TREATMENTTREATMENT ObjectiveObjective: Maintain blood glucose level within normal range, : Maintain blood glucose level within normal range,

without resulting in Hypoglycaemiawithout resulting in Hypoglycaemia.. ‘‘Perfect glycemic controlPerfect glycemic control’: glucose levels are always normal ’: glucose levels are always normal

(70-130 mg/dl, or 3.9-7.2 mmol/L)(70-130 mg/dl, or 3.9-7.2 mmol/L)

NON-PHARMACOLOGICAL MEASURESNON-PHARMACOLOGICAL MEASURES Weight control, regular exercise – Yoga, Aerobics.Weight control, regular exercise – Yoga, Aerobics. Diet modifications – high protein, low carbs-and-fat diet.Diet modifications – high protein, low carbs-and-fat diet. Treat underlying causes – obesity, CV diseases, infections, Treat underlying causes – obesity, CV diseases, infections,

etc. etc. Always carry sweets / sugar / glucose tablets (due to Always carry sweets / sugar / glucose tablets (due to

overactivity of OHAs overactivity of OHAs → severe Hypoglycaemia→ severe Hypoglycaemia).). Avoid spicy, oily foods. Avoid spicy, oily foods. Use Artificial sweeteners (Use Artificial sweeteners (AspartameAspartame).). Diabetic footwear is advisable.Diabetic footwear is advisable. Protect the eyes (shades, day-night glasses).Protect the eyes (shades, day-night glasses).

PHARMACOLOGICAL TREATMENTPHARMACOLOGICAL TREATMENT For Type-I DMFor Type-I DM : Insulin : Insulin For Type-II DMFor Type-II DM : Oral Hypoglycaemic Agents (OHAs / : Oral Hypoglycaemic Agents (OHAs /

OADs).OADs).

INSULININSULIN Type-I DM patients require Type-I DM patients require insulinotherapyinsulinotherapy.. Insulin PumpInsulin Pump, , Insulin penInsulin pen and and Hypodermic needleHypodermic needle.. Monitoring, Diet Control, Patient education and Monitoring, Diet Control, Patient education and

Compliance are vital.Compliance are vital. RiskRisk: Inability to continuously know the blood glucose : Inability to continuously know the blood glucose

levels and adjust insulin infusion appropriately. levels and adjust insulin infusion appropriately.

INSULIN PUMPINSULIN PUMP Continuous S.C. Insulin InfusionContinuous S.C. Insulin Infusion Therapy; Therapy; ComponentsComponents: : - - PumpPump (including controls, processing module, and batteries)(including controls, processing module, and batteries) - - Disposable reservoir for insulin Disposable reservoir for insulin (inside the pump in newer (inside the pump in newer

versions)versions) - - Disposable infusion set Disposable infusion set (including a (including a cannula for s.c. insertioncannula for s.c. insertion

and a and a tubing systemtubing system to interface the insulin reservoir to the to interface the insulin reservoir to the cannula). cannula).

Allows the Allows the replacement ofreplacement of slow-acting insulin for basal slow-acting insulin for basal needsneeds with a with a continuous infusion of rapid-acting insulincontinuous infusion of rapid-acting insulin..

DosingDosing: 2 ways : 2 ways - - Bolus or mealtime dose Bolus or mealtime dose ((to cover food eatento cover food eaten or to or to correct a correct a

high blood glucose level)high blood glucose level).. - - Basal or background dose Basal or background dose (pumped continuously at an (pumped continuously at an

adjustable basal rateadjustable basal rate to deliver insulin needed to deliver insulin needed between meals and between meals and at night)at night). .

Advantages of the Insulin pumpAdvantages of the Insulin pump Offers Offers relative freedomrelative freedom from a structured meal and from a structured meal and

exercise regimenexercise regimen. . More convenient and discreet than the insulin injection. More convenient and discreet than the insulin injection. Deliver more Deliver more precise amounts of insulinprecise amounts of insulin →→ tighter tighter

control over blood sugar and HbA1C levels control over blood sugar and HbA1C levels →→ reducing reducing the chance of long-term complicationsthe chance of long-term complications→→ Long term cost Long term cost savings relative to multiple daily injections. savings relative to multiple daily injections.

