thy, weight polydipsia,

INTRODUCTION loss, dehydration,

fatigue, electrolyte
blurred imbalance,
Diabetes comes from the Greek word vision, etc. and weight
“diabainein,” which means "siphon” or ● Treat with loss.
"pass through.” This refers to the lifestyle ● Treat with
excessive urination experienced by modification replacement
individuals with diabetes, as they pass large s, of ADH
medication, hormone,
amounts of urine due to the presence of
and insulin adequate
glucose. therapy fluid intake

Mellitus is derived from the Latin word

“mel” meaning honey or sweet, due to the
Diabetes Mellitus (DM), commonly referred
sweet taste, similar to honey, observed in
to as diabetes, is a group of metabolic
the urine of individuals with diabetes.
disorders characterized by high levels of
blood glucose or hyperglycemia. This
In ancient times, before the discovery and
results from defects in insulin secretion,
understanding of insulin, the sweet taste of
insulin action (sensitivity), or both.
the urine was recognized as a characteristic
symptom of diabetes.
Type 2 Diabetes Mellitus is the most
common form of diabetes, characterized by
What’s The Difference?
insulin resistance and inadequate insulin
secretion. It typically develops in adulthood,
Diabetes Mellitus Diabetes although it is increasingly being diagnosed
Insipidus in children and adolescents due to rising
obesity rates.
● Pancreatic ● Hypothalami
disorder c disorder
● Chronic ● A disorder EPIDEMIOLOGY
metabolic that affects
disorder the
affecting regulation of Globally
blood sugar water ● More than 95% of people with
regulation balance in diabetes have type 2 diabetes
● Due to the body
(WHO, 2023).
insufficient ● Due to
insulin deficiency ● Diabetes Type 2 was seen only in
production or adults but it is now also occurring
or insulin dysfunction increasingly frequently in children as
resistance of of 2023.
● Symptoms antidiuretic ● Prevalence has been rising more
include hormone rapidly in low- and middle-income
polyuria, (ADH)
countries than in high-income
polydipsia, ● Symptoms
polyphagia, include countries.
polyneuropa polyuria,
 ● Diabetes is a major cause of
blindness, kidney failure, heart
attacks, stroke, and lower limb
amputation
In the Philippines
● In 2020, the 60 and older age group
accounted for 8.6% of the population
and is projected to almost double to
16.5% in 2050. The Philippine
Statistics Authority report from
January to December 2021 lists
diabetes as the 5th leading cause of
death in the country.
ETIOLOGY
Key Factors that Contribute to Type 2
Diabetes Mellitus
1. Obesity: Greater weight means a
higher risk of insulin resistance
due to fat interfering with the
body’s ability to respond to
insulin. Excess body fat, especially
abdominal or visceral fat, leads to
increased insulin resistance, which
means that the body's cells become
less responsive to the effects of
insulin.
2. Sedentary Lifestyle: Lack of
physical activity contributes to
weight gain and obesity, both of
which are significant factors of
Type 2 DM. Regular exercise helps
improve insulin sensitivity and
glucose metabolism, reducing the
risk of developing diabetes.
3. Poor diet: Unhealthy eating habits.
Diets high in processed foods,
sugary beverages, saturated fats,
and low in fruits, vegetables, and
whole grains, contribute to the
development of T2DM. These
dietary patterns can lead to weight
gain, insulin resistance, and
impaired glucose metabolism
4. Genetic Factors: Family history of
diabetes increases susceptibility
among family members and
relatives.
5. Age: The risk of Type 2 diabetes
increases with age, especially
after 45 years.
6. Ethnicity: Background of
African-Caribbean, Black African,
Chinese, or South-Asian are likely
to develop Type 2 DM.
3 Main Types of Diabetes Mellitus
1. Type 1 DM
- aka Insulin-dependent Diabetes
Mellitus (IDDM) or Juvenile
Diabetes
- Results from autoimmune
destruction of the β cells of the
pancreas leading to its inability to
produce adequate insulin.
- Early onset
- Sudden symptoms
- Insulin injection
2. Type 2 DM
- aka Non-Insulin-dependent
Diabetes Mellitus (NIDDM) or
Adult-Onset Diabetes
- Results from insulin resistance, a
condition in which cells fail to
properly respond to insulin
produced.
- With this type, your body doesn’t
make enough insulin and/or your
body’s cells don’t respond normally
 to the insulin (insulin resistance). Type 1 may present acutely with symptoms
This is the most common type of of polyuria, nocturia, polydipsia, polyphasia,
diabetes. It mainly affects adults, but and weight loss.
children can have it as well.
Type 2 children and adolescents are more
3. Gestational Diabetes likely to present with ketones which may
- A transient form of the disease lead to Diabetic ketoacidosis (DKA).
defined as glucose intolerance which Prolonged fasting can produce ketones in
is first recognized during pregnancy. individuals.
It is caused by hormonal and
physiological changes that occur
during pregnancy, which can affect
insulin action and glucose
metabolism.

