Introduction This disease is found in different types of people. Its causes, symptoms, complications and treatment are all different. Therefore, diabetes is not called a disease but a “syndrome”.
Definition
Diabetes is a disease caused due to the relative deficiency or absolute deficiency of the hormone insulin which is released from the pancreas or due to the inability or resistance of the cells to use insulin. This disrupts the metabolism of carbohydrates, fats and proteins. Many genetic and environmental factors play a role in the occurrence of this disease.
This causes the patient to have more sugar than normal in the blood and urine. Along with this, there may also be more fat, as a result of which the patient may suffer from 'Ketoacidosis'. The patient's arteries and capillaries have more fat in the cells. Diabetes has a bad effect on arteries and nerves.
Diabetes is spread all over the world. It is generally called the disease of the rich. This disease makes the body hollow from inside. Types (1) Diabetes (A) Primary or Idiopathic :- • Insulin dependent diabetes (starting in childhood). • Diabetes not dependent on insulin (occurring in adults). > Fat man > Man in the middle > Thin man. • Diabetes in young people. (B) Secondary Due to disease in pancreas. Due to effect of medicines. Due to endocrine disturbance. Due to disturbance in insulin. (2) Possibility of diabetes (Impaired Glucose Tolerance) • Primary :-
> Obesity. > Not being obese.
• Secondary :-
Disorder in pancreas. > Renal failure. Staying hungry. > Heart failure. > Cirrhosis of liver. Cause (Aetiology) • Heredity :- > Children of parents suffering from diabetes are more likely to get this disease. > The chances of getting diabetes are reduced if either of the parents has diabetes. Food habits :- > Overeating and obesity can cause diabetes in adults.
> Eating too little can also cause diabetes. • In India, diabetes is more prevalent in the age group of 45 to 55 years. • It is more prevalent in men than women. • When there is hindrance in the production of insulin due to increasing fibrosis in the pancreas. • Infection. • Excessive mental stress. • Viral infection. • Not doing enough physical labour. • Change in hormones in the body. • Due to calcific pancreatitis caused by prolonged alcohol consumption. • Due to pancreatic cancer. • Due to cystic fibrosis. • Due to the bad effects of medicines like some medicines that cause increased urination and contraceptive medicines. • When there is a disturbance in insulin. • When there is a problem with the insulin receptor. • Due to eating too much sweets and obesity. • Due to shrinkage of pancreas and formation of stones in its ducts. Main symptoms and signs of the disease: - Most diabetes patients come to the doctor with three symptoms: • Frequent urination - the patient complains that he has to get up several times to urinate even at night. • Feeling very thirsty and dry mouth. • Feeling very hungry.
Along with these, there are other symptoms - Feeling tired and weak in the body. • Weight loss. • Mental fatigue and lack of concentration. • Delayed healing of wounds. • Repeated formation of pus in wounds. • Tingling and pain in hands and feet and numbness. • Itching around the genitals. • White spots on clothes. • Weak eyesight and blurred vision. • Sexual weakness or impotence. • Repeated attacks of diseases. • Arterial diseases at a young age. • Fainting due to diabetes. • Lack of interest in any work, feeling of extreme weakness in the body. • Pain and weakness in the legs.
• Sudden swelling in the urinary tract of men and vagina of women.
• On enquiry, it is found that someone in the family has a history of diabetes. • There is always a burning sensation in the soles of the feet. • Dryness on the skin of the body. • Frequent eruption of boils. • Ants gathering on the urine. • The patient has a desire to eat something again and again. • Strong desire to sleep or rest and avoids working hard. • In women, the womb is larger than normal, which causes difficulty during delivery. Many times the child also dies. • Feeling more thirsty even in winters. • Many times diabetes is detected during the investigation of some other disease. Therefore, the physical examination of a diabetic patient should be done properly.