Modern 'smart' pumps have a ‘Modern 'smart' pumps have a ‘Bolus wizardBolus wizard' - ' - calculates how much 'bolus' insulin is needed (taking calculates how much 'bolus' insulin is needed (taking into account the expected carbohydrate intake and into account the expected carbohydrate intake and current blood sugar status). current blood sugar status).

Disadvantages of the Insulin pumpDisadvantages of the Insulin pump

Far more expensiveFar more expensive than syringes used for insulin than syringes used for insulin injection. injection.

Must be worn most of the timeMust be worn most of the time - activities (rough sports - activities (rough sports and activities in the water) may damage the pump. and activities in the water) may damage the pump.

Uncomfortable (Uncomfortable (Wearing the pump all the time). Wearing the pump all the time). DKADKA (if pump user does not receive sufficient fast acting (if pump user does not receive sufficient fast acting

insulin for many hours). insulin for many hours). [ Pump battery is discharged / insulin reservoir runs [ Pump battery is discharged / insulin reservoir runs

empty / the tubing becomes loose and insulin leaks empty / the tubing becomes loose and insulin leaks rather than being injected / cannula becomes bent or rather than being injected / cannula becomes bent or kinked in the body, preventing delivery]. Therefore pump kinked in the body, preventing delivery]. Therefore pump users typically monitor their blood sugars more frequently users typically monitor their blood sugars more frequently to evaluate the effectiveness of insulin delivery. to evaluate the effectiveness of insulin delivery.

Possibility of insulin pump breakingPossibility of insulin pump breaking and and having to resort having to resort back to multiple daily injectionsback to multiple daily injections until new pump arrives. until new pump arrives.

INSULIN PENSINSULIN PENS Insulin injection system for the treatment of diabetes. Insulin injection system for the treatment of diabetes. ComponentsComponents: : disposable needlesdisposable needles, , insulin vialinsulin vial and a and a

‘‘penpen’.’. Pen systemsPen systems: : Replaceable cartridgeReplaceable cartridge and and Pre-filledPre-filled.. Replaceable cartridge pen Replaceable cartridge pen reuses the pen portionreuses the pen portion; ; vial vial

is replaced. is replaced. Pre-filled pen is Pre-filled pen is entirely disposableentirely disposable. When the insulin is . When the insulin is

gone, the entire unit is discardedgone, the entire unit is discarded

DisadvantagesDisadvantages : : a] Restricted to a] Restricted to either full or half unit dosingeither full or half unit dosing. . b] b] Can’t mix two different insulinsCan’t mix two different insulins in the same pen. in the same pen.

Insulin pens (contd.)Insulin pens (contd.)

AdvantagesAdvantages:: a] a] More convenientMore convenient and and easier to transporteasier to transport; ; discretediscrete. . b] b] Relatively more accurate dosagesRelatively more accurate dosages (compared to (compared to

injections). injections). c] Easier to use c] Easier to use for those with visual or fine motor skills for those with visual or fine motor skills impairments. impairments. d] d] Less injection painLess injection pain (as polished and coated needles (as polished and coated needles

are not are not ‘ ‘dulled’ by insertion into the insulin vial before a dulled’ by insertion into the insulin vial before a

second second insertion into the skin) insertion into the skin)

INSULIN GLARGINE (Lantus)INSULIN GLARGINE (Lantus) Marketed by Sanofi-Aventis.Marketed by Sanofi-Aventis. Long-acting basal insulinLong-acting basal insulin analogue. analogue. OD or BDOD or BD . . Duration of action is Duration of action is up to 24 hoursup to 24 hours. ‘ Less peaked profile’ . ‘ Less peaked profile’ Moderate control of serum glucose in Type-II DM (along with Moderate control of serum glucose in Type-II DM (along with

short acting sulfonylurea).short acting sulfonylurea). In the absence of endogenous insulin (Type I DM or depleted In the absence of endogenous insulin (Type I DM or depleted

Type II), Type II), Lantus needs the support of a fast acting insulin taken Lantus needs the support of a fast acting insulin taken with food to reduce the effect of prandially-derived glucosewith food to reduce the effect of prandially-derived glucose. .

