DIABETES

Prepared by
DR/ MOHAMMAD ABDUL BASET BADR
DIABETES MELLITUS
• The number of people with diabetes rose from 108 million in
1980 to 422 million in 2014.

• According to international federation of diabetes In 2019,

Approximately 463 million adults (20-79 years) were living
with diabetes; by 2045 this will rise to 700 million.

• Diabetes is a major cause of blindness, kidney failure, heart

attacks, stroke and lower limb amputation.

• WHO estimates that diabetes was the ninth leading cause of

death in 2019.
• The World Health Organization (WHO) has reported that Saudi
Arabia ranks the 2nd highest in the Middle East, and is 7th in
the world for the rate of diabetes.

• It is estimated that around 7 million of the population

are diabetic and almost around 3 million have pre-diabetes.
• INSULIN is the only hormone that decrease glucose level , while
many hormones increase glucose level as Epinephrine,
Glucagon , Glucocorticoid , Gh …

•WHY ?
Symptoms of diabetes :
• 1- Polydipsia : excessive thirst or excess drinking.
• 2- polyuria : excessive urination.
• 3- Polyphagia : excessive or extreme hunger.
• 4- Unexplained weight loss.
• 5- Slow healing of wounds.
• 6- Tingling, pain, or numbness in the hands/feet .
• 7- Fatiuge.
• 9- men with diabetes may have a decreased sex drive , erectile
dysfunction (ED), and poor muscle strength.
• 10- Women with diabetes can also have symptoms such
as urinary tract infections , yeast infections , and dry, itchy skin.
Symptoms of diabetes :
Types of diabetes :
Diabetes risk factors
GESTATIONAL DIABETES RISK FACTORS
DIABETES LAB TESTS
Goals of treatment

Non glycemic
Glycemic goals
goals
 TREATMENT OF DIABETES
• A- LIFE STYLE MODIFICATION:
Exercise
DIABETES LIFE STYLE TREE
B-Oral DRUGS USED IN TYPE II DM
• I- METFORMIN :(INSULIN RECEPTOR SENSITIZER )

GLUCOPHAGE GLUCARE METFOR FORMIT OMFORMIN

• Maximum daily dose 2000-2550 mg.
• Start with 500 mg then increase dose gradually every 2weeks. Why ?
• Side effects:
• 1- GIT problems . so should take with food.
• 2- lactic acidosis . is very rare but it is serious condition .
• The drug is contraindicated in patients at risk of acidosis (including with renal
insufficiency , hypoxia or severe respiratory disease , alcohol use disorder ,
other forms of metabolic acidosis , or dehydration).
• 3- Decrease vit B12 absorption, so patient should take vit b12 supplement.
( CROSS SELLING )
Contraindications of Metformin :
2- PIOGLITAZONE :(INSULIN RECEPTOR SENSITIZER )

• Rosiglitazone as AVANDIA. ( stopped now ).due to it cause edema not

respond to diuretics lead to heart failure.
• PIOGLITAZONE maximum dose is 45mg/day.
• Decrease LDL & increase HDL
3- SULFONYLUREAS ( SECRETAGOGUE )
BRANDS MAXIMUM DAILY DOSE

GLICLAZIDE 320 MG
( Diamicron – Claz )

GLIMIPRIDE 6-8 MG
( Amaryl – Glim )

GLIBINCLAMMIDE 15 MG
( Daonil – Glibil )
4- MEGLETINIDES (SECRETAGOGUE) :
• REPAGLINIDE as NOVONORM .
• Has rapid onset of action so should take with food .
• Short duration so used for post prandial hyperglycemia only.

• Contraindications :
• 1- with sulphonylurea lead to severe hypoglycemia.
• 2- with gemfibrozil lead to increase repaglinide level lead to
hypoglycemic coma.
5- DPPI ( DI PEPTIDYL PEPTIDASE INHIBITORS ) :
brands picture Maximum daily dose

100 mg
SITAGLIPTIN JANUVIA
50 mg
VILDAGLIPTIN GALVUS
5 mg
LINAGLIPTIN TRAJENTA
5 mg
SAXAGLIPTIN ONGLYZA
25 mg
ALOGLIPTIN VIPIDIA
Sitagliptin + Digoxin
Sitagliptin increases levels of digoxin by unspecified interaction
• 6- SGLT2 INHIBITORS : (SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITORS ):
• 7- ALPHA GLUCOSIDASE INHIBITOR :
• ACARBOSE as GLUCOBAY
•
• 8- INCRETINE ANALOUGES : ( GLP-1 )

LIRAGLUTIDE SEMAGLUTIDE DULAGLUTIDE

Once daily Once weekly Once weekly
• 50% patients used this class , their body form antibodies to this drugs so doctor
May be forced to change to another drug from the same group .
• Used for :
• 1- Obese patients (BMI ≥30).

• 2-Overweight patients (BMI ≥27) who also have weight-related medical

problems (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia).

• 3- children aged 12-17 years with a body weight above 60 kg .

