whole description of DM along with case study all taken from guidelines

2. Presented by: 10260, 9710, 9971
10033,9918, 9867

3. Maheen Tahir CMS# 10260
Lubaba Muhammad CMS# 9710
Sidra Razzaq CMS# 9971
Maria Khalid CMS# 10033
Mamoona Javed CMS# 9918
Huda Batool CMS# 9867

4. Contents
Introduction
Definition
Types of Diabetes
Epidemiology
Pathophysiology
Clinical presentation
– Sign and symptoms
– Diagnostic tests
Pharmacological treatment
– Emergency Management
– Treatment Algorithm
Non-pharmacological treatment
– Diet
– Patient Counseling
References

5. Case
Miss Mobeen is a 40 years old female having 72 kg weight. She is a known
Hypertensive and diabetic (Type-II DM) patient since 2 years. She was admitted
to hospital with the complaint of fever (39 C) since 2 days, heavy bleeding
and clots associa-ted with pain. She took medications to relieve symptoms
temporarily. She was taking oral contraceptives and Primolut-N since 2 months.
Endometrial sampling showed disordered proliferations. She also had poor
glycemic control.

6. Mamoona Javed (9918)

7. Definition
Diabetes is a condition primarily defined by
the level of hyper-glycaemia giving rise to
risk of micro-vascular damage (retinopathy,
nephropathy and neuropathy). It is associated
with reduced life expectancy, significant
morbidity due to specific diabetes related
micro-vascular complications, increased risk
of macro-vascular complications (ischaemic
heart disease, stroke and peripheral vascular
disease), and diminished quality of life.
Diabetes is a group of metabolic diseases
characterized by hyperglycemia resulting
from defects in insulin secretion, insulin
action, or both. The chronic hyperglycemia
of diabetes is associated with long-term
damage, dysfunction, and failure of various
organs, especially the eyes, kidneys, nerves
, heart, and blood vessels.

8. Blood Sugar Levels

9. Pre-Diabetes
The condition in which Blood glucose levels that are higher than normal but not yet high
enough to be diagnosed as diabetes is called Pre-Diabetes

10. Types of
Diabetes
Type-I Diabetes
Type- II Diabetes:

11. Gestational Diabetes:
Diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt
diabetes prior to gestation
Maturity-Onset Diabetes of the young (MODY):
These forms of diabetes are frequently characterized by onset of hyperglycemia at an early
age (generally before age 25 years).
They are referred to as maturity-onset diabetes of the young (MODY) and are characterized by
impaired insulin secretion with minimal or no defects in insulin action.

12. Drug or Chemical-induced Diabetes:
There are also many drugs and hormones that can impair insulin action. Examples include
nicotinic acid and glucocorticoids. Patients receiving α-interferon have been reported to
develop diabetes associated with islet cell antibodies and, in certain instances, severe insulin
deficiency.
Certain toxins such as Vacor (a rat poison) and intravenous pentamidine can permanently
destroy pancreatic β-cells.

13. Epidemiology

16. Huda Batool (9867)

21. Maria Khalid (10033)

22. Diagnosis in Asymptomatic Adults:

23. Diagnosis for Pre-diabetes:

24. Criteria for Type-I DM Diagnosis:
Diagnostic criteria by the American Diabetes Association (ADA) for Type-I DM
include the following :
• A fasting plasma glucose (FPG) level ≥126 mg/dL (7.0 mmol/L), or
• A 2-hour plasma glucose level ≥200 mg/dL (11.1 mmol/L) during a 75-g
oral glucose tolerance test (OGTT), or
• A random plasma glucose ≥200 mg/dL (11.1 mmol/L) in a patient with
classic symptoms of hyperglycemia or hyperglycemic crisis

25. Criteria for Type-II DM Diagnosis:

26. Diagnosis of Gestational DM:

27. Maheen Tahir (10260)

28. Patients with severe hyperglycemia should immediately undergo assessment and
stabilization of the airway and hemodynamic status.
In patients with hyperglycemia, give insulin IV along with fluids and electrolytes.
If patient suffers with hypoglycemia, give 10-20 g glucose in form of syrup or
juice at home, and in hospital, administer IV glucagon
If patient comes with ketoacidosis, Correct fluid loss with intravenous fluids and
hyperglycemia with insulin, correct electrolyte disturbances, particularly potassium
loss, Correct acid-base balance
Naloxone, to reverse potential opiate overdose, should be
considered for all patients with altered mentation.