NPH (Neutral Protamine Hagedorn)NPH (Neutral Protamine Hagedorn) 1936 - 1936 - Neutral protamine + Regular InsulinNeutral protamine + Regular Insulin (Hans Christian (Hans Christian

Hagedorn)Hagedorn) Suspension of Suspension of crystalline zinc insulincrystalline zinc insulin + + polypeptide protamine. polypeptide protamine. Via S.C. - Intermediate duration of action Via S.C. - Intermediate duration of action (longer than that of regular insulin, but shorter than Ultralente, (longer than that of regular insulin, but shorter than Ultralente,

glargine or detemir).glargine or detemir).

ORAL HYPOGLYCAEMIC AGENTSORAL HYPOGLYCAEMIC AGENTS

1] 1] Sulfonyl UreasSulfonyl Ureas

a) a) 11stst Generation Generation Chlorpropamide 100 – 500 mg odChlorpropamide 100 – 500 mg od Tolbutamide 500 – 2500mg bid / tidTolbutamide 500 – 2500mg bid / tid

b) b) 22ndnd Generation Generation Glibenclamide 2.5 – 20 mg od / bdGlibenclamide 2.5 – 20 mg od / bd Glipizide 2.5 – 20 mg od / bdGlipizide 2.5 – 20 mg od / bd Gliclazide 80 – 320 mg od / bdGliclazide 80 – 320 mg od / bd Gliclazide MR 30 – 120 mg odGliclazide MR 30 – 120 mg od Glipizide XL 5 – 20 mg odGlipizide XL 5 – 20 mg odc) c) 33rd Generation Generation Glimepiride 1 – 8 mg odGlimepiride 1 – 8 mg od

OHAs (contd.)OHAs (contd.)

2] 2] Non-Sulfonyl UreasNon-Sulfonyl Ureasa)a) MMetaglinide Analogues ( Repaglinide 1.5 – 10 mg tid).etaglinide Analogues ( Repaglinide 1.5 – 10 mg tid).b)b) BBiguanides (Metformin 250 – 2500 mg bid / tid)iguanides (Metformin 250 – 2500 mg bid / tid)c)c) TThiazolidinediones ( Rosiglitazone 2 – 8 mg od / bd;hiazolidinediones ( Rosiglitazone 2 – 8 mg od / bd; Pioglitazone 15 – 45 mg od)Pioglitazone 15 – 45 mg od)a)a) αα-glucosidase Inhibitors (Acarbose 25 – 300 mg tid)-glucosidase Inhibitors (Acarbose 25 – 300 mg tid)

*** Never administer OHAs to pregnant ladies; Type-I DM; *** Never administer OHAs to pregnant ladies; Type-I DM; heart, kidney and renal failure patients***heart, kidney and renal failure patients***

OHAs : TYPES & MOAOHAs : TYPES & MOA Are used to control DM when diet and lifestyle Are used to control DM when diet and lifestyle

modifications fail to achieve the desired results.modifications fail to achieve the desired results. Are effective only in case of Are effective only in case of Type-II DMType-II DM, and in , and in few cases of few cases of

Secondary DMSecondary DM.. Comprise Comprise Insulin ReleasersInsulin Releasers, , Insulin SensitizersInsulin Sensitizers, , αα--

glucosidase Inhibitorsglucosidase Inhibitors..

1] 1] Insulin ReleasersInsulin Releasers• Stimulate the pancreatic cells to release Insulin.Stimulate the pancreatic cells to release Insulin.• Includes Sulfonyl ureas (mostly 2Includes Sulfonyl ureas (mostly 2ndnd generation) and generation) and

metaglinide analogues.metaglinide analogues.

