diabetes 2003

8/24/2013 Dr.Sachin SarpotdarDhanvantari Foundation

Incorporation Chicago 1

Diabetes Patho-physiology and Principles of management

Dr.Sachin Sarpotdar BAMS, MSc(Health Science)

Ayurved Physician and Panchakarma Consultant.

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Incorporation Chicago 2 2

Diabetes -Historical Aspects

• This term was used first time by Aretaeus of Cappadocia, the Greek physician.

• Paul Langerhans described Islets in the pancreas in 1869.

• Belgian scientist Jean de Meyer used the term “Insulin" in 1909.

• In 1921 the insulin was purified after the series of experiments, by J.J.R Macleod, Charles Best, Frederick Banting and James Collip.

• However one of the Ayurvedic classics “Charka Samhita” long back ago(800-600 BC) has described the term “Madhumeha” which has the same meaning as that of Diabetes Mellitus.

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• In the year 2007; the diabetes was the 5th leading cause of mortality.

• 246 million people world wide have diabetes. • Worldwide;daily 200 children are grabbed by diabetes. • Worldwide;3 million deaths occur per year due to

diabetes. • More than 314 millions people have impaired glucose

tolerance.

Problem Estimation

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Prevalence-

o It is projected that by year 2025 the prevalence of DM will be 5.4% with global diabetic population reaching 300 million.

o Diabetes is prevalent in the age group 45-65 in developing countries and in developed countries it is in the age group above 65 years.

Mortality Rate-

1.5 to 2.5 times higher than that of general population.

Diabetes has recently escalated in all age groups.

Problem Estimation

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Clinical Presentation.

• A 53 years old man

• C/O Burning micturation-since 2 weeks

• Fatigue & pain in the calf muscles since 2 weeks.

• Weight loss of 2 kg in a last 1 month.

• Recurrent boils

• Adv investigation- Haemogram, Urinalysis, BSL-F & PP, Lipid Profile

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What is Diabetes?

• It is a metabolic disorder, specifically, an abnormality in the way the body utilizes the glucose, due to an absolute or relative deficiency of the hormone insulin or resistance by the body tissues to the action of insulin.

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What is Diabetes?

Diabetes is a syndrome of impaired carbohydrate, fat & protein metabolism.

It is caused by lack of Insulin secretion or decreased sensitivity of the tissues for the Insulin.

The characteristic feature is hyperglycemia.

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• Type 1 DM : Insulin Dependent Diabetes Mellitus. (10%)

• Type 2 DM : Non Insulin Dependent Diabetes Mellitus. (80%)

• Gestational Diabetes Mellitus

• Malnutrition Related Diabetes Mellitus

• Other Types : Secondary to pancreatic, hormonal, drug induced & other abnormalities.

Types of Diabetes Mellitus

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Three modes of Hyperglycemia

• Lack or decrease Insulin production

• Insulin resistance

• Increased Glucose production by Liver.

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Contributory factors

Kapha Dosha (One of the biological humor)

Meda Dhatu (Fatty tissue)

Watery waste products, body components like urine, sweat, lymph etc.

Reproductive and regenerative body fluids. (Various hormones, growth factors and healing factors)

Oja (Vital sap)

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Types

Types

Genetic (Sahaja) Life style originated

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Was previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes.

Type 1 diabetes develops when the body’s immune system destroys pancreatic beta cells, the only cells in the body that make the hormone insulin that regulates blood glucose.

Type 1 diabetes

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Type 1 diabetes

This form of diabetes usually strikes children and young adults, although disease onset can occur at any age.

Type 1 diabetes may account for 5% to 10% of all diagnosed cases of diabetes.

Risk factors for type 1 diabetes may include autoimmune, genetic, and environmental factors.

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Was previously called non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes.

Type 2 diabetes may account for about 90% to 95% of all diagnosed cases of diabetes.

It usually begins as insulin resistance, a disorder in which the cells do not use insulin properly.

As the need for insulin rises, the pancreas gradually loses its ability to produce insulin.

