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Clinical Case 9


Clinical Case 9 G. V., a 42-year-old male showbiz personality was known to have Juvenile-onset diabetes. For one week, he complains of feeling bloated or full ... – PowerPoint PPT presentation

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Title: Clinical Case 9

Clinical Case 9
  • G. V., a 42-year-old male showbiz personality was
    known to have Juvenile-onset diabetes. For one
    week, he complains of feeling bloated or full
    despite minimal food intake, nausea and vomiting.
    His blood sugar level is poorly controlled.
  • Question
  • 1.What is your diagnosis and proper therapeutic
    management of this case?
  • 2.What are prokinetic agents?
  • 3.Give the pharmacokinetics, clinical uses and
    side effects of the different prokinetic drugs.

Diagnosis Diabetes mellitus with hyperglycemia.
  • Diabetes mellitus is a chronic disorder of
    carbohydrate, fat, and protein metabolism. A
    relative or absolute deficiency in insulin
    secretory response, which translates into
    impaired carbohydrate (glucose) use, is a
    characteristic feature of diabetes mellitus, as
    is the resulting hyperglycemia.

Classification of Diabetes Mellitus
  • Type I
  • Type II
  • Others specific type.

Type I Diabetes Mellitus
  • Insulin-dependent diabetes mellitus or
    juvenile-onset diabetes.
  • Younger people and usually diagnosis before age
  • lt10 of all DM cases.
  • Definition is hyperglycemia resulting from
    autoimmune destruction of the insulin-producing
    beta cells of pancreas.
  • 80 have HLA (HLA-DR3 and DR4) phenotypes
    associated with anticytoplasmic antibodies
    directed toward pancreatic beta cells (islet cell
    antibodies) and to glutamic acid decarboxylase
    (GAD anti bodies).
  • Extrinsic factors that affect ß cell function
    include damage caused by viral such as mumps or
    coxsackie B4 virus and exposure to cows milk
    instead of human milk during infancy.

  • Recent studies indicate there are two subgroups
    of type I diabetes
  • 1. Type 1A DM (immune-mediated type) results
    from autoimmune beta cell destruction, which
    leads to insulin deficiency.
  • 2. Type 1B DM (idiopathic type) lack
    immunologic markers indicative of an autoimmune
    destructive process of the beta cells. However,
    they develop insulin deficiency by unknown
    mechanisms and are ketosis prone.

Signs and Symptoms
  • Polyuria.
  • Polydipsia.
  • Polyphagia with weight loss.
  • Recurrent blurred vision.
  • Foot ulcers.
  • Will suffer from Diabetic Ketoacidosis (DKA).

Laboratory Founding
  • Fasting serum glucose is gt126 mg/dl.
  • Glucosuria (causes an osmotic diuresis that leads
    to the dehydration).
  • HbA1c is a measure (it can provides an index of
    the average blood glucose levels over the 120 day
    life span of erythrocytes).

Type II Diabetes mellitus
  • Non-insulin-dependent diabetes mellitus or
    adult-onset diabetes.
  • gt80 of diabetes cases which predominantly in gt30
    age adults, but occasionally in adolescents and
    children due to incidence of obesity and
    sedentary lifestyle.
  • Epidemiologic data indicate strong genetic
    influences, since in monozygotic twins is gt90
    (lt50 type I).
  • Definition is hyperglycemia due to insulin
    resistance. The syndrome of insulin resistance
    involves hyperglycemia leading to obesity,
    hypertension, hyperlipidemia, and coronary artery

Signs and Symptoms
  • May be asymptomatic.
  • Complication of diabetes, such as a soft tissue
    infection etc.
  • Signs of hyperglycemia.
  • Increase susceptibility to fungal infections
    (cell-mediated immunity is impaired by acute
  • The nonketotic hyperglycemic hyperosmolar coma
    (NKHC) is also a rare presenting situation.