Signs • Collect the weight, height and skin thickness of the patient and check it. • Also check his blood pressure, temperature and pulse. Check the mouth and skin for local infection. • It is necessary to check the peripheral pulse. • In liver examination, it is found to be enlarged by 20 to 30 percent. • Eye examination: - In the initial stage, there is a slight change in the lens and arteries. In case of severe diabetes, secretion comes out of the arteries and gets deposited on the retina. Due to which the person has blurred vision. If diabetes remains uncontrolled for a long time, the vision of the retina becomes almost nil. The patient may also have cataract. • There is a strain in the muscles. • On examination, the reflex of the knee and ankle is found to be less. The skin's sense of touch, pain and tingling sensation is reduced. • Diabetes is found in children as well as adults these days. This disease is gradually increasing. Scientists are giving more importance to human lifestyle and genetic factors in its causes. Main tests in diabetes and its diagnosis • Tests to detect the presence of sugar in urine: - Testing glucose in urine is the first and important step in the diagnosis of diabetes. It is tested in many ways. By Benedict Test By Clinicist Tablets + By Diastix • Benedict Test: - This is a simple and important test to detect glucose in urine. The patient can also do it easily at home. Method - Benedict solution (not more than 3 months old). • Test tube. • Dropper. • Test tube stand. Take 5 ml Benedict solution in a test tube. Put 10 to 15 drops of urine in it. Mix Benedict solution and urine by shaking the test tube. After that, hold the test tube by the stand and heat it on the gas. The mixture in it will start boiling. Then remove it from the gas to cool down. The color of the mixture changes after cooling. The amount of glucose is determined according to the color of the mixture. Blue color - no glucose. Green color - 0.5% glucose. Yellow color - 1% glucose. Saffron color - 1.5% glucose. Red color - 2% or more glucose content. Normally, 50 to 100 mg of glucose is excreted in 100 ml of urine. Therefore, when the glucose level in urine increases, this test shows its level. Keep in mind • Sometimes, due to the effect of other medicines or chemicals, this test may show wrong level. Therefore, it is necessary to test the blood as well. • Do the test two hours after the meal. • Along with Benedict's test, also do the test with Uristix or Diastix. • It is not necessary that all diabetic patients have high glucose level in their urine or that if glucose level is high, they have diabetes. Sometimes, even if there is low glucose level in blood, due to other diseases, it gets filtered through kidneys and enters the urine. Normally the threshold of kidneys for glucose is 180 mg/100 ml. When the amount of glucose in the blood increases beyond this, only then it starts coming out in the urine. Blood test for diagnosis of diabetes Blood or Plasma Glucose Estimation: The amount of glucose in the blood of a normal healthy person is usually 80 to 100 mg per 100 ml. In a diabetic patient, this amount increases beyond this. Method of blood test: - Advise the patient not to eat anything after 10 pm on the first night. Take a blood sample (2 ml) in a normal bottle at around 8 am. After that, give him about 75 grams of glucose mixed in water or ask him to eat a full meal. Take the second blood sample after 2 hours. The first blood sample is called fasting sample and the second is called glucose or post meal sample. The World Health Organization (WHO) criteria for diabetes are:- Glucose level in fasting sample (F) is 140 mg or more. Glucose level in post glucose sample (PP) is 180 to 200 mg or more. If the glucose level in a person's blood sample is 140 mg per 100 ml after fasting and 180 to 200 mg/100 ml after eating, then he should be declared as suffering from diabetes. Glucose Tolerance Test (GTT) :- It is not necessary to get this done in every patient. If high glucose levels are detected in general blood test, other things should also be checked. If the glucose levels in blood are found to be high more than once, glucose tolerance test should be done. Glucose tolerance test (GTT) should