Type 2 diabetes

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Type 2 diabetes

Type 2 diabetes is associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity.

Indians are at particularly high risk for type 2 diabetes and metabolic disorder.

Type 2 diabetes is increasingly being diagnosed in children and adolescents.

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Etiological and Risk factors.

• Food crazy people.

• Sedentary lifestyle.

• Yogurt / Curd / Dahi.

• Processed food consumption.

• Milk derived products in excess.

• New cereals in excess.

• Carbohydrate rich products.

• Alcohol.

• Genetic predisposition.

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Causes

• Genetic factors

• Obesity

• Viral infections

• Endocrine effect

• Malnutrition

• Maternal diabetes

• Secondary to other diseases

• Other factors

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Pathogenesis

Diabetes occurs when the body does not produce any Insulin or when the body does not utilize Insulin effectively.

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Polyuria

Polyphagia

Polydipsia

Hyperglycemia

Wasting

Loss of Libido

Ketosis

Dehydration

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• Polyuria : Frequent urination • Polydypsia, Polyphagia • Weight loss • Extreme fatigue & weakness • Mental weakness & lack of concentration • Cuts & bruises which heal slowly or not heal properly. • Tingling or numbness in the extremities. • Blurred vision • Infertility

Signs and Symptoms

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Pathogenesis – Phase 1

Diabetes (PRAMEHA)

Genetic predisposition

Environmental factors

Lifestyle factors

Sleep in day time

Lack of physical exercise

Sedentary habits

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Diabetes as a complex phenomenon

The interplay of

Nidana – Etiological & risk factors

Dosha – Biological humors

Dushya – Various contributory body components in the disease

All above factors make diabetes as a complex phenomenon

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Dhatvagnimandya (Low metabolic

conversion)

Fat metabolism (Meda)

Protein metabolism

(Mamsa)

Waste product excretion (Kleda)

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• Increased production of water soluble waste products.

• Excess loss of body components through urine.

• This leads to severe weight loss.

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• Pathological consequences o Impaired fat metabolism – Weight gain or weight

loss, excess sweating with bad odor and skin diseases.

o Impaired protein metabolism – Muscle wasting & nephropathy.

o Waste product excretion – Increased volume of urine along with loss of some metabolically important substances like glucose.

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Risk Factors

• Family history of diabetes (i.e., parent or sibling with type 2 diabetes)

• Obesity (BMI 25 kg/m2)

• Physical inactivity

• Previously identified with IFG, IGT, or an A1C of 5.7–6.4%

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Risk Factors

• History of GDM or delivery of baby >4 kg (9 lb)

• Hypertension (blood pressure 140/90 mmHg)

• HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)

• Polycystic ovary syndrome.

• History of cardiovascular disease

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Blood sugar-Fasting & Postprandial.

Urine test-Urine ®,Urine sugar, Ketone bodies.

Oral glucose tolerance test-OGTT.

Glycohemoglobin test.

Diagnostic tests

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Glucose Tolerance Test (OGTT)

• Fasting BSL is measured

• 1gm/kg glucose is given Usually 75gm of Glucose in 250-300 ml of water on an empty stomach or overnight fasting

• Each half hour BSL and urine sugar measured in standard test in modified version 1 hr, 2hr BSL measured

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Interpretation of OGTT

• Indicated in new diagnosis

• FBSL- 110 – 125 mg/dl i.e. impaired glucose tolerance test

• Any BSL 200 mg/dl i.e. Diabetic

• 140-200 mg/dl Impaired Glucose Tolerance

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Diagnostic criteria

• Fasting blood glucose if >126 mg/dl.

• Blood glucose if >200 mg/dl after 2 hours of OGTT.

• Symptoms of Diabetes plus Random blood sugar if above 200 mg/dl.

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Screening test

• After 45 years of age screening test should be performed annually.

• BP monitoring.

• Ophthalmic checkup.

• Renal function test.

• Examination of feet

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1. Coronary artery & peripheral vascular diseases.