Laboratory Founding
  • Random glucose gt200 mg/dl.
  • Asymptomatic patients require a fasting glucose
    of gt 126 mg/dl on two separate occasions.
  • The oral glucose tolerance test is a plasma
    glucose gt200 mg/dl at two hours (or at any time
    up to two hours) after ingesting 75g of glucose
    in solution.

  • Education for when to seek medical attention,
    side effects of medications, proper foot care,
    ophthalmology visits, and symptoms of
    hyperglycemia and hypoglycemia.
  • Diet recommendations for limit cholesterol to 300
    mg daily, advise a daily protein intake of
    1020, and carbohydrate intake of 5560 of
    total calories. And Insoluble fiber diet which
    tend to retard nutrient absorption rates so that
    glucose absorption is slower and hyperglycemia
    may be slightly diminished.
  • Exercise.
  • Medication therapy.
  • For the type I diabetes the mainstay of
    therapy is insulin injection.

Preparation Onset of action Peak action Duration
Regular insulin 3060 min 24 min 68 hr
Rapid-acting (Lispro) 15 min 3090 min 24 hr
Intermediate-acting (NPH and Lente) 13 hr 612 hr 1826 hr
Long-acting (Ultra-lente and PZI) 48 hr 1424 hr 2836 hr
NPH Neutral Protamine Hagedorn. PZI Protamine
Zinc Insulin suspension.
  • Its major anabolic hormone. Its necessary for
  • Transmenbrane transport of glucose and amino
  • Glycogen formation in the liver and skeletal
  • Conversion of glucose to triglycerides.
  • Nucleic acid synthesis.
  • Protein synthesis.
  • Because insulin is a polypeptide, it is degraded
    in the gastrointestinal tract if taken orally. It
    therefore is generally administered by
    subcutaneous injection.

Side effect Hypoglycemia is the most common side
effect that may occur during insulin therapy.
  • Numbness around the mouth, tingling in the
  • Tremors
  • Muscle weakness
  • Cold temperature
  • Excessive yawning
  • Irritability
  • Loss of consciousness
  • Symptoms
  • Confusion
  • Nausea
  • Hunger
  • Tiredness
  • Perspiration
  • Headache.
  • Heart palpitations.
  • blurred vision

For the type II diabetes is oral hypoglycemic
  • First-generation sulfonylureas
  • Generic name Tolbutamide
  • Second-generation sulfonylureas
  • Generic name Glipizide, Glyburide,
  • Mech. Of action
  • Stimulate insulin secretion.

  • Pharmacokinetics
  • Given orally, these drugs bind to serum proteins,
    are metabolized by the liver, and are excreted by
    the liver or kidney. Tolbutamide has the shortest
    duration of action (612 hr), whereas the
    second-generation agent last about 24hr.
  • Adverse effects
  • Weight gain, hyperinsulinemia, and hypoglycemia
    which delayed excretion of the drug-resulting in
    its accumulation.

  • Meglitinide analogs
  • Generic name Nateglinide, Repaglinide
  • Mech. Of action
  • Stimulate insulin secretion.
  • Pharmacokinetics
  • These drugs are well absorbed orally after being
    taken one to thirty minutes before meals. Both
    meglitinides are metabolized to inactive products
    by CYP3A4 in the liver and are excreted through
    the bile.
  • Adverse effects
  • Although these drugs can cause hypoglycemia, the
    incidence of this adverse effect appears to be
    lower than with the sulfonylureas.

  • Biguanides
  • Generic name Metformin
  • Mech. Of action
  • Decreased endogenous hepatic production of
  • Pharmacokinetics
  • Metformin is well absorbed orally, is not bound
    to serum proteins, and is not metabolized. The
    highest concentrations are in the saliva and
    intestinal wall. Excretion is via the urine.
  • Adverse effects
  • Nausea.

