DIABETES MELLITUS

DIABETES MELLITUS

DEFINATION 

TREATMENT &CONTROL

TYPES/CLASSIFICATION OF   DIABETES MELITTUS  .

Diabetes mellitus is a disease caused by deficiency or diminished effectiveness of endogenous insulin. It is characterised by hyperglycaemia, deranged metabolism and sequelae predominantly affecting the vasculature. The main types of diabetes mellitus are:

• Type 1 diabetes mellitus: results from the body's failure to produce sufficient insulin.
• Type 2 diabetes mellitus: results from resistance to the insulin, often initially with normal or increased levels of circulating insulin.
• Gestational diabetes: pregnant women who have never had diabetes before but who have high blood glucose levels during pregnancy are said to have gestational diabetes. Gestational diabetes affects about 4% of all pregnant women. It may precede development of type 2 (or rarely type 1) diabetes.
• Maturity-onset diabetes of the young (MODY) includes several forms of diabetes with monogenetic defects of beta-cell function (impaired insulin secretion), usually manifesting as mild hyperglycaemia at a young age, and usually inherited in an autosomal-dominant manner.
• Secondary diabetes: accounts for only 1-2% of patients with diabetes mellitus. Causes include:
  • Pancreatic disease: cystic fibrosis, chronic pancreatitis, pancreatectomy, carcinoma of the pancreas.
  • Endocrine: Cushing's syndrome, acromegaly, thyrotoxicosis, phaeochromocytoma, glucagonoma.
  • Drug-induced: thiazide diuretics, corticosteroids, atypical antipsychotics, antiretroviral protease inhibitors.
  • Congenital lipodystrophy.
  • Acanthosis nigricans.
  • Genetic: Wolfram's syndrome (which is also referred to as DIDMOAD: diabetes insipidus, diabetes mellitus, optic atrophy and deafness),Friedreich's ataxia, dystrophia myotonica, haemochromatosis, glycogen storage diseases.

Some patients with type 2 diabetes require insulin, so the old terms of insulin-dependent diabetes mellitus (IDDM) for type 1 diabetes and non-insulin-dependent diabetes mellitus (NIDDM) for type 2 diabetes are inappropriate. Type 2 diabetes is increasingly diagnosed in children and adolescents and so the old term maturity-onset diabetes for type 2 diabetes is also inappropriate.

Type 1 diabetes mellitus

The development of type 1 diabetes mellitus is based on a combination of a genetic predisposition and an autoimmune process that results in gradual destruction of the beta cells of the pancreas, leading to absolute insulin deficiency. There is usually a pre-diabetic phase where autoimmunity has already developed but with no clinically apparent insulin dependency. Insulin autoantibodies can be detected in genetically predisposed individuals as early as 6-12 months of age.
Possible triggers for the process may include viruses, dietary factors, environmental toxins, and emotional or physical stress. Early cessation of breast-feeding has also been linked to increased risk of developing type 1 diabetes, but the association is unproven and controversial.

• Approximately 15% of those with diabetes have type 1 diabetes - usually juvenile-onset, but it may occur at any age. It may be associated with other autoimmune diseases. It is characterised by insulin deficiency.
• There is 30-50% concordance in identical twins and a positive family history in 10% of people with type 1 diabetes. Screening for the diagnosis of diabetes in first-degree relatives of patients with type 1 is therefore reasonable, keeping in mind that the absolute risk is quite low.
• Associated with HLA DR3 and DR4 and islet cell antibodies around the time of diagnosis.
• Patients always need insulin treatment and are prone to ketoacidosis.
• The most at-risk population for type 1 diabetes is Caucasian of northern European ancestry. Incidence is high in Scandinavian people.

Type 2 diabetes mellitus

• Approximately 85% of those with diabetes; they are usually older at presentation (usually >30 years of age) but it is increasingly diagnosed in children and adolescents.
• Type 2 diabetes is associated with excess body weight and physical inactivity.
• All racial groups are affected but there is increased prevalence in people of South Asian, African, African-Caribbean, Polynesian, Middle-Eastern and American-Indian ancestry.
• It is caused by impaired insulin secretion and insulin resistance and has a gradual onset.
• Those with type 2 diabetes may eventually need insulin treatment.

Prevalence^.

• In 2011 there were 2.9 million people with diabetes. It is estimated that 5 million people will have diabetes in the UK by 2025.
• It is estimated that there are around 850,000 people in the UK who have diabetes but have not been diagnosed.
• The UK average prevalence of diabetes in the UK is 4.45% but there are variations between countries and regions.
• The proportion of people with diabetes increases with age.
• However, the incidence of diabetes is increasing in all age groups. Type 1 diabetes is increasing in children (especially those aged <5 years), and type 2 diabetes is increasing, particularly in black and minority ethnic groups.