Other:
Prediabetes: Your blood glucose levels are
higher than normal but not high enough to
be officially diagnosed with Type 2 diabetes.

PHYSIOLOGY
& PATHOPHYSIOLOGY

The pancreas is a long, slender organ, most

of which is located posterior to the bottom
half of the stomach. Although it is primarily
an exocrine gland, secreting a variety of
digestive enzymes, the pancreas has an
endocrine function.

Its pancreatic islets—clusters of cells

formerly known as the islets of
Langerhans—secrete the following
hormones:
● glucagon,
● insulin,
Age onset for Type 1 DM is generally < 20 ● somatostatin, and
years of age, but can present at any age. ● pancreatic polypeptide (PP)
The prevalence of Type 2 DM in children,
adolescents, and young adults is increasing.

·

The pancreatic exocrine function involves
the acinar cells secreting digestive
enzymes that are transported into the small
intestine by the pancreatic duct. its
endocrine function the secretion of insulin
(produced by beta cells) and glucagon
(produced by alpha cells) within the
pancreatic islets or the islets of Langerhans.
These two hormones regulate the rate of
glucose metabolism in the body.
Cells and Secretions
of the Pancreatic Islets
● The beta cell produces the hormone
insulin and makes up approximately
75% of each islet. Elevated blood
glucose levels (hyperglycemia)
stimulate the release of insulin.
● The alpha cell produces the
hormone glucagon and makes up
approximately 20% of each islet.
Low blood glucose (hypoglycemia)
levels stimulate its release.
● The delta cell accounts for 4%
percent of the islet cells and
secretes the peptide hormone
somatostatin. Pancreatic
somatostatin, inhibits the release of
both glucagon and insulin.
○ Nutrient Absorption: After a
meal, somatostatin is
released from the pancreas
to inhibit the secretion of both
insulin and glucagon to
prevent excessive
fluctuations in blood glucose
levels by reducing the
release of insulin, which
promotes glucose uptake,
and glucagon, which
increases glucose
production.
● The pancreatic polypeptide cells
accounts for about 1% of islet cells
and secretes the pancreatic
polypeptide hormone. Its primary
role is to modulate digestion of food
by inhibition of gastric emptying as
well as biliary secretion
Regulation of Blood Glucose Levels by
Insulin & Glucagon
Glucose not immediately taken up by cells
for fuel can be stored by the liver and
muscles as glycogen, or converted to
triglycerides and stored in the adipose
tissue.
Receptors located in the pancreas sense
blood glucose levels, and subsequently the
pancreatic cells secrete glucagon or
insulin to maintain normal levels.
Glucagon:
● It stimulates the liver to convert its
stores of glycogen back into
glucose (glycogenolysis)
● It stimulates the liver to take up
amino acids from the blood and
convert them into glucose
(gluconeogenesis)
 ● It stimulates lipolysis, the
Homeostatic Regulation of Blood
breakdown of stored triglycerides Glucose Levels
into free fatty acids and glycerol.
○ Some of the free glycerol
released into the
bloodstream travels to the
liver, which converts it into
glucose, which is also
considred a form of
gluconeogenesis

Insulin:

● The primary function of insulin is to

Blood glucose concentration is tightly
facilitate the uptake of glucose
maintained between 90mg glucose per
into body cells.
100mL based on the diagram.
● It reduces blood glucose levels by
stimulating glycolysis, the (1) Fed State: ↑ Insulin
metabolism of glucose for ● Secreted in response to
generation of ATP. hyperglycemia
● It stimulates the liver to convert ○ Low levels during
excess glucose into glycogen for fasting (basal insulin)
storage, and it inhibits enzymes ○ Increased levels after
involved in glycogenolysis and eating (prandial
gluconeogenesis. insulin)
● It also promotes triglyceride and ● ↑ Glycogen synthesis
protein synthesis. ● ↑ Triglyceride/ fat synthesis
● ↑ Protein synthesis
(2) Fasted State: ↑ Glucagon
● Secreted in response to
hypoglycemia
● ↑ Glycogenolysis
● ↑ Gluconeogenesis
● ↑ Lipolysis

Underlying Pathophysiologic Defect

Insulin resistance
● The body's cells become less
responsive to insulin, which is
usually acquired or developed due to
obesity.
Impaired insulin secretion (B-cell
dysfunction)
● A condition where the beta cells in
the pancreas are unable to produce
adequate amount of insulin. This
may be due to a combination of
genetic, lifestyle, and environmental
factors.
Increased glucose production
● The liver, which normally regulates
glucose production based on the
body's needs, may overproduce
glucose.
SIGNS OF DM TYPE 2
★ High Blood Sugar Levels
(Hyperglycemia): This is detected
through blood tests indicating
elevated glucose levels in the
bloodstream. It's a measurable
indicator of the condition.
★ Glycosuria (Glucose in Urine):
High blood sugar levels can lead to
the presence of glucose in the urine,
which can be detected through
urinalysis. Again, this is a
measurable sign.
★ Acanthosis Nigricans: Darkened,
velvety patches of skin, typically in
skin folds like the neck, armpits, and
groin, can be a sign of insulin
resistance and are considered a
physical indicator of type 2 diabetes.
SYMPTOMS OF DM TYPE 2
Diabetes symptoms depend on how high
your blood sugar is. Some people,
especially if they have prediabetes,
gestational diabetes or type 2 diabetes, may
not have symptoms. In type 1 diabetes,
symptoms tend to come on quickly and be
more severe.
Some of the symptoms of Type 1 and Type
2 Diabetes are:
● Frequent Urination (Polyuria):
Individuals may notice that they
need to urinate more frequently,
particularly at night. This is due to
the body's attempt to rid itself of
excess glucose.
● Increased Thirst (Polydipsia):
Excessive urination can lead to
dehydration, causing increased thirst
as the body tries to compensate for
fluid loss.
● Excessive Hunger (Polyphagia):
Despite eating regularly, individuals
may feel hungry more frequently due
to the body's inability to utilize
glucose effectively for energy.
● Polyneuropathy: Depending on the
affected nerves, diabetic neuropathy
symptoms include pain and
numbness in the legs, feet and
hands.
● Unexplained Weight Loss: Despite
maintaining or even increasing food
intake, individuals may experience
weight loss due to the body's
inability to properly metabolize
glucose.
● Fatigue: Cells may not receive
sufficient glucose for energy
production, leading to feelings of
tiredness and fatigue.
● Blurry Vision: High blood sugar
levels can cause changes in the
shape of the lens in the eye,
resulting in blurry vision.
 ● Slow Healing of Wounds: Elevated
blood sugar levels can impair
circulation and the body's ability to
repair tissues, leading to slower
wound healing.
● Frequent Infections: High blood
sugar weakens the immune system,
making individuals more susceptible
to infections, including urinary tract
infections, skin infections, and yeast
infections.
● Tingling or Numbness: Prolonged
high blood sugar levels can damage
nerves, leading to tingling,
numbness, or pain, especially in the
hands and feet (diabetic
neuropathy).
Note: Although many of the symptoms of
type 1 and type 2 diabetes are similar, they
present in very different ways. Many people
with type 2 diabetes won’t have symptoms