be done in the following circumstances • Obesity. • During pregnancy (if there is a family history). • Cataract at a young age. • Vascular disease at a young age. • Any complication of diabetes is seen. • Symptoms of low glucose levels in blood are seen. • Before major surgery. • Before doing this test, the patient should fast for 10 to 16 hours and give him a good amount of carbohydrates to eat in the first 3 days. After that, give the patient about 75 grams of glucose dissolved in 300 ml of water to drink. Forbid the patient to smoke or eat anything. After this, take blood and urine samples 4 to 5 times every 1/2 hour and test them. > Glucose tolerance test can give reliable information about the reaction of a person's body to glucose. World Health Organization (W.H.O.) In diabetes: -
After fasting Blood glucose 120 mg or more 2 hours after giving glucose
(Post Glucose)
Blood glucose 180 mg or more Abnormal Glucose Tolerance Test:- After fasting 2 hours after giving glucose (Post Glucose) 2-1/2 hours later Blood glucose more than 120 mg Blood glucose 120 mg to 140 mg or more Blood glucose more than 180 mg From time to time, the element 'Ketone' should also be checked by testing urine. Its presence indicates that diabetes is in a serious stage. ⇒ Keep in mind that the presence of ketone in urine can be fatal for the patient. While testing urine, look at the following points carefully. 1. Amount of glucose. 2. Amount of protein. 3. Pus cells. 4. Bacteria. 5. Ketone elements. ⇒ Diabetic patients also show high fat content in their blood test. ⇒ Therefore, along with other tests, get serum cholesterol and triglycerides tested every year. ⇒ Serum urea and creatinine ⇒ X-ray - Chest X-ray gives information about the size of the heart and any chest infection. ⇒ E.C.G. - Gives information about the condition of the heart. ⇒ A person may have diabetes if he gets boils and pimples repeatedly, wounds do not heal, there is pain and burning in the feet, itching in the reproductive organs or weakness without any apparent reason. Therefore, get him thoroughly examined immediately. Diagnostic symptoms of diabetes:- • Frequent urination. • Excessive thirst. • Overeating. • Uncontrolled weight loss. • Fatigue and weakness in the body. • Itching in the reproductive organs. • Getting up frequently at night to urinate. • Blurred vision. • High glucose levels in blood and urine. • Constant pain in the calves. Treatment of diabetes:- This is a disease that stays with a person for the whole life. Therefore, explain the disease to the patient properly. His cooperation is very important in the treatment of this disease. This disease can be controlled, but cannot be cured forever. The patient can live his life well while suffering from the disease, provided he follows the doctor's advice. Keep the following goals in mind in the treatment of diabetes :- • Control the symptoms. • Instill confidence in the patient. He should feel that he is absolutely fine. • Pay attention to the weight and physical development of the patient. • Protect him from any infection. • Prevent ketoacidosis and hypoglycemia. • Correct excess fat in the blood. • Prevent neuro-vascular problems. • Treatment of diabetes is mainly based on four things:- • Diet. • Exercise. • Glucose-reducing drugs. • Insulin. Diet: It is very important for a diabetic patient to plan his diet. This is an important part of the patient's treatment. While deciding the diet, keep in mind that it should be nutritious and fulfill the patient's vitamin and protein requirement. Decide the diet of each patient by looking at his food habits, lifestyle and needs. It cannot be the same for every patient. The diet of each patient is planned according to the calorie requirement. The daily calorie requirement is estimated based on the lifestyle and work of the patient. For a normal patient, start with 30 calories per kilogram per day, and for a person who works hard, start with 35 to 40 calories per kilogram. Daily calorie chart based on person's work and weight: Calories/kg Low work Intermediate High work Normal weight 30 35 40
Low weight 35 40 45
Overweight 20 25 30 ⇒ In special circumstances, such as pregnancy, breastfeeding or in growing children, this can be increased.
