The complications of diabetes mellitus has been the reason for the development of different drugs and insulin, aimed at slowing down the progression. Complications of diabetes mellitus will be discussed in the next post.
Non-pharmacological treatment is fundamental in the treatment of diabetes mellitus. Under it are diet and physical activity. In type 1, diet has to be combined with insulin therapy. But in type 2 diets is the first line therapy. For type 1 diabetes it is very important to take into consideration the amount of carbohydrate in diet and it must be combined with physical activity and most importantly insulin. It should be maintained that there is no shift in any of the above mentioned.
Calories should be measured with 50% of carbohydrates, 30% of fat and 15% of protein.
In type 2 diabetes mellitus there is chance of postponing the time for the progression of insulin dependency. Weight control and diet plays an important role. It is necessary that we stick to unrefined carbohydrates which take much longer time to digest. Make sure that we do not take in much saturated fat. Breads, cereals, pasta, brown rice could help us. In diabetes mellitus, there is already increased risk of developing cardiovascular disease, so saturated fat which increases bad cholesterol (Low density cholesterol) must be decreased.
Get help from your dietician. Ask them what to eat and what not to. Give some time to read the labels in the food product.
If diet measure fails we go for an oral hypoglycaemic agent.
Here we will discuss about the pros and cons of oral agents.
Your dietary style fails to help you and you are prescribed with an oral hypoglycaemic agent, it not that the drug is going to help you. You still need the help of diet and physical activity.
Sulphonylureas
Drugs: Tolbutamide, Glibenclamide(used in pregnancy & does not cross placenta), Gliclazide,chlorpropamide, Glimiperide(short action so used in elderly).
Action: Promotes insulin secretion in response to glucose. They do not help in type 1 as there is not beta cell to produce insulin.
Side effects: Weight gain, hypoglycaemia, rarely skin rashes occurs, interaction with warfarin.
Biguanides
Drugs: Metformin
Action: Reduces hepaticgluconeogenesis (glucose production from liver) and increase sensitivity of insulin.
Most appreciable thing about biguanides is that it does not cause weight gain.
It can be given in combination with sulphonylreas
Side effects
Anorexia(decreased sensation of appetite), epigastric discomfort and diarrhoea.
Alpha glucosidase inhibitors: For overweight patient
Drug Acarbose
Action: It inhibit the enzymes that break down the carbohydrate in the intestine
Side effects: Abdominal discomfort, flatulence and diarrhoea can result.
Thiazolidinediones
Drugs Troglitazone(not in use), Rosiglitazone, pioglitazone
Action: It reduces insulin resistance by interaction with preoxisome proliferator activated receptor gamma, a nuclear receptor, which regulates genes involved in lipid metabolism and insulin action. It is more useful when combined with other agents rather than used alone. They also reduce hepatic glucose output, so can be used instead of metformin.
Side effects: Anaemia, weight gain, salt and water retention.
New drugs:
Repaglinide (meglitinides)
Action It acts in a similar way to sulphonylureas. It is short acting and it influences insulin secretion after meals and thus reduces hypoglycaemic attacks.
Orlistat reduces fat absorption from diet and helps in weight loss.
Insulin:
When there is total loss of function of the beta cell, we start using insulin but in type 1 diabetes mellitus we start using it from the beginning. It could be human or animal insulin but they render activity in similarity to human insulin. We have many different kinds of insulin types short acting insulin, short acting analogues (amino acid chain of insulin is change but the function is preserved), Intermediate acting , Long acting insulin and mixture insulin.
The dosage of insulin differs from person to person and the types differ as well. For example, short acting insulin (humulin, actrapid) begins to act in 30min, reaches a peak at 1-3h and lasts for 6-8h. The analogues act faster, attains peak at a faster rate and stays for a shorter time.
Intermediate acting insulin (humulin, protophane) acts in 30-60mi, reaches a peak in 4-10h and stays in blood for 16-18h.
Long acting insulin (glargine,determir) starts in 1-4h, reaches a peak at 7-24h and stays in blood for 20-30h.
Chronic complications:
Diabetes as we never have bothered to learn about is the main cause of disorders of cardiovascular system, eye, kidney, neuropathy, dermatological, gastroenterological, infectious, glaucoma and cataracts.
Do not worry, it is true that you cannot stop the progression but you can prevent it and decrease the time period you will be ill. If the patient is in strict control over his diet, insulin regime and physical activity it will take longer than normal for one to develop any of the above mentioned complications. Blood pressure and other disease must be kept under control.
Ophthalmology (Deals with Eye related problems)
It is not sure how many of us know that the risk of developing blindness is 25times more in a person with diabetes mellitus than in a patient without. It has got two stages-proliferative and non-proliferative.
Non-proliferative retinopathy appears in the first or second decade of the disease. It is usually related to the changes in the blood vessels of the retina which leads to decreased blood supply of retina.
Proliferative disease occurs when there is neovascularisation (appearance of new blood vessels in the eye). These could easily rupture. When macular oedema develops then there is 25% chance of developing eye loss in the next 3 years.
Doctors use fluorescein angiography to detect the problem in the eye. Retinal laser photocoagulation is used in the treatment of proliferative disease of the eye.
But nothing is curable. If we stick on a strict principle of glucose control, diet and activity then there is decreased risk of developing the above complications.