fo many years, and their symptoms slowly
over a long period of time. Some people
with type 2 diabetes have no symptoms at
all and don’t discover they have the
condition until complications arise. The
symptoms of type 1 diabetes develop
quickly, typically over the course of several
weeks.
Laboratory /Diagnostic Test
1. Hematology/ Complete Blood
Count
- CBC is a blood test. It checks your
blood for signs of medication side
effects. They use this test to screen
for diseases and adjust treatments.
2. A1C Test
- A simple blood test used to diagnose
glucose levels over the past 2-3
months. The A1C test measures the
percentage of your red blood cells
that have sugar-coated hemoglobin.
People with higher blood sugar have
more sugar attached to their
hemoglobin.
- Prediabetes: 5.7 percent of your
hemoglobin glycated or coated with
sugar
- Type 2 diabetes: 6.5 percent or
more of the hemoglobin is glycated.
INTERPRETATIONS:
Hematocrit: A low hematocrit level means
there are too few red blood cells in the body.
Neutrophils: In most cases, high neutrophils
count is commonly associated with an
active bacterial infection in the body.
Lymphocyte: Lymphocyte counts below the
normal range can also be temporary. It can
occur after a cold or or be caused by
intense physical exercise, severe stress, or
malnutrition
3. Blood Glucose
- Elevated blood sugar which means
patient is hyperglycemic.
4. Fasting Blood Sugar Test
- The doctor measures the amount of
sugar in your blood after you’ve
fasted for at least eight hours usually
overnight. A fasting blood sugar
level of 100 to 125 milligrams per
deciliter indicates that you have
prediabetes. A blood sugar level of
126 milligrams per deciliter or higher
on two separate tests means you
have diabetes.
5. Oral Glucose Tolerance
- The oral glucose tolerance test
involves fasting overnight, followed
by blood sugar measurements
before and after drinking a
glucose-containing liquid. A blood
 sample is taken one and two hours
after consuming the liquid to assess
the change in blood sugar levels.
- Diabetes: 200 milligrams per
deciliter or higher after two hours
indicates diabetes
- Prediabetes: 140 to 199 milligrams
per deciliter suggests prediabetes.
CASE PRESENTATION
Chief Complaint:
"I was recently diagnosed with possible
diabetes and would like to have my blood
sugar tested. I think that my blood sugar is
running low because I have a terrible
headache."
HPI
Sarah Martin is a 43-year-old woman who
comes to the pharmacy for a diabetes
education class taught by the pharmacist.
She would like for the pharmacist to check
her blood sugar before the class begins.
She was diagnosed with diabetes mellitus
Type 2 about 6 months ago. She has been
attempting to control her disease with diet
and exercise but has had no success. Her
physician has recently started her on
gly-buride 5 mg. She has gained 15 lb over
the past year. She monitors her blood sugar
once a day, per her physician, with a range
of 215-260 mg/dL. Her fasting blood sugars
average 170 mg/dL.
РМН
- Type 2 DM × 6 months
- HTN × 15 vears
- Bipolar disorder × 25 years
- Dyslipidemia × 10 years
- Morbid obesity × 15 years
FH
Father has a history of HTN and bipolar
disorder. Mother has a history of
dyslipidemia. Brother has DM secondary to
alcoholism.
SH
Has been married for 21 years. She has two
children who are teenagers. She works in a
floral shop making deliveries. Denies any
use of tobacco products but does drink
alcohol occasionally (five beers/wine per
week).
MEDS
- Glyburide 5 mg po BID
- Lisinopril 20 mg po once daily
- Zyprexa 5 mg po Q HS
- Carbamazepine 200 mg po TID
- Lorazepam 1 mg po TID PRN
- Fluoxetine 20 mg po Q AM EC ASA
81 mg po once daily
- Pravastatin 40 mg po once daily
ROS
Complaints of nocturia, polyuria, and
polydipsia on a daily basis. Denies nausea,
constipation, diarrhea, signs or symptoms of
hypoglycemia, paresthesias, and dyspnea
PHYSICAL EXAMINATION
Gen
WDWN severely obese,
Caucasian woman in NAD
VS
BP 160/90, P 98, RR 18, T 38.6C; waist circ
36 in, Wt 109 kg, Ht 5’8’’
Note: Normal waist circ for men: below 94
cm or 37 in (low risk). Women: below 80cm