29. Thiamine, for acute treatment of Wernicke’s encephalopathy, should be
considered in all patients with signs of malnutrition. In cases requiring intu
bation, the paralytic succinylcholine should not be used if hyperkalemia is
suspected; it may acutely further elevate potassium.
Immediate assessment also includes placing patients on a cardiac monitor
and oxygen as well as obtaining vital signs, a finger-stick glucose, intra
venous (IV) access, and an electrocardiogram to evaluate for arrhythm
ias
and signs of hyper- and hypokalemia.
Obtain blood for laboratory studies
Initiate therapy based on acuity

30. Maheen Tahir (10260)

31. Contd…

32. Contd…

33. Contd…
DPP: Dipeptidyl peptidase;
SGLT: Sodium-glucose co-transporter;
GLP: Glucagon-like peptide

34. Contd…

36. Sidra Razzaq (9971)

37. Class Drug Dose Indications Contra
indications
Adverse effects
Biguanides Metformin
Initially 500 mg OD for 1 week,
then 500 mg BD for 1 week
taken with meals. Max 2g /day
IDDM, NIDDM,
Insulin resistance
Ketoacidosis, Renal &
hepatic impairment ,MI
GI upset, Lactic acidosis,
hepatitis, metallic taste, Reduced
Vit B12 absorption,
Sulfonylureas
Glibenclamide,
Glipizide,
Glimipride
Glibenclamide:
5mg daily ,max 15mg/day
Glipizide:
2.5-5 mg daily, max 20mg/day
Glimipride: 1mg daily, max 6
mg/day
NIDDM
Ketoacidosis,
porphyria,
Avoid in pregnancy
because of neonatal
hypoglycemia
Hypoglycemia, Agranulocytosis,
Blood disorders, Hepatitis,
hypersensitivity, aplastic anemia,
weight gain
Thiazolidine-
diones
Pioglitazone
Rosiglitazone
Pioglitazone:
15-20mg OD
Rosiglitazone:
2 mg BD ,max 8mg/day
NIDDM
Hepatic impairment,
Heart failure
Visual disturbance, edema, weight
gain, anemia, hypoglycemia,
myalgia pharyngitis
DPP-4 inhibiter Sitagliptin
vildagliptin
Sitagliptin:
100 mg OD
Vildagliptin:
NIDDM Ketoacidosis,
Renal impairment,
RTI, GIT disturbances, Edema,
arthralgia, hypoglycemia,
hypersensitivity

38. Drug Dose Indications Contraindications Adverse effects
SGLT2 inhibiter
Canagliflozin: 100 mg OD
Dapagliflozin: 10 mg OD
NIDDM Ketoacidosis,
Hypoglycemia,
Polyurea, Dehydration,
GLP-1 receptor agonist Exenatide: 5 μg BD
Liraglutide: 0.6 mg OD
NIDDM
IBD, ketoacidosis,
Heart failure,
Thyroid dysfunction
Gastric distention,
Hypoglycemia, Alopecia
Dehydration,
α-gulcosidase inhibiter
Acarbose: Initially 50 mg OD
then increased to TID.
Max 200 mg TID
NIDDM
IBD, Hepatic and renal
impairment
Gastric distention,
Hepatitis, Edema,
Insulin 100-500U/ml Daibetes mellitus
(NIDDM & IDDM)
Hypoglycemia,
Hypersensitivity
Hypoglycemia,
Hypokalemia, Convulsions,
Allergy ,Blurred vision, Hyp
otention

