Treatment of Diabetes in Type II Diabetes Mellitus

Treatment of Diabetes in Type II Diabetes Mellitus

Treatment of diabetes starts with educating patient about this disease. He is also educated about symptoms related to low and high sugar levels so that he can recognise these. He is encouraged to carry a diabetes card with his medication, and the name of his doctor written on it. He is also encouraged to carry with him sugar candies etc near him to treat hypoglycemia. Home blood glucose monitoring can be taught to nearly all patients.

The various risk factors are noted and the complications if any are studied. The goal of treatment is to reduce the sugar to near normal levels to ward off complications of diabetes and reduce risk to life, vital organs while permitting a good quality of life.

Non-pharmacologic measures

To reduce risk of heart disease and stroke, weight should be reduced to normal levels. If a person is overweight (BMI ie Wt in kgs/ ht in meters squared) and BMI is between 25 to 29.9 wt can be reduced gradually to with in limits. If a person is obese BMI >30 then more urgent weight reduction is required.

A weight reduction of about 10 kgs will make a substantial difference in diabetic control

Diet

If overweight or obese calories are cut down. About 15% calories should come from proteins and < 30 % from fats. The rest of calories may be from complex carbohydrates. Simple sugars are not advisable. Sugar substitutes can be taken.

If weight does not reduce after 6 months of trial, weight reduction tablets (Orlistat) etc may be considered. In severe obesity cases bariatric surgery may be the only alternative if all else fails.

Exercise

About 150 mins of exercise in a week is recommended. Aerobic exercises are preferred though in younger patients who do not have heart disease or advanced diabetic retinopathy weight lifting twice a week is encouraged.

The exercise should be done on most days of the week and be sufficiently vigorous to be of cardiac benefit.

Smoking

Smoking is a huge risk factor for heart disease. Since diabetes itself is a high-risk state for angina and myocardial infarction continued smoking increased the risk manifold. Smoking should be stopped totally to reduce this risk.

Drugs are required in nearly all cases for sugar control. More about drugs later.

Dialysers

Dialysers

Dialysers are small plastic cylinders. These have an inlet for blood entry and outlet for blood exit.

It also has an entry opening for dialysate and exit for the fluid.

Its main body has hundreds of small tubes all connected to a common plate at the top and bottom portion of the dialyser. Blood enters at the entry point and flows through these tubes. These tubes are again joined at the exit and then blood goes out through a common tube back to the patient.

These tubes are nowadays made of synthetic material of different types. Some common types are polysulfone, polymethamethyl acrylate, poly acrylonitrile and polyamide. Earlier cellular or semisynthetic membranes were also in use (hemophane, cuprophane, cellulose etc. ) These membranes are now gradually being replaced by synthetic membranes. Synthetic membranes are comparatively inert and produce fewer reactions. These are easy to clean and sterilise.

The large no of tubes (called capillariesin medical parlance) increase the surface area to about .5 to 1.8 sq meters. Thus larger amount of blood can interchange impurities across the membranes.

Dialysate fluid flows outside the capillaries and the exchange of water, ions and waste material occurs through the membrane. Membranes have small micropores to facilitate this exchange.

Dialysis reuse : its benefits and harms.

Dialysers are reused in many centers across the world. This has the advantage of reducing dialysis costs. The protein loss (due to protein stuck on membranes) is less when dialysers are reused.

Some patients react when their blood comes in contact with dialysis membrane. This is called a first use effect. In reuse cases this is not seen.

The dialysers are checked prior to reuse to see that capillaries are intact. A large no of capillaries are functional (measured by total volume of capillaries.), and harmful chemicals used in cleaning dialysers are cleared.

Dialyser reuse is done semi-automatically by machines which also check for its safety before reuse is permitted. Manual washing and checking only by visual estimates is not useful and hence discarded by good centers. After cleaning of blood products dialysers are sterilised and kept separately for each patient in a clean container.

 

Hemo – Dialyser

 

Complications of Diabetes Mellitus

Complications of Diabetes Mellitus

Complications of diabetes are due to high sugars and damage to the small and big blood vessels mainly.

High sugars can cause frequent skin and deeper tissue infections. Infections are common, more severe, often require prolonged treatment and may turn serious if not treated fast and appropriately.

In case of very high sugars (DKA or Hyperosmolar states) a person may become unconscious and this may be life threatening. Severe dehydration, salt and water imbalance, accumulation of acids, decreased kidney function may supervene. Treament in hospital is required for patients.

Long term complications are due to blood vessel and nerve tissue damage.

In feet painless wounds (trophic ulcers) may occur and not heal for months. If infected secondarily even amputations may result.

Damage to retina is called retinopathy. In most countries now, diabetes is the major cause of blindness. Regular check up by eye doctors and laser treatment of newly formed blood vessels may prevent blindness at a later stage.