• Saxenda® should be used with a reduced calorie diet and increased

physical activity.
• Before use Saxenda®, make sure that :
• 1- Not taking other medicines from GLP-1 receptor agonists.
• 2- Not have severe problems with stomach, such as slowed emptying of
stomach (gastroparesis) or problems with digesting food.
• 3- Not have or have had problems with pancreas, kidneys or liver.
• 4- Not have or have had depression or suicidal thoughts, or mental health
issues.
• 5- Not use other weight loss product .
• 6- Not have or had history of thyroid cancer .
• Side effects :
• 1- GIT problems ( nausea, diarrhea, constipation, vomiting)

• 2- Inflammation of the pancreas (pancreatitis) .

• 3- Gallbladder problems. including gallstones.

• 4- Depression or thoughts of suicide.

• 5- Thyroid cancer :get a swelling in the neck, hoarseness, trouble swallowing, or

shortness of breath.
• Saxenda is classified as FDA pregnancy risk category X.

• Weight loss normally starts within 2 weeks and continues for 9 to 12 months .
Patient should only continue using Saxenda® if he lost at least 5% of his initial
body weight after 12 weeks on the 3.0 mg/day dose.

• If you forget a dose and remember it within 12 hours from when you usually take
the dose, inject Saxenda® as soon as you remember.
• If more than 12 hours have passed since you should have used Saxenda® , skip
the missed dose and inject your next dose the following day at the usual time.

• If more than 3 days have elapsed since the last dose, reinitiate saxenda at the
dose 0.6 mg daily .
INSULIN
• INSULIN DOSE : ( TOTAL DAILY INSULIN )

• Normal diabetic patient 0.3-0.5 unit/kg/day .

• Type II insulin resistance 0.7-1.5 unit/kg/dose .

Exercise
• Hamad is 45 years old and weigh 84 kg , if he take insulatard
and Humulin R , what are the doses and how can he take
them ?

• If mr Hamad take lantus and novorapid , what are the doses

and how can he take them ?
• Insulin Administration advices : ( patient counselling )
• 1- Wash hands with water and soap.

• 2- Use alchol swab ( cross selling ) to sterile the injection site and
leave it to dry.

• 3- Stand the needle upright at a 90° angle on the skin for adult, and
fold the skin to decrease the pain.

• 4- Thin individuals or children can use short needles or may need to

pinch the skin and inject at a 45° angle to avoid intramuscular
injection, especially in the thigh area.
• 5- leave the needle for 5-10 second in the body to prevent leakage
part of the dose to outside.

• 6- Use a new needle for every injection.

• 7- For all insulin preparations, except rapid- and short-acting insulin

and insulin glargine, the vial or pen should be gently rolled in the
palms of the hands (or shaken gently) to resuspend the insulin.

• 8- For a pen: Attach the needle to the end. Push out a unit or two
(an “air shot”) to make sure the pen is working. Dial up your dose.
• 9- Rotation of the injection site is important to prevent
lipohypertrophy .

• 10- The abdomen has the fastest rate of absorption, followed by the
arms, thighs, and buttocks.

• 11- Exercise increases the rate of absorption from injection sites,

probably by increasing blood flow to the skin .

• 12- Don’t wait more than 15 minutes to eat after taking a mealtime
insulin.
COMPLICATIONS OF DM
• Types of diabetic complications :
• A) Acute complications:
• 1- HYPOGLYCEMIA 2- DKA ( diabetic ketoacidosis )

• B) Chronic complications :
• I - Microvascular :
• 1- RETINOPATHY 2- NEUROPATHY 3- NEPHROPATHY
• II – Macrovascular :
• 1- Coronary artery disease ( CAD )
• 2- Cerebrovascular disease ( STROKE )
• 3- Peripheral vascular disease ( DVT )
Exercise
• A) HYPOGLYCEMIA
• DIABETIC RETINOPATHY :
• At first, diabetic retinopathy may cause no symptoms or only mild vision
problems.
• The longer the patient have diabetes and uncontrolled blood sugar is, the more
likely to develop this eye complication.
• Uncontrolled diabetes can lead to :
• 1- optic nerve damage .
• 2- cataract .
• 3- glaucoma .
• 4- retinal damage and blindness.
• Diabetic patient should refer to ophthalmologist one visit every 2 years if blood
glucose and blood pressure are controlled, and one visit every 6 months if
uncontrolled.