2] 2] Insulin SensitizersInsulin Sensitizers • ↑↑es glucose uptake by peripheral tissues (increase these es glucose uptake by peripheral tissues (increase these

tissues’ sensitivity to insulin, thus enhancing insulin’s tissues’ sensitivity to insulin, thus enhancing insulin’s action in the body).action in the body).

• Includes Metformin and Glitazones.Includes Metformin and Glitazones.

3] 3] αα-glucosidase Inhibitors-glucosidase Inhibitors ↓es glucose absorption after ↓es glucose absorption after meals.meals.

SULFONYLUREASSULFONYLUREAS First widely used OHAs; for Type-II DM only.First widely used OHAs; for Type-II DM only. Limit glucose productionLimit glucose production in liver. in liver. ↓↓es Lipolysises Lipolysis (prevents DKA to an extent) and (prevents DKA to an extent) and Insulin Insulin

clearanceclearance by the liver. by the liver. Bind strongly to Plasma ProteinsBind strongly to Plasma Proteins.. Side effectsSide effects: : Hypoglycaemia; Hypoglycaemia; Unintentional weight gainUnintentional weight gain (due to edema); (due to edema); Abdominal upset, Headache, Abdominal upset, Headache, Hypersensitivity;Hypersensitivity; Teratogenic Teratogenic ((Contraindicated in pregnancyContraindicated in pregnancy))..

NON - SULFONYL UREASNON - SULFONYL UREAS

1] MEGLITINIDES / GLINIDESMEGLITINIDES / GLINIDES For Type-II DM; For Type-II DM; Can be Can be taken with meals to boost insulin responsetaken with meals to boost insulin response.. MOA similar to Sulfonylureas, but different binding siteMOA similar to Sulfonylureas, but different binding site.. Egs.Egs. : Nateglinide 120 mg TID (max. dose 60 mg/day). : Nateglinide 120 mg TID (max. dose 60 mg/day). Repaglinide (max. dose 16 mg/day); 0 to 30 minutes Repaglinide (max. dose 16 mg/day); 0 to 30 minutes

p.c p.c Mitiglinide.Mitiglinide. If a meal is skipped, the medication must be skipped. If a meal is skipped, the medication must be skipped. ADRsADRs : weight gain and hypoglycemia. : weight gain and hypoglycemia.

2] BIGUANIDESBIGUANIDES Insulin sensitizersInsulin sensitizers Egs.Egs. : : • Metformin (Glucophage)Metformin (Glucophage) : widely used to treat Type-II DM : widely used to treat Type-II DM

combined with obesity combined with obesity • Phenformin and BuforminPhenformin and Buformin : withdrawn from markets (toxic : withdrawn from markets (toxic

effects) effects) • ProguanilProguanil (an antimalarial drug). (an antimalarial drug). Side effectsSide effects : Diarrhoea, Dyspepsia, Abdominal pain, Bloated : Diarrhoea, Dyspepsia, Abdominal pain, Bloated sensation, sensation, Lactic AcidosisLactic Acidosis.. Should NOT be used in any conditions that can cause lactic Should NOT be used in any conditions that can cause lactic

acid accumulation (CCF, recent MI, Liver cirrhosis, severe acid accumulation (CCF, recent MI, Liver cirrhosis, severe infection etc.). infection etc.).

3] THIAZOLIDINEDIONES (TZDs) / GLITAZONESTHIAZOLIDINEDIONES (TZDs) / GLITAZONES

Activate PPARsActivate PPARs;; Decrease Insulin resistance Decrease Insulin resistance;; Better use of Better use of glucose by the cellsglucose by the cells

Egs.Egs. : i) : i) RosiglitazoneRosiglitazone ii) ii) PioglitazonePioglitazone iii) iii) TroglitazoneTroglitazone withdrawn (drug-induced hepatitis). withdrawn (drug-induced hepatitis). Side effectsSide effects : : • Edema & weight gainEdema & weight gain (can lead to HF). (can lead to HF).• Pioglitazone – Significant protection from Pioglitazone – Significant protection from micro and macro micro and macro

vascular diseases and plaque progressionvascular diseases and plaque progression..• Rosiglitazone – Rosiglitazone – Increased risk of Heart attacks and CHDsIncreased risk of Heart attacks and CHDs..