39. Class Insulin Brands Doses
Rapid Acting Analogs
Lispro Humalog 0.5-1.2 units/kg/day SC
Aspart Novorapid
0.5-0.8 units/kg/day SC (Type-I DM)
0.1 units/kg/day SC (Type-II DM)
Glulisine Apidra 0.5-1 units/kg/day SC
Inhaled Insulin Afrezza 4 units at each meal inhalation
Intermediate Acting Analogs
Human NPH
Humulin-N
0.5-0.8 units/kg/day SC (Type-I DM)
0.5-1.5 units/kg/day SC (Type-II DM)
Short Acting Analogs
Human Regular
Humulin-R
0.5-1 unit/kg/day SC divided q8hr (Type-I DM)
0.1-0.2 unit/kg/day SC (Type-II DM)
Basal Analogs
Glargine Lantus 10 units/day SC
Detemir Levemir 0.1-0.2 units/kg/day SC
Degludec Tresiba
0.2-0.4 units/kg/day SC (Type-I DM)
10 units/day SC (Type-II DM)
Premixed products
NPH/Regular 70/30 Novolin ; Humulin 70/30
0.5 units/kg/day SC (Type-I DM)
0.5-1 units/kg/day SC (Type-II DM)
Lispro 50/50 Humalog Mix 50-50
0.5-1 unit/kg BID (before breakfast and evening
meal)
Lispro 75/25 Humalog Mix 75-25 0.3 units/kg/day SC
Aspart 70/30 NovoMix 30 0.5-1 unit/kg/day SC

41. At least once a year asses urinary albumin (albumin-creatinine ratio) and estimated
GFR in type 1 & 2 diabetes and in patients with co morbid hypertension.
Optimize the glucose control and blood pressure control to reduce DKD disease pr
ogression.
For patients with non dialysis dependent DKD, dietary protein intake 0.8g/kg per d
ay. Patient dependent on dialysis should consider higher protein in take.
In non pregnant patient with diabetes and hypertension, ACE’I and ARB is recomm
ended.
Periodically monitor Scr and k levels when ACE ,ARBS and diuretics are used.
When estimated GFR<60ml/min/1.73m2 then evaluate complications of DKD .

46. In some cases of diabetic retinopathy, blood vessels on the retina are
damaged. The retina manufactures new, abnormal blood vessels.
Neo-vascular glaucoma can occur if these new blood vessels grow
on the iris (the colored part of the eye), closing off the fluid flow in the eye and raising the
eye pressure.
Neo-vascular glaucoma is a difficult disease to treat.
Beta blockers (such as Timolol), Prostaglandin analogues (such as latanoprost), Carbonic anhydrase
inhibitors (such as Acetazolamide)
Laser surgery is another alternative option to reduce abnormal blood vessels on the iris and on the
retinal surface.

47. Cataracts are one of the sight-related complications of diabetes that can cause misting or blurring of vision.
Surgery is often prescribed, with the lens removed and replaced with an artificial one.

48. For diabetics, problems with the teeth and gums can be more common and
more serious than for the average person.
Gum disease is a very common infection and occurs when bacteria within the mouth begins to form
into a sticky plaque which sits on the surface of the tooth.
Dentist should be visited every six months to ensure that any infection will be treated as early as
possible.
If patient is on medication that can lead to hypoglycemia, such as insulin or sulfonylureas, he should
consult dentist to see if diabetic treatment regime needs to be modified before the dental work.
High blood sugar levels may affect the time the teeth and gums take to heal. If dental work is taking
an unusually long time to heal, patient should contact diabetes healthcare team or dentist
immediately for advice.

