Clinical pharmacy I ( practical ) University of Sana'a

Dr. Ashraf Rafeq alammari Pharmacy 5th year

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Diabetes Mellitus
Definition :-
A syndrome characterized by hyperglycemia resulting from impaired insulin
secretion or effectiveness ,,,and may cause diabetic ketoacidosis
Insulin secretion :-
pancreas is a glandular organ in digestive system composed of 2 types of
tissues :
pancreatic acini (exocrine part 80% ,secrete pancreatic juices )
Islet of langerhans ( endocrine part 20% , secrete insulin & other
hormones)
O is global symbol of diabetes
 The insuln is secreted slightly ,but increased rapidly if the blood glucose level
elevated .

Types :-
1- Type 1 DM :(insulin deficiency)
Insulin – dependent daibetes mellitus IDDM ,or Juvenile diabetes :-
- mainly due to autoimmune destruction of insulin-producing β cell of
pancreas .
- usually occur in young age .
- may lead to ketoacidosis .
2- Type 2 DM or NIDDM :-
- mainly decrease tissue sensitivity to insulin .
- usually after the age of 40 yrs .
3- Type 3 Gestational Diabetes :-
Placental hormones e.g: lactogen ,make the cells more resistant to insulin .

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Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
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* Classical Symptoms :-
Polyuria : osmotic diuresis
Polydispia : increased thirst d/t fluid loss .
Polyphagi a : increased appetite , d/t cell starvation of glucose .
* Symptoms specific for type 1 DM :-
- Ketoacidosis .
- Weight loss ; there is utilizing of fatty acid & triglycerides to
overcome inracellular glucose deficiency .
*Risk Factor :-
Genetic : specially . in type 1
Race : American & Asians are at higher risk
Over weight – inactivity – abnormal cholesterol ,, (spec. I n Type2 )
Age ; as mentioned earlier .
Hypertension .

 Complications :

Neuropathy : numbness , tingling & pain that begins at the tips of the toes
or fingers and spread upward .
→ Nephropathy : Glomerulosclerosis ( fibrosis of mesangial cells of nephron )
→ Retinopathy : damage of retina blood vessel
→ Other :- Diabetic foot :
Ulceration of feet ,that is d/t combination of peripheral vascular PVD
,peripheral neuropathy & susceptibility to infections ,,,
this complication is mostly associated with type2DM

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Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
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Diagnosis :
1- Glycated hemoglobin A1C test :- detect hyperglycemia of previous 3m.
Normal value = 4.7 – 6.5 %
2- FBS : 70 – 110 mg/dl , while in DM is over 126mg/dl .
3- Random blood sugar ,RBS test :-
70 – 140 mg/dl . Diabetic when being over 200mg/dl .
4- Glucose load or Glucose Tolerance Test :
Detection of blood sugar after 2hrs of taking 75g of glucoe (in 300ml water)
-Normal if < 140
Impaired glucose tolerance > 140 < 200
Diabetic if > 200 mg/dl
5- Urine analysis :-
If there is sugar in urine
→Note :- Renal Threshold of Glucose RTG > 180mg/dl
Kidney (at proximal tubule) start to excrete glucose in urine if its conc
exceed 160-180mg/dl (+) .

Treatment :-
1-Insulin therapy ,,,,,,, for type 1 DM .
 Give the types of insulin ,,, Research .

Write the conditions in which the insulin is recommended rather than DM1.

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Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
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2- Antidiabetics :-
A- insulin secretagogues :-
1-sulfonylurea :
Example :- Gliclazide – glimepride – glibenclamide or glyburide .
MOA : act by binding to ATP dependent K-channel , by its blocking →
Depolarization of β-cell membrane & thus increasing intracellular ca+2 and
thus secreting insulin .
S.E : Weight gain ,hyperinsulinemia and hypoglycemia
Note : Meglitinde (Repaglinide – Nateglihide – Mitiglinide) have same
action of sulfonylurea with less side effect
2- Gliptins :
e.g : Sitagliptin ,Vildagliptin , Saxagliptin ,Linagliptin ,Alogliptin
Inhibit DPP – 4 enzymes → ↑ GLP & GIP (Incretin analogues) : these
peptides inhibit glucagon synthesis , thus increasing level of insulin .
S.E : Nasopharyngitis ,headache ,nausea and hypersensitivity
3- Glucagon-like peptide- 1 (GLP-1) agonist :
Example : Liraglutide , Albiglutide Lixisenatide
Similar to glpitin's action
B – Sensitizers:-
1-Metformin :
- Increase the affinity of cell receptors to insulin .
- Activate the AMP activated protein kinase ( AMPK) →
inhibit hepatic gluconeogenesis .
- ↓ glucose absorption from gut & ↑ its utilization by cell .

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 Clinical pharmacy I ( practical ) University of Sana'a
Dr. Ashraf Rafeq alammari Pharmacy 5th year
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S.E : Gastrointestinal upset , Vit B 12 deficiency , Lactic acidosis

2-Thiazolidinediones : glitazone
Pioglitazone increase the gene expression by binding to the nuclear
receptors → ↓ metabolism/ catabolism of lipids and glucose .
S.E : liver toxicity , water retention
Increase risk of coronary heart disease
** Others: - α –Glucosidase inhibitor :-
Example : Acrabose - Miglitol - Voglibose
S.E : flatulence ,diarrhea
C/I : IBD

*.Sodium/glucose co-transporter -2 inhibitor ,, in kidney ;

Examples : Dapagliflozin - Canagliflozilozin - Empagliflozin

S.E : Hypotension , hypoglycemia , Hyperkalemia ,UTI

C/I : in heart failure and renal impaire