The amount of carbohydrates, fats and proteins in the daily diet depends on the individual. The quantity of all these is decided according to the eating habits of the patient. The following ratio is kept in the diet of a normal diabetic patient. Carbohydrates - 60% Proteins - 15% to 20 Fats - 20% to 25% In India, the main sources of carbohydrates are wheat, millets, rice and vegetables and fruits. The patient's diet should contain more unrefined grains, pulses, green vegetables and fruits. Due to the high amount of fiber in them, the amount of glucose in the blood does not increase immediately. • An alcoholic patient can also take a little alcohol but its quantity should be limited. However, prohibition of alcohol is better. • Do not take sugar, jaggery, honey, butter, ghee, sweets, fatty milk, ice cream, chocolate, potatoes, rice, mango and banana in the diet. Due to the high amount of carbohydrates in all these, they increase blood glucose. • In beverages, advise to consume cola, coffee, alcohol, canned juice as little as possible. • The patient should be advised not to consume dry fruits like cashews and pistachios. • The patient can use saccharine instead of sugar for sweetness. Exercise: Exercise increases the effect of insulin on the body. • Due to the presence of insulin in the body, (i) the entry of glucose in the muscles increases. (ii) The number of receptors on the target cell also increases. ⇒ When fasting blood sugar reaches above 300 mg, the effect of exercise is not visible because the amount of insulin in the blood becomes very low. Therefore, it is necessary to give insulin to such patients. ⇒ Many times, due to excessive exercise, the amount of glucose in the blood decreases, due to which the patient starts feeling dizzy. Therefore, it is necessary to maintain an equal balance between exercise, food and medicines. ⇒ In case of obesity or overweight, ask the patient to reduce his weight by paying attention to exercise and food. Medicines that reduce glucose in the blood Oral Hypoglycemic Agents Two types of medicines are used in diabetes that is not dependent on insulin. • Sulphonylureas • Biguanides These medicines are used only when diabetes is not controlled by food. Allopathic medicines used in diabetes ⇒ Tolbutamide: This medicine can be given when diabetes is low. It should be given 30 minutes before breakfast or food. ⇒Tablet Restinon 500 mg N. Hext Dosage: 1 gram daily. Maximum 0.5-3 grams. ⇒ Chlorpropamide: • Stimulates the production of insulin. • Prevents the release of glucose from the liver. • Increases the tolerance of tissues and muscles to insulin. Commercial name:- ⇒ Chlorformin Cadila ⇒ Copamide 250 mg Days ⇒ Diabinese 100 mg 250 mg Pfizer Dosage: Initially 100-250 mg daily after breakfast, thereafter it can be increased or decreased according to the condition of the patient. Maximum 500 mg daily. Adverse effects: Skin disease, stomach upset, blood cancer.
⇒ Glibenclamide:-
• On taking it, insulin (hormone) is immediately secreted from the pancreas. Which controls the amount of glucose in the blood. It is an excellent medicine for controlling diabetes. If taken for a long time like 10 years, its effect reduces a bit but the amount of glucose in the blood still remains controlled.
⇒ Sulphonylureas :-
• These drugs stimulate the production of insulin. The production of insulin is stimulated as soon as glucose, fat and protein are taken in the food. • These drugs also increase the effect of external insulin. • They cannot be used in insulin dependent patients. • The presence of insulin is necessary for their functioning. These drugs are more effective in those in whom: • Diabetes is not more than 10 years old. • Age should be more than 35 years. • Body structure is fine or obese. • The need of insulin is maximum 40 units per day. It is not used in the following types of patients. • During pregnancy or mental stress. • In case of severe diabetes. • When "ketone" element is present in urine. • In case of extreme weakness. • In case of surgical infection. • In case of kidney or liver disease.
Names of drugs
Tablet dosage
Daily dosage
1. Tolbutamide 0.5 to 1 gram 0.5 - 3 gram (Tolbutamide)
2. Chlorpropamide 100 mg 50 - 500 mg (Chlorpropamide) 250 mg
3. Glybenclamide 5 mg 2.5 - 20 mg (Glybenclamide)
4. Glipizide 5 mg 2.5 - 30 mg (Glipizide)
5. Gliclazide 80 mg 80 - 320 mg (Gliclazide)
Commercial name: -
⇒ Tab. Betanase 5 mg N. Elidec ⇒ Tab. Daonil 5 mg N. Hext ⇒ Tab. Euglucon 5 mg N. Boehringer Mannheim
Dosage: Initially 2.5 to 5 mg daily with breakfast, thereafter can be increased or decreased depending upon the level of glucose in the blood of the patient. Maximum - 15 mg daily.