50. Patients with diabetes and hypertension should be treated with goal to maintain systolic <140
mmHg and diastolic <90mmHg
For individuals at high risk of CVD, should be maintained at goal BP of 130/80mmHg
Such antihypertensive drugs which reduce cardiovascular events in diabetic patients are
recommended (ACEI, ARB, thiamine diuretics)
ACE inhibiter is the recommended first line treatment for treatment of hypertension in patient
with diabetes.
Patients treated with any of ACE, ARB or diuretics, Scr and estimated K level and GFR must be
monitored.

51. Use aspirin therapy (75-162mg/day) as secondary prevention in diabetic
patients with history of artheriosclerotic CVD.
For patients with artheriosclerotic CVD and aspirin allergy, clopidogrel
(75 mg/day) must be used.
Consider aspirin therapy (75-162mg/day) as primary prevention for
diabetic patients with increased risk of CVD (>50yrs )

52. In presence of atypical cardiac symptoms ,symptoms of vascular disease
or ECG abnormalities consider investigation for coronary heart disease.
In patients with known artheriosclerotic CVD, use aspirin and statin therapy
(if not contraindicated) and consider ACE inhibiter therapy to reduce risk of
cardiovascular events.
In patients with prior MI, β blockers should be continued for at least 2
years.
Patients with symptomatic heart failure thiazolidinedione therapy should
not be used.
Type-2 diabetic patients with stable congestive heart failure, metformin
may be used if eGFR is >30 ml/min but should be avoided in unstable con
gestive heart failure patients.

53. Preexisting Diabetes:
Women with preexisting type-1 & 2 diabetes with pregnancy should be counseled for the risk
of development of diabetic retinopathy.
Dilated eye examinations should be performed frequently.

54. General principles for management of diabetes in pregnancy:
Potentially teratogenic medications (ACEI ,Statins) should be avoided.
In pregnant patient with diabetes and chronic hypertension BP target of 120-160/80-105 mmHg a
re suggested.
Fasting and postprandial self-monitoring of glucose is recommended.
Due to increase RBC’s turnover , A1C is lower in pregnancy.A1C target in pregnancy is 6-6.5%
(42-48mmol/mol).

55. Lubaba Muhammad (9710)

57. Nutrition Therapy
All individuals with diabetes should receive individualized medical nutrition
therapy (MNT)
There is not a one-size-fits-all eating pattern for individuals with diabetes.
Nutrition therapy has an integral role in overall diabetes management.

58. 5% of initial body weight (to improve glycemic control and to reduce the
need for glucose-lowering medications).
Weight loss can be attained by :
o 500–750 kcal/day energy deficit or
o 1,200–1,500 kcal/day for women
o 1,500–1,800 kcal/day for men
(adjusted for the individual’s baseline body weight)
Obese individuals (Type 2 diabetes); weight loss ＞5% is needed
Sustained weight loss of ≥7% is optimal

59. Carb intake from veggies, fruits, whole grains, legumes, dairy is
recommended.
Avoid other carb sources, especially those with added fats, sugar, sodium.
Dietary fiber and whole grains: consumption of at least:
o Fiber: 25 g/day women; 38 g/day men
o ≥50% of all grains should be whole grains
For those with diabetic kidney disease, dietary protein should be
maintained at the recommended daily allowance of 0.8 g/kg body weight/
day.

60. People with diabetes should limit their sodium consumption to ,2,300 mg/
day.
The Institute of Medicine has defined an acceptable macronutrient
distribution for total fat for all adults to be 20–35% of energy
Non-nutritive sweeteners (to reduce carbs & calorie intake), physical activity
(children: 60 min/day; Adults: 150 min/day)
Psychosocial care should be integrated with a collaborative, patient-
centered approach and provided to all people with diabetes, with the goals
of optimizing health outcomes and health-related quality of life.