WHAT ARE PPARs?WHAT ARE PPARs?

4] αα-GLUCOSIDASE INHIBITORS-GLUCOSIDASE INHIBITORS Pancreatic Pancreatic αα–Amylase–Amylase αα–Glucosidase–Glucosidase Egs.Egs.: : AcarboseAcarbose, , MiglitolMiglitol and and VogliboseVoglibose (lesser side effects (lesser side effects

and cheaper).and cheaper). Taken at start of mealsTaken at start of meals for maximal effect. for maximal effect. Side effectsSide effects: : • Flatulence and Diarrhoea (bacteria digest the Carbohydrates Flatulence and Diarrhoea (bacteria digest the Carbohydrates

in colon).in colon).• HypoglycaemiaHypoglycaemia

PEPTIDE ANALOGUESPEPTIDE ANALOGUES A] Incretin MimeticsIncretin Mimetics IncretinsIncretins : : Insulin Secretagogues (drugs that Insulin Secretagogues (drugs that

stimulate secretion of Insulin).stimulate secretion of Insulin). Egs.Egs.: i) : i) Glucagon-Like Peptide-1Glucagon-Like Peptide-1 ( (GLP-1GLP-1) ) ii) ii) Gastric Inhibitory PeptideGastric Inhibitory Peptide ( (Glucose-dependent Glucose-dependent Insulinotropic PeptideInsulinotropic Peptide / / GIPGIP).). GLP-I and GIP GLP-I and GIP → → Stimulates insulin release Stimulates insulin release Inhibits Glucagon releaseInhibits Glucagon release ↓↓ Elevated Blood Glucose is loweredElevated Blood Glucose is lowered GLP-I and GIP are rapidly inactivated by GLP-I and GIP are rapidly inactivated by Dipeptidyl Dipeptidyl

peptidase-4peptidase-4..

[NOTE: [NOTE: DPP-4DPP-4 enzyme inhibits GLP-I; enzyme inhibits GLP-I; DPP-4 Inhibitors block DPP-4]DPP-4 Inhibitors block DPP-4]

B] Glucagon-like peptide (GLP) analogues and agonistsGlucagon-like peptide (GLP) analogues and agonists Bind to a membrane GLP receptorBind to a membrane GLP receptor→→ Insulin release Insulin release

increased. increased. Endogenous GLP has a half life of only a few minutesEndogenous GLP has a half life of only a few minutes. .

Exenatide / Exendin-4 (Byetta)Exenatide / Exendin-4 (Byetta): : • First GLP-1 agonist approved for the treatment of Type-II DM. First GLP-1 agonist approved for the treatment of Type-II DM. • Dose is 5Dose is 5μμg BD by Insulin pen increased to 10g BD by Insulin pen increased to 10μμg BD after 4 g BD after 4

weeksweeks. . • Increased resistance to degradation by DPP-4Increased resistance to degradation by DPP-4→→ extended extended

Half-lifeHalf-life.. Liraglutide (Victoza)Liraglutide (Victoza): : • a OD dose; developed by Novo Nordisk. a OD dose; developed by Novo Nordisk. • Approved by FDA in June 2010. Approved by FDA in June 2010.

Side effectsSide effects: decrease in gastric motility, nausea, weight : decrease in gastric motility, nausea, weight loss. loss.

Peptide analogues (contd.)Peptide analogues (contd.)

C] Gastric inhibitory peptide (GIP) analogsGastric inhibitory peptide (GIP) analogs None are FDA approved None are FDA approved

D] Dipeptidyl peptidase-4 (DPP-4) inhibitors / DPP-4 Dipeptidyl peptidase-4 (DPP-4) inhibitors / DPP-4 inhibitorsinhibitors

Inhibit degradation of GLP-I by DPP-4 Inhibit degradation of GLP-I by DPP-4 → → increase blood increase blood concentration of the incretin GLP-1. concentration of the incretin GLP-1.