• Omega 3 and eye health: ( cross selling )

• DHA is naturally concentrated in the retina of the eye and is thought to promote
healthy retinal function.
• Studies show that Omega-3 can help reduce dry eye syndrome, a chronic eye
disease caused by a decrease in tear production or increase in tear evaporation.
• Diabetic neuropathy :
• is a serious complication that may affect as many as 50% of people with diabetes.
• patient can prevent diabetic neuropathy or slow its progress with consistent blood sugar
management and a healthy lifestyle.
• Symptoms
• According to affected neuron
• I- autonomic neurons :
• 1- Stomach : Decrease gastric motility lead to nausea and vomiting and loss of appetite (
gastroparesis ) .
• 2- Intestines : Lead to constipation or diarrhea .
• 3- Urinary bladder : lead to urinary problems and infections .
• 4- Sex organ neurons : lead to sexuall dysfunction .
• B- sensory neurons : lead to
• Numbness or reduced ability to feel pain or temperature changes .
• Tingling or burning sensation .
• Serious foot problems, such as ulcers and infections.
• Treatment:
• Anti-seizure medications. such as gabapentin and pregabalin may relieve nerve
pain.
• Topical treatments. Capsaicin cream, can cause improvements in peripheral
neuropathy symptoms.
• Antidepressants. Certain TCAs, such as amitriptyline and nortriptyline .
• Duloxetine and Venlafaxine also ease the pain of neuropathy caused by diabetes.
• Omega 3 – vit B12 – alpha lipoic acid - acetyl-L-carnitine ( cross selling )
• Diabetic foot :
• People with diabetes are prone to foot problems that develop due to prolonged
periods of high blood sugar levels.
• Diabetic neuropathy and peripheral vascular disease are the two main foot
problems that occur, and both can have serious complications.
• Diabetes is responsible for over 50 percent of all foot amputations in the United
States.
• Diabetic foot care :
• 1- Control blood sugar

• 2- Check the feet each day

• 3- Wash the feet daily : Keep the feet clean to prevent infections.

• 4- Dry skin : can crack, which can allow germs to enter. Use moisturizing soaps
and lotions ( cross selling ) to keep skin moist and soft.
• 5- Receive regular examinations on the feet: by a doctor

• 6- Trim nails carefully : Trim toenails straight across and keep them short .

• 7- Care for corns : Treat corns and bunions carefully. Never shave corns, as this
increases the risk of infection.

• 8- Wear supportive shoes and socks

• 9- Promote blood flow to the feet

• Diabetic nephropathy :
• high blood glucose levels can damage the part of the kidneys that filters blood by
cause scarring of the glomerulus (called glomerulosclerosis).

• As the scarring gets worse, the kidneys stop being able to filter waste products
from the blood. The damaged filter becomes ‘leaky’ and lets protein into urine.

• diabetic nephropathy can progress to chronic kidney disease and kidney failure .
• People who have diabetic nephropathy also often have high blood pressure. High
blood pressure can further contribute to kidney damage.

• People with microalbuminuria or proteinuria are treated with medicines (ACE

inhibitors) or (ARBs).

• they decrease the amount of protein in the urine and can prevent or slow the
progression of diabetic kidney disease
• Dyslipidemia :
• Long-term diabetes is associated with an increased prevalence of atherosclerosis.

• The increased cardiovascular morbidity and mortality in diabetes has naturally

been related to the high prevalence of hyperlipidemia in the disease.
• Treatment of hyperlipidemia :
• A) life style modification :
• 1- Eat a balanced, heart-healthy diet as
• foods that decrese cholesterol level :
• Oats and barley - Nuts - Soy products - Vegetables and fruit - Legumes and beans.
• Avoid foods that increase cholesterol level :
• Fatty cuts of meat.
• Full fat dairy products (such as milk, cream, cheese and yoghurt)
• Processed foods (such as biscuits and pastries)
• Takeaway foods (such as hamburgers and pizza)
• 2- Regular physical activity
• 3- Weight loss .
• 4- Avoid smoking
• B) Statins :
• Class of drugs that lower cholesterol levels in the blood. Studies show
that, statins reduce the risk of heart attack, stroke, and even death from heart
disease by about 25%-40% .
• Statins lower LDL cholesterol and total cholesterol levels. At the same time, they
lower triglyceride and raise HDL cholesterol levels.
• Statin Drug and Food Interactions
• Grapefruit juice,increase level of statins .
• Gemfibrozil and fibrates increase the risk of side effects such as liver damage and
rhabdomyolysis .
• Amiodarone, clarithromycin and itraconazole increase level of statins .
• Serious Side Effects of Statins
• 1- Myositis, which is inflammation of the muscles.
• Treated with coenzyme Q10 supplements( cross selling ).

• 2- Rhabdomyolysis extreme muscle inflammation and damage. The severely

damaged muscles release proteins into the blood that collect in the kidneys lead
to renal damage.

• 3- increase liver enzymes level as a result of hepatitis .

• 4- Teratogenic : studies link statin use with birth defects.

•C) Omega 3
• Omega-3 fatty acids lower plasma triglyceride levels, particularly in persons with
hyper-triglyceridemia , by inhibiting the synthesis of very-low-density lipoprotein
(VLDL) cholesterol and triglycerides in the liver.

• A review of human studies concluded that approximately 4 g per day of omega-3

fatty acids reduced serum triglyceride concentrations by 25 - 30 %
• Approaches to prevention of diabetic complications include the
following:

• HbA1c every 3-6 months

• Yearly dilated eye examinations
• Annual microalbumin checks
• Foot examinations at each visit
• Blood pressure < 130/80 mm Hg, lower in diabetic nephropathy
• Statin therapy to reduce low-density lipoprotein cholesterol