61. Lubaba Muhammad (9710)

62. Aim for at least 2 ½ hours (150 minutes) of moderate physical activity per
week including walking, cycling etc.
If you are overweight, work to come up with a target goal for weight loss.
Avoid smoking.
Check your blood glucose routinely.
Use foods that are high in protein and healthy fats.
Fruits, vegetables (low carb e.g. lettuce or spinach), bread, cereal, beans, nuts,
and seeds.
Fresh foods that are in season
Unprocessed foods (foods that do not contain additives, artificial flavoring and
other chemical ingredients)
Fruit for dessert
Low amounts of sugar or honey

63. Healthy fat, such as olive oil, instead of butter
Low-to-medium amounts of dairy, eggs, red meat.
Wash your feet daily especially in summers to avoid diabetic foot
Get an eye examination atleast once a year
Take your anti-diabetic medicines regularly.

65. Case
Miss Mobeen is a 40 years old female having 72 kg weight. She is a known
Hypertensive and diabetic (Type-II DM) patient since 2 years. She was admitted
to hospital with the complaint of fever (39 C) since 2 days, heavy bleeding
and clots associated with pain. She took medications to relieve symptoms
temporarily. She was taking oral contraceptives and Primolut-N since 2 months.
Endometrial sampling showed disordered proliferations. She also had poor
glycemic control.

66. Chief complaint:
– Heavy menstrual bleeding associated with pain
– Fever (39 C)
Past medical history:
– Diabetes mellitus and hypertension since 2 years
Past medication history:
– Primolut-N
– Oral contraceptives

67. Subjective finding
– Heavy menstrual bleeding
– Pain
Recently diagnosed for
– Patient is recently diagnosed for gonorrhea

68. Sign Normal 1 2 3 Comments
BP 120/80 140/90 140/90 130/90 Raised BP
TEMP 37 39 38 38 Pyrexia
RR 12-18 16 18 18 Normal
PR 60-100 82/min 80/min 84/min Normal

69. Normal range Lab value interpretation
Hematology Data
HCT 12-16 g/dL 14.7 Within normal range
Platelet 150-400x 10/L
293 X 10/L Within normal range
TLC 5000 to 10,000/mm3. 9800 Within normal range
urea and electrolytes
urea 1.7 – 8.3 mol/l 3.9 mol/l Within normal range
Na 135 to 145 (mEq/L). 139 mol/l Within normal range
K 3.5-5.0 mEq/L) 4.4 mol/l Within normal range

70. Contd…
Normal range Lab value interpretation
LFT’S
Serum bilirubin 0.3 to 1.9 mg/dL. 0.6 mg/dL Within normal range
RFT’S
Creatinine
For women is 0.6-1.
2 mg/dL
0.7 Within normal range
Urinalysis
Urine R/E
Pus cells Infection
Protiens Proteinuria
Glucose Glucosuria

71. Contd…
Blood Sugar BSR/BSF Comments
219 mg/dl BSR hyperglycemia
306 mg/dl BSR hyperglycemia
308 mg/dl BSF hyperglycemia
150 mg/dl BSR Slight raised
101 mg/dl BSR Blood sugar levels ar
e controlled with dr
ugs
120 mg/dl BSF Slight raised

72. Therapeutic Problem
Heavy menstrual Bleeding
Fever
Poor glycemic control
Goal of Therapy
To treat infection using
Antibiotic (cefspan)
To reduce fever using Anti-
pyretics
Insulin is administered to
control Sugar levels

73. Brand name Generic name Dose Prescribed for Date started
Norethisterone 5-10 mg Menstrual Bleeding 20-12-16

74. Brand name Generic name Formulation
Prescribed dose
(9/02/2017)
Prescribed dose
(11/02/2017)
Prescribed dose
(14/02/2017)
Humulin-N Insulin NPH Inj
14 units morning
and evening (BD)
18 units morning
and evening (BD)
22 units morning
and evening (BD)
Humulin-R Regular insulin Inj
14 units morning,
and evening (BD)
18 units morning
and evening (BD)
18 units M, 20
units E (BD)

75. Contd…
Brand name Generic name Formulation Prescribed dose Prescribed For Date Started
Flagyl Metronidazole Tablet 400 mg TID
Diarrhea associated
with cefspan
09/02/2017
Cefspan Cefixime Capsule 400 mg OD Infection 09/02/2017