⇒ Adverse effects are vomiting, nausea, loss of appetite, itching, blood cancer.
Gliclazide:-This medicine not only reduces glucose in the blood but also affects the blood vessels. The effect of insulin remains for 24 hours and the amount of glucose in the patient's blood does not decrease. It also prevents blood from thickening or clotting.
Commercial name:-
⇒ Tab. Diabend 80 mg N. Bal Pharma ⇒ Tab. Diamicron 80 mg N. Sardia ⇒ Tab. Glizid 80 mg N. Penasia ⇒ Tab. Glycigon 80 mg N. Aristo
Dosage: Generally 160 mg daily. Maximum 320 mg. Adverse effects: Skin diseases, blood diseases.
Glipizide:-
This is a relatively new drug and has all the properties of glyclazide and glibenclamide.
Commercial name:-
⇒ Tab. Glynase 5 mg N. U.S. Vitamins ⇒ Tab. Glide 5 mg N. Franco India ⇒ Tab. Glucolip 5 mg N. Wallace
Dosage: 2.5 to 5 mg daily. Take 30 minutes before breakfast. Increase the dose gradually if needed.
Adverse effects: Skin diseases, vomiting, dizziness, headache, blood diseases.
Biguanides:-
There are two drugs in this group. • Phenformin • Metformin
These drugs are completely different from the previous group. They work in the following ways. • By increasing the use of glucose in the superficial tissues. • By reducing the production of glucose in the liver. • By reducing the absorption of glucose in the intestines. Among the two drugs, “Metformin” is used more. It reduces lactic acidosis. Mostly in obese patients, “sulfonyl urease” is given along with them to increase their effect. Sometimes biguanides are also used alone. Adverse effects • Loss of appetite. • Change in the taste of the mouth. • Nausea. • Vomiting. • Pain in the epigastric region. • Lactic acidosis. • Its side effects are reduced if the medicine is taken with food. Caution: - These medicines should not be taken in liver, kidney and heart diseases. Commercial name: - ⇒ Tab. DBI (Phenformin) 25 mg. N. U.S. Vitamins Amount: 25 mg 1 to 4 times daily. Maximum 100 mg. N. Boehringer Mehnheim ⇒ Tab. Gluformin (Metformin) 500 mg. ⇒ Tab. Glyciphage (Metformin) 500 mg D. Franco Indian Dosage: Start with 250 mg 2 to 3 times a day. Give upto a maximum of 3 grams. ⇒ Tab. Glycomet (Metformin) 500 mg D. U.S.V. ⇒ Tab. Walaphage (Metformin) 500 mg D. Wallace Give in the above mentioned quantity. Insulin therapy in diabetes: - Insulin is required in the following conditions - • Insulin dependent diabetes (IDDM). • In pregnancy. • In stress like infection or surgery. • When diabetes is not controlled with other medicines.
• When diabetes is not controlled by food. • Diabetes caused by pancreatic disorder in young people. • In weak and thin patients. Different types of insulin are available in the market. The time of effect of each is different. Some show effect for 8 hours and some for 24 hours. • Insulin also varies in purity and quality. • Give the amount of insulin to the patient according to his blood sugar. Diabetes cannot be controlled if insulin is not taken in full quantity and at the right time. • Along with taking insulin, it is necessary for the patient to control his food. He should follow the diet chart prepared by the doctor. Keeping calories in mind, some changes can be made in the food according to your taste. Insulin obtained from animals:- ⇒ Actrapid 40 units mln. nol ⇒ Actrapid MC 40 units/ mln. nol These are used when immediate and more effective insulin is required. Insulin infusion is given during emergencies such as diabetic unconsciousness and surgery. Dosage: As per the requirement of the patient. It can be given several times a day. ⇒ Lentard 40 units/ mln. nol
Dosage: As per the patient. One to two injections have to be given in a day. Its effect lasts for a long time.