2. Diabetic nephropathy

3. Diabetic neuropathy

4. Diabetic ketoacidosis

5. Diabetic coma

6. Problems in Diabetic retinopathy

7. matrimonial relations

Diabetic complications

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Diabetic foot

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Dhanvantari Foundation Incorporation Chicago

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Diabetic Complications

in Ayurvedic Perspective.

• All the complications of Diabetes are due to early degeneration.

• Vata and Pitta are the two biological humors which are responsible for early degeneration and emaciation.

• Both of these bioenergies are light & sharp and are responsible for altered sensory and motor functions.



Dhanvantari Foundation Incorporation Chicago

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Diabetic Complications in Ayurvedic Perspective.

• These are also responsible for low immune mechanism, altered immunity & autoimmune mechanism.

• These are directly or indirectly responsible for recurrent infections and give inflammatory response.

• Due to the dryness of Vata and it’s obstructive nature the blood flow get affected; which, deteriorate the tissue perfusion.

• Pitta leads to faster degenerative & metabolic transformations in the body tissues; which leads to tissue destruction i.e. “Dhatu Pak”



Treatment of DM

• Should be Started with non drug therapy

• It include diet control

• Regular exercise

• Normalizing life style

• Alcohol abstinence

• Vegetarian diet

• Reducing stress

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Treatment of DM

• Start with non drug therapy

• It include diet control

• Regular exercise

• Normalizing life style

• Alcohol abstinence

• Vegetarian diet

• Reducing stress

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Insulin

It is must in certain cases

• Type I DM

• Infection

• Pregnancy

• Operative procedure

• Short term treatment

• Complications like keto acidosis

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Insulin Formulations

• Human ACTRAPID – 40 U/ ml (Regular Insulin)

• Human MONOTARD – 40 U/ ml (Lenteinsulin)

• Human MIXTARD 30/70 - 40 U/ ml (30 % soluble insulin + 70% isophane insulin)

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Preparations of insulin

• Insulin is mainly divided into short acting and long acting

• Short acting (regular) is always clear and long acting (ultra lente) is turbid

• Two can be mixed together for treatment

• Insulin may be from animal source i.e. Pork or beef.But now-a-day human insulin is used, which is less antigenic

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Appearance

Onset Peak Dur

Short acting

clear 1 2-4 6-8

Long acting

turbid 4-6 14-18 24-36

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Clinical Use of Insulin

• 0.6 -1.2 IU/Kg/day

• 2/3 dose should be given in morning before breakfast

• 1/3 dose should be given in evening before dinner

• Morning dose should be split as 1/3 neutral and 2/3 Isophane (NPH)

• Evening dose should be split 50-50% in combination

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Adverse effect of insulin

• Hypoglycemia

• Local reaction like swelling, erythema, or stinging sensation at site of injection

• Allergic reactions which are uncommon to human insulin

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1. Glibenclamide (Glyburide)

Generic Name Glibenclamide

Brand name DAONIL,

EUGLUCON

Size of tablet 2.5, 5 mg Tab

Doses 2.5 – 15 mg

OD

When taken Before meal

Duration of action

18 – 24 hr

Price 5.25, 9.50 INR 51 8/24/2013



2. Glipizide

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Generic Name

Glipizide

Brand name GLYNASE, GLIPI,

GLIDE

Size of tablet 5 mg

Doses 5 – 20 mg OD/BD

When taken Before Meal

Duration of action

12 – 18 hr

Price 5, 6 INR 8/24/2013



3. Gliclazide

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Generic Name Gliclazide

Brand name Diamicron,

Dianorm,

Reglide

Size of tablet 30, 40, 80 mg

Doses 40 – 240 mg

OD/BD

When taken Before Meal

Duration of action

12 -24 hr

Price 70 INR 8/24/2013



4. Glimepiride

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Generic Name Glimepiride

Brand name GLYPRIDE, GLIMY,

GLIMER,AMARYL

Size of tablet 1,2,3,4 mg

Doses 1 – 6 mg OD

When taken Before first meal

Duration of action 24 hr

Price 46, 74, 101 INR

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1. Repaglinide

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Generic Name Repaglinide

Brand name EUREPA, RAPLIN

Size of tablet 0.5,1,2 mg

Doses 1.5 – 8 mg q.d.