or 31.5 in ( low risk)
HEENT
PERRLA, EOMI, R and L fundus exam
Problem Identification
without retinopathy
Neck/Lymph Nodes
WNL
Lungs
Clear to A & P
CV
RRR, no MRG
Abd
NT/ND
Genit/Rect
Deferred
MS/Ext
Carotids, femorals, popliteals and right
dorsalis pedis pulses 2+ throughout; left
dorsalis pedis 1+; feet show mild calluses
on MTPs
Neuro
DTRs 2+ throughout, feet with normal
sensation (5.07 monofilament) and vibration
ASSESSMENT
The patient reports that she exercises at
most once a week and her diet is difficult to
maintain due to the nature of her job as a
delivery person. Her glycemic control has
been maintained with an 8.9% A1C 6
months ago. She has a moderate weight
gain of 15 lb (6.8 kg) over the past year. Her Desired Outcome
blood pressure and cholesterol are not at
goal on the current drug therapy. Her bipolar
disorder is moderately controlled on the
current drug therapy. When the patient is in
a depression or manic phase, she tends to
use food to “treat” the symptoms
1. Inadequate Glycemic Control:
Despite being on glyburide, the
patient's blood sugar levels are not
well-managed, leading to an A1C of
8.9%.
2. Uncontrolled Hypertension: Blood
pressure remains elevated at 160/90
mmHg despite treatment with
lisinopril.
3. Suboptimal Bipolar Disorder
Management: While moderately
controlled, bipolar disorder may
impact eating habits during mood
swings.
4. Weight Gain and Obesity: The
patient has gained 15 lb over the
past year, contributing to morbid
obesity.
5. Dyslipidemia Not at Goal: Lipid
levels are not at the target range
despite being on pravastatin.
6. Psychosocial Factors Impacting
Health: The patient uses food to
cope during depressive or manic
phases of bipolar disorder.
7. Lifestyle Challenges: Irregular
exercise and challenges in
maintaining a healthy diet due to the
nature of the job.
8. Medication Adherence: The
complexity of the medication
regimen may pose challenges in
adherence.
1. Glycemic Control:
- Achieve and maintain target blood
glucose levels.
- Reduce A1C to within the
recommended range.
 2. Hypertension Management:
- Attain and maintain optimal blood
pressure control.
- Lower blood pressure to within the
target range.
3. Bipolar Disorder:
- Stabilize mood and minimize the
impact of bipolar disorder on eating
habits.
4. Weight Management:
- Implement effective strategies to
manage weight.
- Gradual reduction in obesity and
prevention of further weight gain.
5. Lipid Control
- Achieve target lipid levels.
- Improve overall lipid profile.
6. Psychosocial Well-being:
- Enhance mental health and
well-being.
- Develop healthier coping
mechanisms during depressive or
manic phases.
7. Lifestyle Changes:
- Establish and maintain a balanced
lifestyle.
- Regularize exercise routine and
adopt a sustainable, healthy diet.
8. Medication Adherence:
- Improve adherence to the prescribed
medication regimen.
- Simplify dosing regimens for better
adherence.
Explanation for Desired Outcome:
(GOODS NA)
Glycemic Control:
- Achieve and maintain target blood glucose
levels to prevent complications associated
with uncontrolled diabetes, such as
neuropathy, nephropathy, and retinopathy.
Neuropathy, nephropathy, and retinopathy
are all complications that can arise from
uncontrolled diabetes, particularly when
blood sugar levels remain consistently high
over time.
1. **Neuropathy:** High blood sugar levels
can damage the nerves throughout the
body, especially in the feet and legs. This
condition, known as diabetic neuropathy,
can lead to numbness, tingling, pain, or
weakness in these areas.
2. **Nephropathy:** Diabetes is one of the
leading causes of kidney disease, known as
diabetic nephropathy. Persistent high blood
sugar levels can damage the blood vessels
in the kidneys, impairing their ability to filter
waste products from the blood effectively.
Tight glycemic control is essential to prevent
or delay the onset of diabetic nephropathy
and preserve kidney function.
3. **Retinopathy:** High blood sugar levels
can also damage the small blood vessels in
the retina, the light-sensitive tissue at the