⇒ Mixtard 10 mln. vial nol ⇒ Insulatard isophane insulin nol The effect of these insulins lasts for a long time, from 18 to 24 hours. Their quantity is given as per the requirement of the patient, one to two injections in a day in the form of S/C (under the skin). ⇒ Rapidica Procaine Insulin 40 units/ml Ni. Sarabhai ⇒ Rapimix 10 ml vial Ni. Sarabhai Their quantity is as per the requirement of the patient. Insulin from Human Source: ⇒Actraphane H.M. Penfill 100 units/ml Ni. nol
Dosage: As per the patient - Effect 18 hours to 24 hours - Injection in the form of S/C.
⇒ Human Actrapid 40 units, 100 units/ml This is human neutral insulin. Effect 6 to 8 hours Ni. nol This is human neutral insulin. Effect 6 to 8 hours. ⇒ Human Insulatard Isophane Insulin Ni. Nol Its effect lasts for 18 to 24 hours. ⇒ Human Mixtard 40, 100 units/ml Ni. Nol Injection under the skin of the patient as per requirement. ⇒ Human Monotard Zinc Suspension Ni. Nol ⇒ Insuman Basal 40 units/ml Ni. Hext For long term treatment in controlled diabetes Dosage: Initially give 6 to 8 units in the form of injection. Gradually increase 1 to 2 units. Adverse effects: Edema, allergy, hypoglycemia. ⇒ Insuman 25/75 40 units/ml Ni. Hext It can also be given with Dynal. Can also be used during pregnancy, lactation and surgery. Dosage: Initial dose of 8 to 16 units S/C. Increase by 2 to 4 units if needed. ⇒ Insuman 50/50 40 units/ml Ni. Hext Dosage: Initial dose of 8 to 16 units S/C. ⇒ Insulins Soluble 40, 80 units/ml Ni. Nol ⇒ Insulin Zinc (Lente)] 40, 80 units/ml • Effect lasts for 18 to 24 hours. ⇒ Insulin Protamine Zinc 40, 80 units/ml Ni. Nol • Its effect lasts for 28 to 36 hours. Dosage : By S/C or I/M injection as per patient's requirement.
In brief:-
Insulin is available in the market in 40, 80, 100 units/ml.
Insulin Type Prepartions and synonyms Duration of Action
General:-
Short-acting Regular, Soluble 6-8 hours. 8-10 hours. NIT
Long-acting
Isophane or NPH 18-24 hours.
Insulin Zinc Suspension
18-24 hours. (IZS) or Lenti
⇒ Long-acting
Protamine Zinc (PZI) Ultralente 28-36 hours.
New Insulin:-
⇒ Quick-acting - Act Rapid. ⇒ Short-acting - Semitard. ⇒ Intermediate effective - Monotard, Insulatard, Mixtard. ⇒ Long term effective - Ultratard, Ultralente.
Human-
Actrepid HM Monotard HM Regular and intermediate types of insulin are most commonly used. It comes in 40 and 80 units per ml. Therefore, it is easy to use. Normal insulin can also be given through the vein route.
Place of insulin administration: - It is administered deep under the skin (Deep S/C) in the following places.
• On the thighs. • On the hands. • On the stomach. • On the hip.
Generally, initially insulin is given twice a day, after that the quantity can be increased or decreased as per the requirement of the patient.
Quantity: Start with 40 units per day. Give it 20 minutes before breakfast. Lack of glucose in the blood (hypoglycemia) is the most dangerous and harmful effect of insulin.
Complications of diabetes
• Ketoacidosis. • Lactic acidosis. • Infection. • Numbness of hands and feet. • Bad effect on the heart. • Cataract. • Bleeding in the eyes, poor vision. • Changes in the kidneys. • Changes in skin, boils, change in colour. • Wounds not healing quickly. • Gangrene in legs. • Danger in pregnancy.