76. Class Brand name
Dosage regimen
prescribed
Route of
administration
Cost of
treatment
1st line of drug for
respective disease
Intermediate
acting
insulin
Humulin N 22 units BD SC Rs.495/-
Strength Frequency Calculations Per Day
22 units
0.5-1.5units/kg/day
(36-108 units/
Day)
BD BD 44 units 36-108 units

77. Drug Caution ADRs Interactions Contraindications
Insulin NPH --
Hypoglycemia,
Hypokalemia,
Convulsions,
Allergy ,Blurred
vision,
Hypotension,
Excessive fluid
retention
--
Hepatic & renal
Impairment,
hypersensitivity

78. Prescribed time of administration Effect of Food Pharmacist Recommendation
Half hour before breakfast and
Half hour before dinner
Should be taken before meal, as food will p
revent sudden hypoglycemic effect
associated with insulin
Should e taken before meal, regularly m
onitor blood sugar levels
Is the drug rational Is the drug cost effectiveness Any alternative drug
Yes, because no other cheaper alternative
is available
Insulatard-HN
Rs. 500/-

79. Class Brand name
Dosage regimen
prescribed
Route of
administration
Cost of
treatment
1st line of drug for
respective disease
Short acting
insulin
Humulin R 20 units BID SC Rs.495/-
Strength Frequency Calculations Per Day
20 units
0.1-0.2 unit/kg/day
(7.2-14.4 units/
Day)
BD BD 40 units 7.2-14.4 units

80. Drug Caution ADRs Interactions Contraindications
Insulin
regular
--
Hypoglycemia,
Hypokalemia,
Convulsions,
Allergy ,Blurred
vision,
Hypotension,
Excessive fluid
Retention, seizures,
loss of
Consciousness, SOB
--
Hepatic & renal
Impairment,
hypersensitivity

81. Prescribed time of administration Effect of Food Pharmacist Recommendation
Half hour before breakfast and
Half hour before dinner
Should be taken before meal, as food will p
revent sudden hypoglycemic effect
associated with insulin
Should e taken before meal, regularly m
onitor blood sugar levels
Is the drug rational Is the drug cost effectiveness Any alternative drug
Yes, because no other cheaper alternative
is available
---

82. Gonorrhea will be treated using Cefspan
Fever will be controlled when infection is treated, but symptomatic
treatment must e given to the patient (i.e. Anti pyretics)
Poor glycemic control will be managed using Humulin-N and Humulin-R
No treatment is given for patient’s hypertension, so an Anit- hypertensive
must be added (ACE inhibitors are first line therapy for HTN in diabetes)

83. Check your blood glucose and blood pressure routinely.
Use Low amounts of sugar or honey
Aim for at least 2 ½ hours (150 minutes) of moderate physical activity per
week
Use Fruits, vegetables (low carb e.g. lettuce or spinach), bread, cereal, bean
, nuts, and seeds
Wash your feet daily especially in summers to avoid diabetic foot
Get an eye examination atleast once a year
Take your anti-diabetic medicines regularly.
Keep appointments for regular follow-ups

84. References
International Diabetes Federation. (2017). Diabetes: facts and figures. [online] Available at: http://www.idf.org/a
bout-diabetes/facts-figures.
Guideline.gov. (2017). NGC-3306_1. [online] Available at: https://www.guideline.gov/algorithm/3306/NGC-3306
_1.html.
World Health Organization. (2017). Diabetes. [online] Available at: http://www.who.int/mediacentre/factsheets/f
s312/en/].
Ndei.org. (2017). ADA Diabetes Management Guidelines A1C Diagnosis | NDEI. [online] Available at: http://ww
w.ndei.org/ADA-diabetes-management-guidelines-diagnosis-A1C-testing.aspx.html [Accessed 25 Apr. 2017].