Introduction,types, clinical features and standard treatment guidlines of diabetes mellitus

2. STANDARD TREATMENT GUIDELINES
OF
DIABETES MELLITUS(DM)
Submitted by,
Aakash prasanth
Ardra Krishna P.V
Dinesh .G
Kalaiselvan
Shivaprakash
Kavitha.G
Lavanya

4. DIABETES MELLITUS(DM)
■ Diabetes mellitus is commonly referred to as diabetes, is a group of metabolic disorders in
which there are high blood sugar level over a prolonged period.
■ Symptoms of high blood sugar include frequent urination , increased thirst , and increased
hunger . If left untreated, diabetes can cause many complications . Acute complications
can include DIABETIC KETOACIDOSIS , HYPEROSMOLAR HYPERGLYCEMIC STATE , OR
DEATH.
■ Serious long term complications include cardiovascular disease, stroke, chronic kidney
disease , foot ulcers, and damage to the eyes.
■ Diabetes is due to either the pancrease not producing enough insulin or the cells of the
body not responding properly to the insulin produced .There are three main types of
diabetes mellitus.
– TYPE 1 DM
– TYPE 2 DM
– GESTATIONAL DIABETES
■ Most of the cases OF DM in children are of insulin dependent diabetes mellitus (type 1) and
have hyperglycemia with glucosuria.

7. https://youtu.be/lLGpRQNAku4?list=PLF_-tIFq2lApk8O5YTIS9-YcJBrgdFH20

9. https://youtu.be/jxbbBmbvu7I type 1 DM
https://youtu.be/OXAe3eOjqCk type 2 DM
TYPE 1 AND TYPE 2 DIABETES MELLITUS

10. INSULIN

11. INSULIN
■ Insulin is used in the treatment of patients with diabetes of all types.The need for insulin
depends upon the balance between insulin secretion and insulin resistance.
WHICH PATIENTS NEED INSULIN
■ ●Type 1 diabetes – Insulin must be given to all patients with type 1 diabetes, which is
usually due to autoimmune islet-cell injury that eventually leads to virtually complete
insulin deficiency. Ideally, physiologic replacement of insulin, emulating the secretory
pattern of the nondiabetic pancreas, but keeping in mind the limitations associated with
subcutaneous administration, is desirable.
■ ●Type 2 diabetes –This disorder is characterized by both insulin resistance and relative
insulin deficiency.Therapy should begin with diet, weight reduction, and exercise, which
can frequently induce normoglycemia ,if compliance is optimal. Metformin, based on its
safety profile, neutral effect with regard to weight gain, and ability to lower glycemia, is
recommended early in the course of type 2 diabetes. Patients with persistent
hyperglycemia are often started on a second oral hypoglycemic drug or an injectable
agent, potentially including "basal" insulin, which is meant to supplement endogenous
insulin.
■ All patients with type 1 diabetes need insulin treatment permanently, unless they receive
an islet or whole organ pancreas transplant; many patients with type 2 diabetes will require
insulin as their beta-cell function declines over time.

12. INSULIN (NORMAL VALUE)
CPG <200 mg/dL
FPG <100 mg/dL
OGTT <140 mg/dL
HbA1c <5.7 %

13. CLINICAL FEATURES

14. CLINICAL FEATURES
■ While some cases present with classical symptoms of polyphagia, polydipsia, polyuria
and weight loss many children at the onset present in the state of diabetic
ketoacidosis (DKA).
■ A minority of Cases , while asymptomatic are detected to have glucosuria and
hyperglycemia .
■ Diagnosis of DM is made by demonstrated of hyperglycemia (random plasma glucose
more than 200 mg/dL ) .
Impaired glucose tolerance (IGT) Diabetes mellitus (DM)
Fasting glucose 110 -125 mg/dL
2 h plasma glucose during the OGTT < 200
mg/dL but ≤ 140 mg/dL
Symptoms of DM plus random plasma
glucose ≥ 200 mg/dL
Or
Fasting plasma glucose ≥ 126 mg /dL
Or
2 h plasma glucose during the
OGTT ≥200 mg /dL

15. TREATMENT

16. The major components of the treatment of
diabetes are:
■ 1. diet (combined with exercise if possible)
■ 2. oral hypoglycaemic therapy
■ 3. insulin treatment