Risk factors for type 2 diabetes^.

• Obesity, especially central (truncal) obesity.
• Lack of physical activity.
• Ethnicity: people of South Asian, African, African-Caribbean, Polynesian, Middle-Eastern and American-Indian descent are at greater risk of type 2 diabetes, compared with the white population.
• History of gestational diabetes.
• Impaired glucose tolerance.
• Impaired fasting glucose.
• Drug therapy - eg, combined use of a thiazide diuretic with a beta-blocker.
• Low-fibre, high-glycaemic index diet.
• Metabolic syndrome.
• Polycystic ovarian syndrome.
• Family history (2.4-fold increased risk for type 2 diabetes).
• Adults who had low birth weight for gestational age.

Presentation

• Patients with all types of diabetes may present with polyuria, polydipsia, lethargy, boils, pruritus vulvae or with frequent, recurrent or prolonged infections.
• Patients with type 1 diabetes may also present with weight loss, dehydration, ketonuria and hyperventilation. Presentation of type 1 diabetes tends to be acute with a short duration of symptoms.
• Presentation in patients with type 2 diabetes tends to be subacute with a longer duration of symptoms.
• Patients with diabetes may present with acute or chronic complications, as outlined in the section 'Complications', below.

PatientPlus

• Assessment of the Patient with Established Diabetes
• Insulin Regimens
• Audit of Diabetes Care
• Diabetes Diet and Exercise

Diagnosis

• Diabetes may be diagnosed on the basis of one abnormal plasma glucose (random ≥11.1 mmol/L or fasting ≥7 mmol/L) in the presence of diabetic symptoms such as thirst, increased urination, recurrent infections, weight loss, drowsiness and coma.
• In asymptomatic people with an abnormal random plasma glucose, two fasting venous plasma glucose samples in the abnormal range (≥7 mmol/L) are recommended for diagnosis.
• Two-hour venous plasma glucose concentration ≥11.1 mmol/L two hours after 75 g anhydrous glucose in an oral glucose tolerance test (OGTT).
• The World Health Organization (WHO) now recommends that glycated haemoglobin (HbA1c) can be used as a diagnostic test for diabetes. An HbA1c of 48 mmol/mol (6.5%) is recommended as the cut-off point for diagnosing diabetes. A value less than 48 mmol/mol does not exclude diabetes diagnosed using glucose tests.

Management

The management plan for a person with diabetes includes:

• Diabetes education: structured education and self-management (at diagnosis and regularly reviewed and reinforced) to promote awareness.
• Diet and lifestyle: healthy diet, weight loss if the person is overweight, smoking cessation, regular physical exercise.
• Maximising glucose control while minimising adverse effects of treatment, such as hypoglycaemia.
• Reduction of other risk factors for complications of diabetes, including the early detection and management of hypertension, drug treatment to modify lipid levels and consideration of antiplatelet therapy with aspirin.
• Monitoring and early intervention for complications of diabetes, including cardiovascular disease, feet problems, eye problems, kidney problems and neuropathy.

Health & Medicines pharmacist tips : PHARMACIST & PHARMACY

Health & Medicines pharmacist tips : PHARMACIST & PHARMACY:  Pharmacist Numbers Increase Globally, Report Finds. The number of pharmacists per head of population has increased in many count...

PHARMACIST & PHARMACY

 Pharmacist Numbers Increase Globally, Report Finds.

The number of pharmacists per head of population has increased in many countries around the world but there remains a shortage in low-income and middle-income nations, according to an analysis. 

Data from 51 countries showed all but three saw a rise in the number of pharmacists per 10,000 population between 2006 and 2012, found a report by the International Pharmaceutical Federation Education Initiative (FIPEd), which was published at the FIP World Congress in Dusseldorf, Germany. 

All six World Health Organization regions — Africa, Eastern Mediterranean, Europe, Pan-America, South East Asia and Western Pacific — experienced an increase between 2006 and 2012. The highest relative increase was in the Western Pacific region, where pharmacist density — the number of pharmacists per 10,000 population — rose by 43.1%. 

“It is important to monitor the global pharmacy workforce so that we can make informed decisions on how best to use our pharmacists,” said Ian Bates, director of the FIPEd development team and an expert advisor to the Royal Pharmaceutical Society (RPS). 

“There is still a need for more pharmacists; low-income and middle-income countries still have very low density compared with high-income countries. In particular, the increases we have seen may not be keeping pace with shifts in disease burden.” 