ExamplesExamples: : Vildagliptin, SitagliptinVildagliptin, Sitagliptin. .

IS GIP REALLY BENEFICIAL????IS GIP REALLY BENEFICIAL????

AMYLIN ANALOGUESAMYLIN ANALOGUES Amylin agonist analogues Amylin agonist analogues slow gastric emptying and and

suppress glucagon.. Have all the incretins actions except stimulation of Have all the incretins actions except stimulation of

insulin secretion. insulin secretion. PramlintidePramlintide - only clinically available amylin analogue - only clinically available amylin analogue

(2007).(2007). via S.C. inj. via S.C. inj. adverse effect – Nausea. adverse effect – Nausea.

TREATMENT FOR COMPLICATIONSTREATMENT FOR COMPLICATIONSDiabetic retinopathyDiabetic retinopathy: : i) 3 treatments are laser surgery, triamcinolone inj. into i) 3 treatments are laser surgery, triamcinolone inj. into

the eye and vitrectomy. the eye and vitrectomy. ii) Can’t cure; Monitoring is essential.ii) Can’t cure; Monitoring is essential.iii) Avoid tobacco use, correct HTN.iii) Avoid tobacco use, correct HTN.

Diabetic NephropathyDiabetic Nephropathy: : i) ACEIs (to reduce proteinuria, slow progression of disease) i) ACEIs (to reduce proteinuria, slow progression of disease)

+ ARBs.+ ARBs. ii) Antibiotics (for UTIs). iii) C-peptide (By-product of insulin ii) Antibiotics (for UTIs). iii) C-peptide (By-product of insulin

production; prevents diabetic nephropathy).production; prevents diabetic nephropathy).iv) Dialysis (end-stage renal disease).iv) Dialysis (end-stage renal disease). v) Blood glucose monitoring. v) Blood glucose monitoring. vi) Avoid Common NSAIDs, Ivi) Avoid Common NSAIDs, I22-containing contrast medium. -containing contrast medium.

Diabetic NeuropathyDiabetic Neuropathy :: i) Treat the nerve pain with Gabapentin (Neurontin), i) Treat the nerve pain with Gabapentin (Neurontin),

Phenytoin (Dilantin), CBZ (Tegretol), Desipramine Phenytoin (Dilantin), CBZ (Tegretol), Desipramine (Norpraminine), Amitriptyline (Elavil), topically-released (Norpraminine), Amitriptyline (Elavil), topically-released Capsaicin. Capsaicin.

DIET CONTROLDIET CONTROL1] 1] Nutritious dietNutritious diet : need not be totally different from normal : need not be totally different from normal

diet.diet. Goals of Nutrition TxGoals of Nutrition Tx : :• Maintain near-normal blood glucose levels;Maintain near-normal blood glucose levels;• Achieve optimum serum lipid levels;Achieve optimum serum lipid levels;• Adequate calories.Adequate calories.• Prevent, delay or treat complications.Prevent, delay or treat complications. Glycaemic Index (GI):Glycaemic Index (GI): • Indicates the Indicates the ↑ in blood sugar post-eating, against the ↑ in ↑ in blood sugar post-eating, against the ↑ in

blood sugar after consuming an equivalent amount of blood sugar after consuming an equivalent amount of glucoseglucose..

• Useful in planning diet for diabetics.Useful in planning diet for diabetics.• High GIHigh GI : Cereals (wheat, rice); veggies (potato, carrot) 65 – : Cereals (wheat, rice); veggies (potato, carrot) 65 –

75%75%• Intermediate GIIntermediate GI : fruits 45 – 55% : fruits 45 – 55%• Low GILow GI : Legumes & lentils 30 – 40%; beneficial for : Legumes & lentils 30 – 40%; beneficial for

diabetics.diabetics. Fats & OilsFats & Oils : : • Avoid butter, ghee, coconut & palm oil; use mustard, corn, Avoid butter, ghee, coconut & palm oil; use mustard, corn,

sunflower, groundnut and gingelly oil. sunflower, groundnut and gingelly oil.