17. TREATMENT
NON PHARMACOLOGICAL
Diet .Regulatory of eating pattern is very important so that diet and insulin dosing is synchronized.
 General nutritional guidelines are followed.
 Caloric mixture should have 55% carbohydrates, 30% fat and 15% proteins.
 Avoid carbohydrate with refi need sugars to prevent metabolic swings. Carbohydrated drinks
should be of sugar free variety.
 Fats derived from animals sources to be reduced and should be replaced by fats of vegetable origin
.
 Caloric intake should be split as 20% breakfast 20% lunch 30% dinner and 10% each for 3 snacks at
mid morning , mid afternoon and evening .
PHYSICAL ACTIVITY AND FITNESS ; usual exercise advised to diabetic children and adolescents include
vigorous walking ,jogging, swimming, tennis etc. though diabetics can undertake any exercise , but
unusual exercise may require modification in insulin dosing . For the schedule day of unusual exercise ,
insulin dose may be reduced by 10 -15%.
https://youtu.be/28oRB1LWWEw?list=PLF_-tIFq2lApk8O5YTIS9-YcJBrgdFH20 how to test blood
glucose

18. PHARMACOLOGICAL
Initial therapy: treatment is initiated in the hospital with fast acting(regular) insulin.
At the onset of DM 9or after recovery from DKA ),the dose of insulin is 0.5-1.0 unit /kg/day.
Inj. Regular insulin 0.1-0.25 unit /kg subcutaneous injections are given 6-8 hourly before meals.
Simultaneous blood glucose level monitoring is done.one to two days therapy is required to find total
daily insulin requirement .once the patient stabilizes on 6 hourly insulin injections, the patient is switched
over to “2 daily injections” schedule.
In “2 daily injection” schedule the insulin is administered as follows :
– Combinations of intermediate acting (usually lente) insulin and fast acting (regular) insulin in the
ratio 2-3: 1 .Two -third of the total daily dose is injected before breakfast and one third before dinner.
Each injection has combination of both types of insulin . Eg ; total dose of insulin is 30 unit – 20 units
(14 units lente and 6 units regular ) are injected before breakfast and 10 units (6 units lente and 4
units regular) are injected before dinner.
– Blood glucose levels are monitored before each metal and the dose of insulin adjusted accordingly .
Blood glucose levels should ideally be 80 mg/dL fasting and 140 mg/dL after meals (acceptable
range between 80-240 mg/dL). Early morning 3 AM blood glucose level should be more than 70
mg/dL.
https://youtu.be/QKbczu4TR_Q?list=PLF_-tIFq2lApk8O5YTIS9-YcJBrgdFH20 -treatment of type 1

19. ■ Insulin therapy is usually initiated at a dose of 0.4 to 1.0 units/kg/day in the treatment
of type 1 diabetes.
■ Research regarding the efficacy of metformin in type 1 diabetes is mixed, but it does
not appear to improve glycemic control and can lead to more gastrointestinal adverse
effects.
■ Metformin remains the foundational drug for the treatment of type 2 diabetes. It may
be used among patients with an estimated glomerular filtration rate down to 30
mL/minute/1.73 m2, provided that these patients have regular follow-up.
■ Metformin can promote vitamin B12deficiency, and clinicians should consider checking
vitamin B12 levels among patients receiving metformin, particularly in patients with
anemia or peripheral neuropathy.
■ All patients should receive lifestyle management to control their diabetes. If the
HbA1c level is less than 9%, treatment may include lifestyle management plus
metformin alone.
■ If the HbA1c level is between 9% and 10%, clinicians should consider metformin plus
another agent:
– If the patient has known ASCVD, clinicians should prefer drugs such as
canagliflozin, empagliflozin, or liraglutide, which have proven cardiovascular
benefits in treating diabetes.
– If there is no history of ASCVD, clinicians may choose the second agent based
on drug-specific effects and patient factors such as the risk for adverse effects
and cost of treatment. Possible choices include sulfonylureas, a

20. ■ Most patients with type 2 diabetes can initiate insulin therapy with basal insulin
at a dose of 10 units/day, or 0.1 to 0.2 units/kg/day.
■ GLP-1 RAs generally should be continued after addition of basal insulin.
However, sulfonylureas, GLP-1 RAs, and DPP-4 inhibitors are usually stopped
after the insulin regimen grows more complex with basal-bolus dosing.
■ If the HbA1c level is not controlled effectively with basal insulin alone, clinicians
can add a dose of rapid-acting insulin before the biggest meal of the day. The
usual start dose is 4 units, or 0.1 unit/kg, or 10% of the current basal dose.
■ Other options for these patients include a GLP-1 RA and premixed insulin.
Premixed insulin 3 times daily has been found to be noninferior to basal-bolus
regimens for glycemic control, with similar rates of hypoglycemia.