Christopher John, director of the joint FIP-RPS global workforce observatory, said: “The overall growth we have found reflects positive changes in policy and capacity building to facilitate extended roles, and a shift in focus in pharmacy to patients.” 

He added: “Pharmaceutical service development and new scope and roles for clinical pharmacy implies increased demand on the pharmacy workforce worldwide.”

ALLERGY.

Allergy & Treatment :

What is an Allergy?

An allergy is the response of the body's immune system to normally harmless substances, such as pollen, foods, and house dust mite. Whilst in most people these substances (allergens) pose no problem, in allergic individuals their immune system identifies them as a’ threat’ and produces an inappropriate response.

Allergies are classified into IgE mediated and non-IgE mediated allergies. In IgE mediated allergies the immune system produces exaggerated amounts of a distinct class of antibodies known as IgE antibodies that are, specific for the particular offending allergens. These IgE antibodies bind to the surface of cells in the body called mast cells which become ‘IgE-sensitised’ such that these cells can then identify particular allergens the next time they come in contact with the body. This process is called sensitisation, and at this stage there are no physical symptoms of an allergy.

ALLERGY INCREASING .

Allergy is caused when the body's immune system reacts to a normally harmless substance, such as pollen, food, or house dust mite. The body identifies the substance as a threat and produces an inappropriate, exaggerated response to it. What we are only beginning to understand is what tips the balance in favour of allergy. Researchers have suggested that a number of factors might cause someone to become allergic:

Genetics:

Children born into families where allergies already exist have a higher than average chance of developing allergies themselves. In the UK today, children have a 1 in 5 predisposition of developing an allergy. However, the risk is doubled if one parent has an allergy (particularly if that parent is the mother). If both parents have allergies, the risk is increased to 60-80%. This increased tendency for individuals to develop allergies because of their genes is known as being atopic.

The Hygiene Hypothesis:

This suggests that the immune system needs to come into contact with a variety of micro-organisms and bacteria while it is developing at the infant stage, in order that it responds appropriately later in life. We now live in an environment where we use cleaners containing anti-microbial agents, and food preparation is more hygienic than ever. Whilst children living in farms were previously directly exposed to animals, and their environment contained a range of microbial agents and plant derived agents, most of us now live in cities where we have minimal exposure to animals. We know that children with regular contact with farm animals have a lower incidence of allergy. Inadequate exposure to environmental micro-organisms may therefore result in the immune system of atopic children developing a tendency towards allergy.

Changes in the foods we eat:

Our diets tend to include more processed foods and less fruit and vegetables. It has been suggested that the increase in food allergy might be due to more allergenic foods, such as peanut, in our diet. However, there is no evidence that this has happened, and many cultures traditionally eat high amounts of certain allergenic foods

Environmental factors:

Our environment today is very different from 50 years ago. While there is evidence that pollutants can exacerbate existing airway allergy, the question of whether pollution can cause new allergy remains controversial. One hypothesis for which there are accumulating data, is that the increase in allergy mirrors our declining exposure to bacteria and other micro-organisms in our environment. This has led to the Hygiene Hypothesis.

Conclusion

So an intriguing possibility is that many of the above dietary and environmental factors may increase allergy risk by regulating genes which promote an allergic-type immune system. Hopefully, our understanding of genetics will increase over the coming years, offering new potential strategies by which we might be able to prevent allergy.

CLASSIFICATION .

ALLERGY CLASSIFIED ACCORDING TO THERE DIFFERENT ACTION .

DRUG- DRUG ALLERGY 

DRUG FOOD ALLERGY 

ENVIRONMENTAL ALLERGY 

GENETICALLY .

 TREATMENT .

ANTI HISTAMINE DRUGS 

STEROID DRUGS 

SYSTEMIC TREATMENT

Water Importance

Importance of water .

water & human physiology

How Much Water Should You Drink Per Day?

The body is about 60% water, give or take.

We’re constantly losing water from our bodies, primarily via urine and sweat.

There are many different opinions on how much water we should be drinking every day.

The health authorities commonly recommend eight 8-ounce glasses, which equals about 2 liters, or half a gallon.

This is called the 8×8 rule and is very easy to remember.

However, there are other health gurus who think we’re always on the brink of dehydration and that we need to sip on water constantly throughout the day… even when we’re not thirsty.

As with most things, this depends on the individual and there are many factors (both internal and external) that ultimately affect our need for water.

I’d like to take a look at some of the studies on water intake and how it affects the function of the body and brain, then explain how to easily match water intake to individual needs.

Can More Water Increase Energy Levels and Improve Brain Function?