The main aim is to mention here that it is very essential that a person with diabetes mellitus goes for a regular eye check up as early the diagnosis, easier the treatment.
Diabetic Nephropathy (kidney disease):
It is disorder related to the kidney function of diabetic patient. Only 20-40% of patient with diabetes develop kidney disease and they have a genetic influence as well. This is how it works. During the first years when diagnosed with diabetes the glomerular filtration rate (the amount of plasma filtered out from glomerulus into the Bowman’s capsule) is increased and all the other structures of kidney undergoes hypertrophy. This period will not be prominent in type 2 DM.
In about 5-10 years time, patient will start to excrete small amount of albumin in urine – Microalbuminuria (30-300mg/d) and later on it increases to macroalbuminuria(>300mg/d)
Patient with type 2 DM will already be having micro or macroalbuminuria when diagnosed with diabetes mellitus.
When macroalbuminuria builds up there is a risk of developing hypertension and the changes occurred in kidney are irreversible. When macroalbuminuria ensues, development of kidney failure is irrefutable.
There is a risk of developing end stage kidney disease and the kidney fails to perform its normal functions.
Three main principles must be taken into account
1. Strict control of the blood glucose level
2. Blood pressure must be controlled
3. Angiotensin converting enzyme inhibitors /Angiotensin receptor blockers must be used.
Diabetic Neuropathy:
It is certain in patients who have no control of their blood glucose. Obesity, smoking, cardiovascular disease, elevated triglycerides contribute to the development of neuropathy.
The mechanism is that the increased formation of sorbitol and fructose in Schwann cells (non-neuronal cells that maintain homeostasis and forms myelin &gives support and protection for brain neurons). These sugars damage the function and structure of the cells.
Types:
Autonomic neuropathy:
This you will never feel the symptoms and is related with organ system. There will be disturbances in following system
Cardiovascular system: Tachycardia at rest and orthostatic hypotension.
Gastrointestinal tract: Gastroparesis(stomach takes longer than usual time to empty its contents into duodenum) and it results in vomiting. Diarrhoea can occur.
To control this patient must take smaller but frequent meals that are easier to digest. Dopamine agonists metoclopromide 5-10mg and domperidone 10-20mg before each meal could reduce the symptoms. Erythromycin can also help in the early gastric emptying. If diarrhoea, then loperamide can be used but if it is of infectious aetiology then antibiotic must be added.
Bladder: Loss of tone, incomplete emptying and stasis can occur.
This can be controlled by timed voiding which means to empty your bladder on a regular interval.
Impotence: Incomplete erection which may progress to complete impotence. 5-phosphodiesterase inhibitors can help in impotence but it is of decreased utility than in non-diabetic population.
Foot: There will be anhydrosis (lack of sweating) in the lower extremity which can promote development of foot ulcers.
Patient should take proper care of their foot. Patient should examine foot daily, even if a small damage consult the doctor at the earliest, check shoes for anything sharp in the shoes before wearing, do not wear shoes that does not fit. If you do not take proper care of your foot, then amputation has to be done if necessary.
Above mentioned all are due to disturbances in the autonomic nervous system.
(Human body has two division of nervous system-Autonomic controls heart rate, digestion, respiration rate, salivation, perspiration, diameter of the pupils, micturition (urination), and sexual arousal and peripheral nervous system controls sensation and movement of the limbs))
The most important thing is to have a regular check up with your doctor and keep good control of the blood glucose.
Polyneuropathy/Mononeuropathy: Patient will have different sensation of numbness, tingling sensation, sharpness or burning in the foot. This results when there is impairment in the function of peripheral nervous system. This pain sensation progresses to sensory deficit and the patient will not have any normal sensation of the affected part. Patient will have sensory loss, reflex loss and abnormal position sense.
Neuropathy also depends on the nerve root. If there is involvement of the lumbar plexus or the femoral artery then the pain will be in the thigh. Mononeuropathy is when there is involvement of one nerve or mononeurpathy multiplex when there is involvement of more than one nerve.
Treatment
1. Strict blood glucose control
2. Avoid smoking and alcohol
3. Give supplement for deficiency(Vit B12, folate)
4. As there is sensory loss, one will not feel the pain if he is injured and will neglect it and this will cause ulcers which are hard to heal in a diabetic patient.
5. Painful diabetic neuropathy can be treated by tricyclic antidepressants.
Cardiovascular complications:
There is increased risk of developing atherosclerosis in Diabetes mellitus patient because of insulin resistance. Smoking, hypertension, obesity, reduced physical activity and hyperlipidemia are contributing factors. There is increased risk of developing stroke and myocardial infarction (involvement of more than 2 vessels ). Treatment principles are same as according to the one discussed in myocardial infarction.
Dyslipidemia and hypertension must also be kept in control.
The below given is a table which shows us the index of normal glucose, blood pressure and lipid level that must be maintained in a diabetic patient.
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Source: Fauci As, Kasper DL, Braunwald E, HauserSL, Longo DL, Jameson JL, Loscalzo : Diabetes Mellitus in Harrison’s principles of Internal medicine, 17th edition
The above complications all can be prevented if glucose is kept in control with regular physical activity and not any symptoms must be neglected. Each individual must know what is happening in his system and must learn to ask all possible question related to the disease.
See you in the next post