21. CLINICAL IMPLICATIONS
■ In its 2018 guidelines for standards of medical care for diabetes, the ADA
recommends a target HbA1c level of less than 7% for most adults with diabetes, but a
goal of less than 6.5% is reasonable for healthy, younger adults. Conversely, more
frail adults with a history of severe complications of diabetes and high risk for
hypoglycemia may be treated more effectively to a target HbA1c level of less than
8%.
■ If lifestyle and metformin are insufficient to reduce the HbA1c level to less than 9%
among patients with known ASCVD, the ADA recommends that clinicians consider
treatment with canagliflozin, empagliflozin, or liraglutide. These drugs have been
demonstrated to improve cardiovascular outcomes among patients with type 2
diabetes.
■ Implications for the Healthcare Team: There are many options in the pharmacologic
management of diabetes. The healthcare team should practice active surveillance of
these patients and advance or withdraw therapy based on drug efficacy and safety.

22. Monitoring glycaemic control
■ Glycaemic control should always be monitored.The absence of symptoms alone
■ should not be taken as an indicator of good control.
• Self-monitoring should be encouraged.
• Methods and frequency of monitoring depend on the type of treatment, the local
■ facilities available, and therapy targets set.
• Methods include:
— urine glucose testing;
— blood glucose measurements;
— others tests like glycated haemoglobin (HbA1c) or fructosamine measurement;
— urine ketones should also be tested during intercurrent illnesses and periods of
poor control.

23. MODIFICATION INTHE INSULIN DOSES
Modification in the insulin doses will be required depending upon the blood glucose levels .
■ Any increase or decrease in insulin dose is by 10-15%. Generally not more than 6 units.
■ After initial stabilization, newly diagnosed cases may have gradual decline in insulin
requirement even up to 0.5 units/kg/day.This may persist for several weeks to several
months.
■ Decrease total dose of insulin by 10% at the time of discharge from hospital as the
increased activity at home will decrease the insulin requirement.

24. Assessment of diabetic control or response to therapy
Blood glucose estimation should be done before each meal and at bedtime in the first few weeks after
diagnosis.After stabilization, it can be reduced to twice a week.
Periodically blood glucose estimation at 3-4 AM is required to detect early morning hypoglycaemia.
Urine for sugar is also monitored initially 3-4 times daily before meals.This can be done less frequently
after initial few weeks, preferably on the days when blood sugar is not done.
Urine for ketones once daily should be done.
Glycosylated haemoglobin (HbA1C) estimation-once every 3 months. - HbA1C goals are: 0-6 years <8.5%
(but > 7.5%); 6-12 years < 8%; 13-19 years < 7.5%.
Serum lipids-cholesterol, HDL, LDL,VLDL, triglycerides and urine for protein should be done once every
year. Serum cholesterol should be less than 200 mg/dl, LDL less than 130 mg/dl and triglycerides less than
140 mg/dl.
Thyroid function tests should be done once every year to detect concomitant hypothyroidism.

25. ■ Wikipedia
■ Diabetes Mellitus, WHOTechnical Report Series, 727, 1985.
■ 2. Diabetes Management and Control. A Call for Action, WHO-EM/DIA/3/E/G. 1993.
■ 1. Diabetes Mellitus. In: Nelson’s Textbook of Paediatrics. Behrman RE, Kliegman RM, Jenson HB
■ (eds), 19th Edition, WB Saunders Co, 2011; pp 1968-1977.
■ 2. International Guidelines for Paediatric and Adolescent Diabetes (ISPAD) Consensus Guidelines,
■ 2000.
■ 3. Standards of Medical Care in Diabetes 2006. American Diabetes Association: Clinical Practice
■ Recommendations. Diabetes Care 2006; 29: Suppl 1:54-42
■ INTERNET: https://www.uptodate.com/contents/general-principles-of-insulin-therapy-in-diabetes-
mellitus
■ VIDEO COURTESY :YOUTUBE
REFERENCE