Damage to nerves may cause numbness usually more in hands and feet. Involvement of nerves supplying muscles can cause weakness in moving limbs. Involvement of nerves supplying bladder and large intestines may result in disturbance in acts of passing urine and defecation. Constipation , diarrhea and retention of urine may occur.

Long term diabetes can damage kidney in multiple ways. The details can be seen later in the kidney care part.

Involvement of coronary arteries results in high risk of heart attacks and angina. Similarly strokes causing paralysis etc occur with a much higher frequency in diabetics.

Dialysis Machines

Dialysis machines

 

Machines used to perform hemodialysis are of different varieties. The following fuctions are carried out by these machine

Proportionate mixing of dialysate concentrate and treated water to form dialysate. The composition of dialysate is similar to blood without cells, proteins, lipids and some other complex salts. The dialysate consists mainly of water and various main salts and ions eg sodium, potassium, chloride , bicarbonate, calcium etc.

The dialysate is freed of dissolved gases, and is heated to body temperature. Very low temperature may cause hypothremia and high temperature of dialysated may cause fever.

These machines has a self cleaning mechanism with hot water and various chemicals to take care of various pathogens.

It pulls blood at speeds set by the dialysis personnel and also supplies dialysate at required rate. It can also create negative pressure so that extra fluid can be removed from the body.

During dialysis a person may require various medicines to be administered. This is facilitated by the machine.

Additionally, machines have safety measures. It can detect air in blood so that air does not enter patients’ blood vessels. The machines go into auto shut mode if air is detected in returning blood.

If blood gets hemolysed (hemoglobin leaks out of RBCs) a serious situation for a patient may develop. Machines can detect leaked hemoglobin and sound an alarm.

Most newer machines have built in blood pressure monitoring system. If blood pressure becomes lower or higher than set range, an alarm is sounded and corrective measures can be taken.

Machines also monitor the flow of blood from the patient. If the pressure in the tubing is recorded higher or lower than set limits, alarms sound for the call to dialysis nurse or technician.

Modern machines can also measure dialysis dose. (more about this later in dialysis adequacy)

Next topic in dialysis series is dialysers.

Diabetes mellitus

Diabetes Mellitus

Diabetes is a condition where a person either does not produce required amounts of insulin or is unable to utilise insulin appropriately. It is a common (about 10% of the population), complex disease. It can cause complications if not treated and controlled well.

Types of Diabetes:

There are 2 common types of diabetes Type I and Type II. There are other rare varieties due to pancreatic diseases, hormonal disorders, in pregnancy, after drugs and even rarer genetic disorders.

Type I is the cause in about 10 % of cases, onset is in childhood or young age and insulin is required for treatment.

Type II is the common variety, onset is usually around 50 Yrs of age, often associated with overweight and the risk is high if one parent is diabetic (30 %) and if both parents are diabetic (50 %). During initial stages, diet modification and oral drugs may control sugars but later insulin may be required.

Symptoms:

Classically symptoms in diabetes are polyuria (more urine), polydypsia (more thirst ) and polyphagia ( more eating). In children very high sugars may develop suddenly and patient may become unconscious at the onset (DKA etc). Infections both recurrent and difficult to treat may occur. However in a large no the disease remains without many symptoms and found out accidentally or when complecations arise.

Signs are seen only in advanced and long standing diseases. These are few and may include eye, heart, nerve changes, dehydration and very rapid breathing due to acid accumulation in the body.

Diagnosis of diabetes:

Diabetes is diagnosed by blood glucose testing or glycated hemoglobin levels.

Normal Plasma glucose level after 8 hrs of fasting is < 100 mg/dl. Normal 2 hrs after breakfast (called PP) or after 75 gms of glucose orally is <140 mg.   Diabetes is diagnosed if either fasting plasma glucose is >126 or PP or oral GTT (after 75 gms of glucose is >200 mg/dl.

If fasting value is 100 -125 it is called impaired fasting glucose and if PP or Oral GTT is between 140 and 199 mg/dl it is called impaired glucose tolerance( IGT).

In a person with symptoms of diabetes a random value of plasma sugar >200 mg /dl or fasing plasma sugar >126 mg/dl qualifies for diagnosis of diabetes.

Lab tests for diabetes  

For common types of diabetes the following tests may be required at the time of initial diagnosis.

Complete blood counts, Blood sugar, kidney and liver function tests, urine routine and urine for microalbumin, lipid profile, Chest X Ray, ECG. Ultrasonography of abdomen, fundus examination, foot examination and blood pressure is noted.

In Type I cases or where genetic, pancreatic or hormonal disorders are suspected, tests for these are carried out as appropriate.

This is a chronic disease and lifelong follow up and treatment are required.

 

 

Coming next ~

Complications of diabetes

Treatment of diabetes.