Panel consisted of Dr Ehsan Assad,Dr Mehboob Ashraf,Dr Arshad Javaid Sh,
Dr Saleem A Rana
| Stunning Opening Remarks.:Management starts from prevention
of Diabetes Mellitus in the general population!!!! We can prevent in two out of every six patients development of DM!!!! |
(Opening remarks were a long monologue of a person who is acutely worried,stressed and experiencing the strong and deep desire to do something)
Management of Diabetes Mellitus should start from measures to prevent it.UKDPS (UK Diabetes Prospective Study)has proved it finally that type 2 DM is a definitely preventive disease.If appropriate modifications are made to life style of those persons who are at risk of developing type 2 DM,this risk can be reduced upto 48 %.
Incidence: This disease is assuming epidemic proportions.WHO has estimated that incidence is going to be doubled in next 25 years.Most of the burden is going to be born by developing counteries like Pakistan.
Scope of the Disease: Much of the misery,morbidity and mortality can be attributed to DM.Stroke is the biggest cause of disability.DM is the commonest finding in Stroke patients.If complications of DM are considered,Cardio vascular diseases,renal failure,disability due to neuropathy,stroke,amputation,blindness and other innumerable conditions are estimated,huge ecnomical burden can be ascribed to this disease.So much agony,morbidity and even mortality can be saved if incidence and later on control of this disease is improved.
Prevention: We have to revert back to the life style of our forefathers.Whole populations have to revert back to more and more primitive life styles as far as dietary habits and physical activity levels are concerned.
The Whole Question
Revolves around
How to use
Or
How to misuse
Life
Physical Activity: It sensitizes peripheral tissues to insulin.So this can reduce peripheral resistance to insulin.It reduces the stress index.It reduces blood pressure,heart rate,arrythmias,platelet stickiness,clot retracting time and most of all catecholmines levels.All these factors are strong risk factors in morbidity and mortality causes by DM.Exercise improves lipid profile.This increased HDL and decreases LDL.
Meditation: Just like exercise it reduces all risk factors which have been mentioned above.It reduces stress in life.Stress index which is measured by heart rate,blood pressure,cathecolomine levels is significantly reduces.NAMAZ,ZIKAR and yoga are well known meditations.Meditation can be best helpful when the intensity is such that you forget yourownself.You are so deeply absorbed in this exercise that you forget all your worries,anxieties,concerns and problems.NAMAZ is a 5 times a day buffer between man and his anxieties.
A study was carried out in Mayo Hospital to compare NAMAZ and propranolol 10 mgs tid for the stress reducing action.NAMAZ was found better in reducing stress index.
Dietary Habits: Apple Obesity,or Trunkal Obesity is a product of Coca colization of our civilization.We must revert back to things like SATTOO instead of refined sugars.Oligosacchrides shall be replaced by complex carbohydrates.Fats and Oils shall be reduced to minimum.Simple foods mixed with increased physical activity spaced by NAMAZ is the answer to modern day diseases.
METFORMIN as a preventive tool
Type 2 DM has a genetic predispositions.Obesity is certainly a precipitating factor.So we can select those individuals who are overweight,have diabetic patients in the family and are leading a sedentary life.These are individuals whom we can prescribe metformin 500 mgs tid as a prophylactic ,in addition to changes in life style.Life style changes ,if successful can reduce 48 % of the risk.Metformin can further reduce 38 % of this risk.This also decreases trigylcerides levels.
Other Preventive Tools to be applied in general population and specifically in those patients who are at increased risk.
Glucobay: This can also be used like metformin.It reduces 12 % of the risk.
Glitazones: These are going to be reduces withen few weeks.Registeration has been granted.These are expensive but effective insulin sensitizers.These can also be uses as prophalactives.This has similar action on lipid profile as metformin.
Aspirin: This must be uses by all of us.This has been proved as most effective measure in protecting against cardiovascular incidents.
Ace Inhibitors: Even in the absence of hypertension these should be prescribed to diabetic patients to protect against renal complications.
Our Nation A nation of careless persons.
These measures are more important in our population where diagnosis and so treatment can be much delayed.Under the best circumstances ,as in the west,complications may be present even at the time of diagnosis.We can prevent in 2 out of every 6 patients developing DM.Just calculate how big this accomplishment can be !!!!!
Treatment of Type 2 Dm.
Targets.
q Blood Pressure Levels.It should be much lower than in nondiabetic patients.? How much.
q Lipid Profile.Dyslipidaemia is to be managed with diet,exercise and with medicines.Statins can be used.Aspirin can be used against the expected effects.HDL should go up and LDL and triglycerides should be lowered.
q Diet:Planned calories shall come in a measured way.60 % from complex carbohydrates.Oligosacchrides should be avoided or used in minimum amounts.Fibre shall be part of the regular carbohydrate intake.Fat should be used as little as possible.Monopolysaturated fats should be used.Most of the oils now being imported are not perfectly healthy.These contain impurities.Fish,poultery not made heavy with oil are the best source of proteins.Vegetables & fruits should also be consumed.
q Early and aggressive Insulin:Once maximum dose of any oral hypoglycaemic has been tried with unsatisfactory response,no time should be wasted in instituting insulin.Early and aggressive use of Insulin is advisible.
q Microalbuminurea: This should be checked as frequently as possilbe.The moment it is there Ace Inhibitors shall be instituted even with normal BP.
q Monitoring HbA1c should be used to gauge the control over longer period of times.Routine monitoring for control of BGL 6 readings at intervals of 4 hours should be done to get the profile for whole day.Target is 90 –100 mgs /dl Fasting BGL.
Diagnosis of Type 2 ,Type 1 and MODY DM/
Response to Sulfonylureas.
C –peptide is produced in equomolar amounts of Insulin.Identification of C peptide means that some insulin production is going on.So patient can be labelled as type 2 or MODY in young age.If it is absent then patient should be labelled as type 1.
All sulfonylureas are almost same.Not much difference amongst these.Pick up anyone and go upto its advised maximum dose.If no response then institute insulin without wasting time.20 –25 % of type 2 patients are non responders in the beginning.Out of the rest i.e responders 10 –15 % will stop responding each year.So these are the patients who are initially well controlled with sulfonylureas but later on they are going to require insulin.
Insulin
This is better than anything.The trick to use it is in a way which mimicks natural insulin secretions.Insulin used 30 –40 minutes before meals reaches the peak before blood glucose levels peak after meal.Traditionaly 3 doses before meal and one at bed time is given of regular insulin.NPH can be used in 2 or even 3 doses.Patients on insulin can gain weight.It should be watched.Second point is that if they miss few doses of insulin,they can go into DKA.Patients should be trained to recognize hypoglycaemia by producing it under controlled conditions.Patient should be given 4 units of insulin intravenously on hourly basis.When he starts experiencing the symptoms insulin can be stopped and some snacks given.