When taken Before each meal

Duration of action

2-3 hr

Price 56, 92. 142 INR

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2. Nateglinide

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Generic Name Nateglinide

Brand name GLINATE

Size of tablet 60, 120 mg

Doses 180 – 240 mg q.d.


Duration of action 2-3 hr

Price 55, 91 INR

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a. Metformin

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Generic Name Metformin

Brand name GLYCIPHAGE, GLYCOMET

Size of tablet 250,500, 850 mg

Doses 0.5 - 2 gm q.d.


Duration of action

6 – 8 hr

Price 5.5, 11, 14 INR

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Pioglitazone

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Generic Name Pioglitazone

Brand name PIONORM


Doses 15 – 45 mg OD

When taken Before dinner

Duration of action 24 hr

Price 35.5, 51 INR

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a. Acarbose

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Generic Name Acarbose

Brand name GLUCOBAY


Doses 25 – 100 mg TID


Duration of action 4 – 6 hr

Price 42, 50 INR

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b. Miglitol

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Generic Name Miglitol

Brand name MIGLIT, MIGNAR


Doses 25 – 100 mg TID


Duration of action

4 – 6 hr

Price 60, 108 INR

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Anti Diabetic Herbs- Minerals & Compound Drugs

• Most of the anti diabetic herbs are astringent and bitter. They contain tannins & flavonoids.

• These have Anti-Kapha properties. • Drugs are metabolic regulators( Deepan) • Drugs with Pachan quality are beneficial. • Drugs with cleansing property are preferred. • Drugs reduce the Kleda i.e watery waste product by

decreasing its production or eliminating it through urine.

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• Research work across the world have focused on their -

• cytoprotective, anti inflammatory, immune boosting and antimicrobial actions.

• Stimulate insulin secretion. • Inhibit auto antibodies. • Inhibit hepatic gluconeogenesis and regulate

the FBS. • Increase the glucose utilization and reduce the

insulin resistance.

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• These herbs improve the lipid profile and used as metabolic regulators.

• Some of these herbs are Nephro protective. • These herbs inhibit the new abnormal growth

of the vessels and inhibit the platelets sticking • Minerals are used to induce the enzymes and

regulate the metabolism. This is done by regulating the transcription process.

• Compound products improve the nutritional status.

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Important Pancreatic Stimulants & Insulin Sensitizers.

• Amalaki-.Emblica officinalis

• Bibhitak-Terminalis belerica.

• Haritaki-Terminalia chebula.

• Shunthi-Dry ginger

• Marich-Piper nigrum.

• Pimpali-Piper longum.

• Turmeric.

• Daruhalad-Berberis aristata

• Guduchi-Tinospora cordifolia.

• Lodhra-Symplocos recemosa.

• Nimba-Azadirachta indica.

• Chandan-Santalum album.

• Usheer-Vetiveria zizanioidis.

• Khadir.-Acacia catechu.

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Herbs for Prevention of Insulin Resistance.

• Amalaki-.Emblica officinalis • Bibhitak-Terminalis belerica. • Haritaki-Terminalia chebula. • Shunthi-Dry ginger • Marich-Piper nigrum. • Pimpali-Piper longum. • Turmeric. • Daruhalad-Berberis aristata • Guduchi-Tinospora cordifolia. • Karela (Bitter Gourd)- Momordica charantia. • Meshshringi- Gymnema sylvestre.

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Ayurvedic Products

• D.B.T= 1-2 BD/TDS

• Diabecon 1-2 BD/TDS

• Vijaysar Ghan =1-2 BD/TDS

• Daruharidra Ghan =1-2 BD/TDS

• Meshashringi cap= 1 BD

• Haridra cap= 1-2 BD

• Karela cap= 1BD/ TDS

• Vrikshamla cap- 1 BD

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Ayurvedic Products

• Lodharasava- 3 tsf BD (After meal) with Warm Water.