FibresFibres : :• ↓ ↓ post-prandial blood glucose levels.post-prandial blood glucose levels.• Fruits & veggies (soluble fibres) – lower the blood Fruits & veggies (soluble fibres) – lower the blood

cholesterol levels.cholesterol levels.• Fibres intake : 20 – 35 gms /day.Fibres intake : 20 – 35 gms /day. Artificial SweetenersArtificial Sweeteners : : • Aspartame and Saccharine.Aspartame and Saccharine.• Low calorie and non-calorie types are useful; shouldn’t Low calorie and non-calorie types are useful; shouldn’t

exceed daily intake.exceed daily intake. AlcoholAlcohol ::• ↑↑es B.P., triglyceride levels; weakens the heart muscles es B.P., triglyceride levels; weakens the heart muscles

→ cardiomyopathy.→ cardiomyopathy.• Affects liver and peripehral nerves.Affects liver and peripehral nerves.• ↑ ↑ in calorie and no nutritive value (‘Empty calories’).in calorie and no nutritive value (‘Empty calories’).• Best to avoid alcohol. Best to avoid alcohol.

2] 2] ExerciseExercise : : Can vary based on age, sex, type of diabetes, diabetic Can vary based on age, sex, type of diabetes, diabetic

complications and con-current diseases.complications and con-current diseases. ↓↓es Blood glucose levels, B.P. and cholesterol levels; es Blood glucose levels, B.P. and cholesterol levels;

strengthens the heart and muscle tone; ↑es metabolism.strengthens the heart and muscle tone; ↑es metabolism. 45 mins. – 1 hour45 mins. – 1 hour is sufficient; ‘warm up’ and ‘cool down’ is sufficient; ‘warm up’ and ‘cool down’

phases are vital.phases are vital. Choose longer route while walking; use steps instead of Choose longer route while walking; use steps instead of

elevator.elevator. Park vehicle at a distance and walk.Park vehicle at a distance and walk. Yoga Yoga : improves blood circulation, pancreatic activity; : improves blood circulation, pancreatic activity;

stimulates insulin secretion and food digestion.stimulates insulin secretion and food digestion.

3] 3] Foot care for DiabeticsFoot care for Diabetics : : Wash the feet daily w/ ordinary soap and lukewarm water.Wash the feet daily w/ ordinary soap and lukewarm water. Dry feet w/ soft towels (focus on areas b/n toes also).Dry feet w/ soft towels (focus on areas b/n toes also). Trim the nails straight regularly (in case of poor eyesight, ask Trim the nails straight regularly (in case of poor eyesight, ask

relatives or family to do it).relatives or family to do it). Wear shoes and footwear that fit well.Wear shoes and footwear that fit well. Never soak the leg for too long in water.Never soak the leg for too long in water.

Foot care for Diabetics (contd.)Foot care for Diabetics (contd.)

Never walk barefoot and never expose the toes.Never walk barefoot and never expose the toes. Never try to self-treat in case of injury.Never try to self-treat in case of injury. Monitor the feet for blisters.Monitor the feet for blisters.

4] 4] Eye care for DiabeticsEye care for Diabetics : : Wash the eyes regularly; use soft towel.Wash the eyes regularly; use soft towel. Use sunglasses (while outside).Use sunglasses (while outside). Utmost safety and surety while using contact lenses.Utmost safety and surety while using contact lenses.

PRECAUTIONS FOR DIABETICSPRECAUTIONS FOR DIABETICS Always carry Always carry diabetic identity carddiabetic identity card.. Carry sugar, glucose, Carry sugar, glucose, candycandy.. Drink plenty of water to avoid dehydration.Drink plenty of water to avoid dehydration. Avoid strenuous exercise (for patients w/ eye bleeds).Avoid strenuous exercise (for patients w/ eye bleeds). Stop exercising if chest pain or discomfort develops. Stop exercising if chest pain or discomfort develops.