Many people claim that if we don’t stay hydrated throughout the day, our energy levels and brain function can start to suffer.

There are actually plenty of studies to support this.

In one study in women, a fluid loss of 1.36% after exercise did impair both mood and concentration, while increasing the frequency of headaches .

There are other studies showing that mild dehydration (1-3% of body weight) caused by exercise or heat can negatively affect many other aspects of brain function .

However, keep in mind that just 1% of body weight is actually a fairly significant amount. This happens primarily when you’re sweating a lot, such as during exercise or high heat.

Mild dehydration can also negatively affect physical performance, leading to reduced endurance .

Does Drinking a Lot of Water Help You Lose Weight?

There are many claims about water intake having an effect on body weight… that more water can increase metabolism and reduce appetite.

According to two studies, drinking 500 ml (17 oz) of water can temporarily boost metabolism by 24-30% .

The top line below shows how 500 ml of water increased metabolism (EE – Energy Expenditure). You can see how the effect diminishes before the 90 minute mark :

The researchers estimate that drinking 2 liters (68 ounces) in one day can increase energy expenditure by about 96 calories per day.

It may be best to drink cold water for this purpose, because then the body will need to expend energy (calories) to heat the water to body temperature.

Drinking water about a half hour before meals can also reduce the amount of calories people end up consuming, especially in older individuals .

One study showed that dieters who drank 500 ml of water before meals lost 44% more weight over a period of 12 weeks, compared to those who didn’t .

Overall, it seems that drinking adequate water (especially before meals) may have a significant weight loss benefit, especially when combined with a healthy diet.

Does More Water Help Prevent Health Problems?

There are several health problems that may respond well to increased water intake:

• Constipation: Increasing water intake can help with constipation, which is a very common problem .
• Cancer: There are some studies showing that those who drink more water have a lower risk of bladder and colorectal cancer, although other studies find no effect .
• Kidney stones: Increased water intake appears to decrease the risk of kidney stones .
• Acne and skin hydration: There are a lot of anecdotal reports on the internet about water helping to hydrate the skin and reducing acne, but I didn’t find any studies to confirm or refute this.

Do Other Fluids Count Toward Your Total?

Plain water is not the only thing that contributes to fluid balance, other drinks and foods can also have a significant effect.

One myth is that caffeinated drinks (like coffee or tea) don’t count because caffeine is a diuretic.

However, the studies show that this isn’t true, because the diuretic effect of these beverages is very weak (22).

Most foods are also loaded with water. Meat, fish, eggs and especially water-rich fruits and vegetables all contain significant amounts of water.

If you drink coffee or tea and eat water-rich foods, then chances are that this alone is enough to maintain fluid balance, as long as you don’t sweat much.

Bottom Line: Other beverages that you drink also contribute to fluid balance, including caffeinated drinks like coffee and tea. Most foods also contain water.

Trust Your Thirst… It’s There For a Reason

Maintaining water balance is essential for our survival.

For this reason, evolution has provided us with intricate mechanisms for regulating when and how much we drink.

When our total water content goes below a certain level, thirst kicks in.

This is controlled by mechanisms similar to things like breathing… we don’t need to consciously think about it.

For the majority of people, there probably isn’t any need to worry about water intake at all… the thirst instinct is very reliable and has managed to keep us humans alive for a very long time (23).

There really is no actual science behind the 8×8 rule. It is completely arbitrary.

That being said, there are certain circumstances that may call for increased water intake… that is, more than simple thirst commands.

The most important one may be during times of increased sweating. This includes exercise, as well as hot weather (especially in a dry climate).

If you’re sweating a lot, make sure to replenish the lost fluid with water. Athletes doing very long, intense exercises may also need to replenish electrolytes along with water.

Water need is also increased during breastfeeding, as well as several disease states like vomiting and diarrhea.

Older people may need to consciously watch their water intake, because some studies show that the thirst mechanisms can start to malfunction in old age .

Bottom Line: Most people don’t need to consciously think about water intake, because the thirst mechanism in the brain is very effective. However, certain circumstances do call for increased intake.

How Much Water is Best?

At the end of the day, no one can tell you exactly how much water you need. As with most things, this depends on the individual.

Do some self experimentation… some people may function better with more water than usual, while for others it only causes the inconvenience of more frequent trips to the bathroom.

That being said, I am not sure if the small benefits of being “optimally” hydrated are even worth having to consciously think about it. Life is complicated enough as it is.

If you want to keep things simple (always a good idea), then these guidelines should apply to 90% of people:

1. When thirsty, drink.
2. When not thirsty anymore, stop.
3. During high heat and exercise, drink enough to compensate for the lost fluids.
4. That’s it.