  • Thiazolidinediones (glitazones)
  • Generic name Pioglitazone, Rosiglitazone
  • Mech. Of action
  • Binds to peroxisome proliferators-activated
    receptor-? in muscle, fat and liver to decrease
    insulin resistance.
  • Pharmacokinetics
  • Both pioglitazone and rosiglitazone are absorbed
    very well after oral administration and are
    extensively bound to serum albumin. Both undergo
    extensive metabolism by different cytochrome
    P450. The metabolites are primarily excreted in
    the urine, but the parent agent leaves via the
  • Adverse effects
  • Weight gain and risk of heptotoxicity

  • a-Glucosidase inhibitors
  • Generic name Acarbose, Miglitol
  • Mech. Of action
  • Decreased glucose absorption.
  • Pharmacokinetics
  • Acarbose is poorly absorbed. Its metabolized
    primarily by intestinal bacteria, and some of the
    metabolites are absorbed and excreted into the
    urine. On the other hand, miglitol is very well
    absorbed but has no systemic effects. It is
    excreted unchanged by the kidney.
  • Adverse effects
  • The major side effects are flatulence, diarrhea,
    and abdominal cramping. Patient with inflammatory
    bowel diease, colonic ulceration, or intestinal
    obstruction should not use these drugs.

  • The first and scond-generation sulfonylureas and
    meglitinide have risk of hypoglycemia.
  • The classification, or type, of diabetes is
    determined by the underlying cause of the
    diabetes, not the type of therapy that is used to
    treat the diabetes. Many patients with type 2
    diabetes will progress insulin to control of
    blood glucose levels, but these patients are
    still type 2 diabetics.

  • 1. Hyperglycemia
  • A condition in which an excessive amount of
    glucose circulates in the blood plasma. Caused by
  • Impaired secretion of insulin.
  • Decreased insulin effectiveness at glucose
  • Impair inhibition of hepatic gluconeogenesis.
  • Sign and Symptom
  • Extreme thirst.
  • Hunger.
  • Headache.
  • Blurred vision.
  • Dry skin.
  • Feeling drowsy.
  • Feeling sick with stomach.

  • 2. Diabetic Ketoacidosis (DKA)
  • It is metabolic acidosis due to ketoacid
    accumulation due to severely depressed insulin
    levels. Blood sugar levels exceed 240 mg/dl for
    an extended period of time the diabetic is at
    risk of going into diabetic ketoacidosis. Cause
  • Severe insulin deficiency so lead the body to
    switch from metabolizing carbohydrates to
    metabolizing and oxidizing lipids.
  • Precipitated by lapse in insulin treatment, acute
    infection, or major trauma.
  • Sign and Symptom
  • Polyuria, nausea, vomiting.
  • Signs of dehydration and hypotensive and
  • Kussmaul respirations (rapid deep breaths).
  • Aceton (fruity) odor breath.

Complications of Diabetes (Types I and II)
  • Hypoglycemia may be cause by injecting too much
    insulin (overdose) or not eating enough food
    during a daily diet regimen so lead blood sugar
    level below the normal which is 70120mg/dl.
  • Diabetic Ketoacidosis (usually type I).
  • Nonketotic hyperosmolar coma (usually type II).
  • Retinopathy.
  • Stroke, MI.
  • Renal insufficiency.
  • Neuropathy.
  • Infection.

Others Specific Type of Diabetes Mellitus
  • 1. Maturity-onset diabetes of the young (MONDY)
  • This subgroup is a relatively rare monogenic
    disorder characterized by non-insulin-dependent
    diabetes with autosomal dominant inheritance and
    an age at onset of 25 years or younger.
  • 2. Gestational diabetes mellitus (GDM)
  • Its happen during pregnancy. But in the serum,
    the HbA1c detect is normal and it will become
    normal after delivery of six-week.
  • 3. Impaired glucose tolerance (IGT)
  • The before and after meals sugar blood level are
    between normal and diabetes mellitus.
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