DM UpdatesDM Updates

The US FDA has announced the approval of a drug called The US FDA has announced the approval of a drug called FarxigaFarxiga ( (DapaglifozinDapaglifozin) to help treat adults with type 2 ) to help treat adults with type 2 DM. The tablets, DM. The tablets, in combination with diet and exercisein combination with diet and exercise, , are said to improve control of blood sugar levels.are said to improve control of blood sugar levels.

Farxiga, a Farxiga, a sodium-glucose co-transporter 2 inhibitor sodium-glucose co-transporter 2 inhibitor (SGLT2), works by (SGLT2), works by preventing the kidney from preventing the kidney from reabsorbing glucosereabsorbing glucose. This . This increases the excretion of increases the excretion of glucose glucose and and reduces blood sugar levelsreduces blood sugar levels. .

According to the US FDA, 16 clinical trials involving more According to the US FDA, 16 clinical trials involving more than 9,400 patients with type 2 diabetes assessed the than 9,400 patients with type 2 diabetes assessed the safety and effectiveness of the drug. safety and effectiveness of the drug.

These trials demonstrated that Farxiga was These trials demonstrated that Farxiga was able to able to improve HbA1c levels in type 2 diabetic patientsimprove HbA1c levels in type 2 diabetic patients. .

The FDA says as well as being assessed as a The FDA says as well as being assessed as a stand-alone stand-alone therapytherapy, the drug has also been tested in , the drug has also been tested in combinationcombination with other treatments for type 2 diabetes, including with other treatments for type 2 diabetes, including insulin, pioglitazone, metformin, glimepiride, and insulin, pioglitazone, metformin, glimepiride, and sitagliptin. sitagliptin.

BUTBUT…..….. Clinical trials have found that Farxiga is Clinical trials have found that Farxiga is not suitable for not suitable for

individuals with type 1 diabetes, diabetic ketoacidosis, individuals with type 1 diabetes, diabetic ketoacidosis, patients with moderate or severe kidney deterioration, patients with moderate or severe kidney deterioration, end-stage kidney disease, or patients receiving dialysisend-stage kidney disease, or patients receiving dialysis. .

Clinical trials revealed that among users of Farxiga, there Clinical trials revealed that among users of Farxiga, there were an increased number of were an increased number of bladder cancerbladder cancers s diagnosed. diagnosed.

Therefore, the FDA recommends Therefore, the FDA recommends that patients with that patients with bladder cancer do not use the drugbladder cancer do not use the drug, and that patients , and that patients with a history of the disease should consult their with a history of the disease should consult their physician prior to using it. physician prior to using it.

Dehydration Dehydration was found to be a side effect of the drug. was found to be a side effect of the drug. The FDA notes that elderly patients with The FDA notes that elderly patients with impaired kidney impaired kidney function and patients using diuretics seemed to be more function and patients using diuretics seemed to be more susceptible to thissusceptible to this. .

The most common side effects from Farxiga in clinical The most common side effects from Farxiga in clinical trials were trials were fungal infections fungal infections and and urinary tract infectionsurinary tract infections. .

The FDA have asked for The FDA have asked for six post-marketing studiesix post-marketing studies to s to be performed. These include a be performed. These include a cardiovascular outcomes cardiovascular outcomes trial trial ((CVOTCVOT) in order to analyze how Farxiga affects ) in order to analyze how Farxiga affects patients with high risk of heart disease, and a double-patients with high risk of heart disease, and a double-blind randomized and controlled analysis of the risk of blind randomized and controlled analysis of the risk of bladder cancer for patients who are a part of the CVOT bladder cancer for patients who are a part of the CVOT trial.trial.

(http://www.medicalnewstoday.com/articles/270986.php) (http://www.medicalnewstoday.com/articles/270986.php) 9 Jan 20149 Jan 2014

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