back of the eye. This condition, called
diabetic retinopathy, can lead to vision
problems and even blindness if left
untreated.
- Reducing A1C to within the recommended
range (typically below 7%) helps decrease
the risk of long-term complications and
improves overall quality of life for the patient
by minimizing symptoms associated with
hyperglycemia.
Hypertension Management:
- Attaining and maintaining optimal blood
pressure control reduces the risk of
cardiovascular complications, such as
stroke, heart attack, and kidney disease.
- Lowering blood pressure to within the
target range (usually below 130/80 mmHg)
decreases the strain on the heart and blood
vessels, promoting better overall
cardiovascular health.
Bipolar Disorder:
- Stabilizing mood and minimizing the
impact of bipolar disorder on eating habits
helps prevent erratic eating behaviors that
can exacerbate weight gain and worsen
metabolic control.
- By effectively managing bipolar disorder
symptoms, the patient can experience
improved mental well-being and better
adherence to dietary and medication
regimens.
Weight Management:
- Implementing effective strategies to
manage weight is crucial for reducing the
risk of obesity-related complications, such
as cardiovascular disease, joint problems,
and sleep apnea.
- Gradual reduction in obesity and
prevention of further weight gain can
improve insulin sensitivity, enhance
glycemic control, and reduce the burden of
managing comorbid conditions associated
with obesity.
Lipid Control:
- Achieving target lipid levels, including LDL
cholesterol, HDL cholesterol, and
triglycerides, helps reduce the risk of
atherosclerotic cardiovascular disease.
- Improving the overall lipid profile
contributes to better cardiovascular health
and lowers the likelihood of experiencing
cardiovascular events, such as heart
attacks or strokes.
Psychosocial Well-being:
- Enhancing mental health and well-being is
essential for improving overall quality of life
and promoting adherence to lifestyle and
medication regimens.
- Developing healthier coping mechanisms
during depressive or manic phases reduces
the reliance on food as a coping mechanism
and promotes long-term emotional stability.
Lifestyle Changes:
- Establishing and maintaining a balanced
lifestyle, including regular exercise and a
healthy diet, is fundamental for managing
diabetes, hypertension, dyslipidemia, and
obesity.
- Regularizing exercise routines and
adopting sustainable, healthy dietary habits
support long-term disease management and
contribute to improved overall health
outcomes.
Medication Adherence:
- Improving adherence to the prescribed
medication regimen is crucial for achieving
therapeutic goals and preventing disease
progression.
- Simplifying dosing regimens, such as
consolidating medications or utilizing
once-daily formulations, can enhance
patient compliance and optimize treatment
effectiveness.
Therapeutic Alternatives
Non- pharmacologic approach:
● Healthy lifestyle modifications
(nutritional interventions, weight
loss, regular physical activity)
● Educate the patient on glycemic
control using insulin and oral
antidiabetic medication
● Educate the patient on how to
monitor blood glucose in the
morning, evening, and before each
meal.
● DASH diet to control blood pressure
and maintain weight BMI < 25kg/ m2
OUTCOME EVALUATION
Type 2 DM
● Monitor A1C four times a year until
at goal, then two times a year
● Manually monitor glucose in the
morning, evening, and prior to meals
● Check blood pressure at each doctor
visit
● Have a foot exam annually
● Take a lipid exam, eye exam,
urinalysis, and dental exam annually

Pharmacologic approach:

1. Take Metformin 500 mg BID with

food
2. Discontinue Glyburide usage
3. Start Canagliflozin 100 mg QD.
4. Start Insulin glargine 10 U/day or
0.15 U/kg/day, titrate every 3 days to
achieve FBG target
5. Continue taking EC ASA 81 mg po
once daily as a secondary
prevention

OPTIMAL PLAN

Type 2 DM
● Target A1C <7%
● Target FBG 80-130 mg/dL
● Reduce risk of microvascular and
macrovascular complications
● Ameliorate symptoms and improve
quality of life
\\\\\\