• Beejakarishta- 3tsf BD( After meal) with warm water.

• Bhallataksava – (Rasashala) 2tsf BD with water.

• Ayaskruti - 2tsf BD with warm water.

• Mustharishtum- 3tsf BD with warm water.

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Ayurvedic Products

• Methi Ghan

• Maka Ghan

• Gudmar Ghan

• Guduchi Ghan/Cap

• Gokshur

• Punarnava

• Ashwagandha Churna Vati /Cap

• Rasayan Churna

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Ayurvedic Mineral Products

• Jasad Bhasma

• Abhrak Bhasma

• Trivanga Bhasma

• Suvarna Bhasma

• Rajat Bhasma

• Loha Bhasma

• Suvarna Makshik Bhasma

• Shilajeet

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Ayurvedic Compound Products

• Arogyavardhini

• Chandraprabha

• Saptamrut Loha

• Gokshuradi Guggul

• Triphala Guggul

• Navak Guggul (Medohar Guggul)

• Shilajatwadi Vati

• Tapayadi Loha

• Vasant Kusumakar

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Patent & Proprietary Products

• Amree Plus – Amil Pharma – 20 tabs- 84 INR

• Yesaka Liq- Simandhar Herbals- 500-ml-180 INR

• Madhumehari Chrna- Baidyanath- 100Gm- 97 INR

• Madhumehari with Gold Tab- 40 tabs-560 INR

• Jumbola Liq- Luna Pharma- 450ml- 190 INR

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Patent & Proprietary Products

• Ojamin Liq-Everest Pharma Pune- 1lit-450 INR.

• Beejakarishtum Nisha Herblals- 400ml-220 INR.

• Diabecon – Himalaya- 60 Tab-100 INR

• D.B.T- Sharangadhar- 100 Tab- 190 INR.

• Asanad Tablet – Ayurved Rasashala Pune-

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Eye diseases.

• Retinopathy, cataract and glaucoma are more common in diabetic patients.

• Eye is the sight of Pitta and bleeding tendency is the Pitta predominant condition.

• In such condition “Bowel cleansing” is recommended. • Triphala decoction is used to wash the eyes and for

bowel cleansing purpose. • For the prevention of eye diseases the compound

TRIPHALA can be used in the form of MEDICATED GHEE. • This can be taken orally as well as locally. • Saptamrut Loha 2 BD

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Nephropathy.

• Nephro protective herbs can be used. Some of the Nephro protective herbs are 1)Punarnava-Boerhavia diffusa. 2)Gokshur-Tribulus terrestris. These herbs can be given in the form of

decoction or herbal tea. Medicated enema are also given.

3) Chanrprabha, Shilajatawadi Vati in a dose of 2 BD are also used.

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Diabetic foot

• Wound healing is the function of Shukra Dhatu.

• It is associated with reproduction as well as regeneration.

• Herbs like Shatavari, Ashwagandha are recommended in wound healing.

• Dressing with Vrana Ropan oil to take care of ulcers.

• Pressure relieving modification is essential. • Tapyadi Loha & Vasant Kusumakar are also

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Neuritis

• Sensory and motor nerves are affected in diabetes. • As per Ayurveda sensory, cognitive and motor functions

are regulated by Vata. • The skin is one of the site of Vata. • Oil is supposed to be the best for the control of Vata

ailments. • Hence in the prevention of neuritis the oil massage is

recommended. • Massage improves the local blood supply, lymph

drainage and nerve conduction. • Massage also stimulate the Neuro-endocrinal system.

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Infections.

• Recurrent infections of skin, urinary and genital tracts are very common in diabetic patients.

• Herbal bath ,local wash with herbal decoctions and herbal powders application to the skin are very effective in skin care.

• Herbs like Nimba, Khadir, Daruharidra Triphala are used in the skin care and in its hygiene.

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diabetes 2003

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