prevent blood sugar from becoming extremely high or low.

People with type 2 diabetes should follow a well-balanced and low-fat diet.

　

HOW TO TAKE MEDICATION :-

Medications to treat diabetes include insulin and glucose-lowering pills called oral hypoglycemic drugs.

People with type 1 diabetes cannot make their own insulin. They need daily insulin injections. Insulin does not come in pill form. Injections are generally needed one to four times per day. Some people use an insulin pump. It is worn at all times and delivers a steady flow of insulin throughout the day. Other people may use inhaled insulin.

Unlike type 1 diabetes, type 2 diabetes may respond to treatment with exercise, diet, and medicines taken by mouth. There are several types of medicines used to lower blood glucose in type 2 diabetes.

Medications may be switched to insulin during pregnancy and while breastfeeding.

Gestational diabetes may be treated with exercise and changes in diet.

　

EXERCISE :-

Regular exercise is especially important for people with diabetes. It helps with blood sugar control, weight loss, and high blood pressure. People with diabetes who exercise are less likely to experience a heart attack or stroke than those who do not exercise regularly.

Here are some exercise considerations:

· Always check with your doctor before starting a new exercise program.

· Ask your doctor or nurse if you have the right footwear.

· Choose an enjoyable physical activity that is appropriate for your current fitness level.

· Exercise every day, and at the same time of day, if possible.

· Monitor blood glucose levels before and after exercise.

· Carry food that contains a fast-acting carbohydrate in case you become hypoglycemic during or after exercise.

· Carry a diabetes identification card and a cell phone in case of emergency.

· Drink extra fluids that do not contain sugar before, during, and after exercise.

You may need to change your diet or medication dose if you change your exercise intensity or duration to keep blood sugar levels from going too high or low.

　

FOOT CARE :-

People with diabetes are more likely to have foot problems. Diabetes can damage blood vessels and nerves and decrease the body's ability to fight infection. You may not notice a foot injury until an infection develops. Death of skin and other tissue can occur.

If left untreated, the affected foot may need to be amputated. Diabetes is the most common condition leading to amputations.

To prevent injury to the feet, check and care for your feet every day.

Drugs used in the treatment of Diabetes :-

Treatment of Type 1 Diabetes :

Injectable insulin is used for the treatment of Type 1 Diabetes mellitus. Injectable insulin is available in following forms.

Ultra Short Acting/ Rapidly acting Analogs

· Lispro

· Aspart

· Glulisine

Short Acting ;

· Human Regular Insulin

Intermediate acting

· NPH ( Neutral Protamine Hagedorn )

Long acting Analogs

· Glargine

· Detemir

　

Treatment of Type 2 Diabetes :-

· Metformin

· Sulphonylureas

Ø Glibenclamide

Ø Gliclazide

Ø Glimepiride

· Acarbose

· Repaglinid

· Thiazolidinedione ( TZD )

Ø Pioglitazone

　

And finally Type 2 diabetes is treated with Inject able Insulin.

 

Generic Name	Dose	Frequency	Brand	Manufecturer
Lispro	100 IU/ml; 10 ml Vial	administer within 15 minutes before a meal or 20 minutes after starting a meal.	Humalog	Eli Lilly
Aspart	100 IU/ml; 10 ml Vial	Immediately following ingestion of carbohydrates and given by subcutaneous route.	NovoLog
Glulisine	100 IU/ml; 10 ml Vial	administer within 15 minutes before a meal or 20 minutes after starting a meal.	Apidra
Human Regular Insulin	100 IU/ml; 10 ml Vial	According to the requirement of patient.	Humulin-R	Eli Lilly
NPH	100 IU/ml; 10 ml Vial	According to the requirement of patient.	Humulin-N	Eli Lilly
Glargine	100 IU/ml; 10 ml Vial	Subcutaneous injections once daily at the same time everyday.	Lantus	Aventis
Detemir	100 IU/ml; 10 ml Vial	Subcutaneous injections once daily at the same time everyday.	Levemir
Metformin HCl	250mg, 500mg, 850mg, 1 g	Initially 500mg twice daily or 850mg daily with meals usually 3*500mg daily in divided doses. Maximum dose is 3 grams daily.	Glucophage	Merck Marker
Glibenclamide	5mg	Treatment should started with ½ tablet (2.5mg), if necessary increase the dose until blood sugar control is obtained. Maximum daily dose is 3 tablets. Maximum single dose is 2 tablets.	Gliben	Popular
Gliclazide	80mg	½ - 1 tablet daily, increase if necessary to maximum of 4 tablets daily.	Diabetron	Ferozsons
Glimepiride	1mg, 2mg, 3mg, 4mg	Initial dose is 1mg daily, usual maintenance dose is 1mg to 4mg daily.	Glucoride	Star Labs
Acarbose	50mg, 100mg	Initially 50mg three times daily before meals. Maximum 200mg three times daily.	Glucobay	Bater
Repaglinide	1mg, 2mg	Initiall 0.5mg, 15-30 minutes before each meal. Maimum 4mg as single dose before each meal.	Repaglin	Raazee Therapeutics
Pioglitazone	15mg, 30mg, 45mg	15-30mg once daily and increasing to 45mg once daily if necessary. And can be used in combination with Metformin or Sulfonyl Urea.	Piozer	Hilton

 

BY

Fahed Ali

Dp-307-221

Doctor Of Pharmacy

University Of Lahore