1. Diabetes mellitus

2. Fasting venous plasma glucose ≥ 7mmol/l(126mg/dl) Metabolic disorder, hyperglycemia, abnormality in C.H,fat, protein metabolism. Defect in insulin secretion, insulin sensitivity or both Type I D.M Due to Pancrease B-cell destruction result in absolute insulin defficiency.

3. Type 2 D.M accounts for 90%, it associated with both insulin resistance and relative insulin defficiency. Insulin resistance : increase lipolysis,free fatty acid production, increase hepatic glucose production and decrease skeletal muscle uptake of glucose.

4. Causes of D.M Gentic defect of B-cell function Gentic defect in insulin action Endocrine disorder ; acromegaly, cushing syndrom,pancreatitis, cystic fibrosis, pheochromocytoma. Drug ;thiazide, diuretic, α- interferone, glucocorticoid, oral contraceptive, diazoxide, thyroid Hr and pentamidine.

5. Causes of D.M Viral infection by cytomegalo virus Gestational diabetes (GDM)

6. Diagnosis HbA1C≥ 6.5% FPG ≥ 126mg/dl (7mmol/l) OGTT ; measurement of glucose 2hr post prandial of ≥ 200mg/dl (111.1 mmol/l). RPG ≥ 200MG/dl. Prediabetic : Imparied glucose tolerence (IGT); when OGTT (7.8-11 mmol/l) or 140-199mg/dl Imparied fasting glucose (IFG); when FPG of 100- 125mg/dl or (5.6-6.9 mmol/l)

7. Treatment Nonpharmacology treatment : Aerobic regular exercise, wt reduction, smoking cessation, focus on regular insulin adminstration with a balanced diet to achieve healthy body wt. Reduce saturated fat,and Carbohydrate.

8. Treatment Pharmacology : Insulin : 1-rapid acting insulin ; adm. Before 10min of meals with duration 3-5 hr.e.g; (lispro, aspart, and glulisine insulins) humalog (vial + pen + car.),( novorapid (vial,+pen+cartridge ),novolog (vial,+pen+cartridge ), apidra (car. + opticlik pen sys.) 2-short acting,regular insulin ; adm. Before 30min of meals with duration 3-6 hr e.g. (humulin r (vial ) novoline r (vial, pen, cartridge and innolet),actrapid vial, insuman rapid (cartridge )

9. INSULIN 3- intermediate action(NPH) its neutral protamine hagedorn also called isophane protamine ; admin before 2-4 hr with duration 8-12hr, its may contribute to labile glucose response, nocturnal hypoglycemia and fasting hyperglycemia. e.g. humulin N, (vial + pen) Novolin N (vial, pen, innolet), insulitard vial, insulitard penfill, insulitard innolet

10. INSULIN 4-Long acting ; detemir admin before 2hr with duration of 14-24 hr, while glargine before 4- 5 hr with duration of 22-24 hr, its less nocturnal hypoglycemia compared with NPH, IF given at bed time e.g. levemir™ (detemir), lantus™ (glargine ) Levemir flexpen, levemir penfill cartridges ) Lantus vial+ pen + cartildge

11. INSULIN 5-premixed insulin ; humalog mix 75/25(75% neutral protamine lispro, 25% lispro) (vial+pen + cartridge ) Novolog mix 70/30; 70% aspart protamine suspension and 30% aspart. Humalog mix 50/50; (50% neutral protamine lispro and 50% lispro) NPH regular combination ; humulin 70/30, novolin 70/30; 70% isophane, 30% regular

12. INSULIN In type 1 D.M ; Insulin dose 0.5 to 0.6 unit /kg may fall to 0.1-0.4 unit/kg in honey moon phase.max 0.5-1 u/kg in sever ketosis. In type 2 D.M ; 0.7- 2.5 U/KG Adverse effect ; hypoglycemia, wt gain. Hypoglycemia : treated by dextrose I.V, glucagon

13. INNOLET

14. PEN

15. OTHER INTECTION Other injectable preparation glucagon-like peptide 1(GLP-1) agonists : 1-Exenatide (byetta)™: enhance glucose dependent insulin secretion and reduce hepatic glucose production, also it reduce appetite and reduce gastric emptying rate causing wt loss. Also inhibit glucagon secr. 2-liraglutide (victoza)™; similar in action to exenatide with longer duration

16. OTHER INJ. Amylinomimetic : Pramlintide (symlin)™; neurohormone cosecreted from B- CELL with insulin, its suppress glucagon secretion,increase satiety ( which can cause wt loss).

17. SULPHONYL UREA Sulfonyl ureas: stimulate pancreatic secretion of insulin. 1-glipizide(minodiab) 5mg, 10mg, the duration about up to 20hr.( Metabolized by liver), glipizide XL (slow release form) (Daily before breakfast or lunch) 2-glyburide(glibenclamide ) 1.25, 2.5,5 mg, duration up to 24hr, (liver +renal ),daily during or after breakfast. 3-glimepiride (amaryl)™ 1,2,3,4,6 mg, duration up to 24hr (metabolized by liver). Given shortly before breakfast.

18. SULPHONYL UREA 4-Gliclazide (diamicron)™ 30,40,80mg, diamicron MR, taken daily with breakfast.

19. Adverse effect of sulphonyl urea Hypoglycemia specialy with longer half life Wt gain Less common haemolytic anemia, GIT upset, and cholestasis

20. MEGLITINIDE Meglitinides: short acting insulin secretory, they should be adminstered 30 min before meal. If a meal is skipped, the medication should also be skipped. 1- repaglinide (prandin)™ ( novonorm )™; 0.5,1,2mg, given three to four times daily. 2-nateglinide (starlix)™ ; 60mg,120mg,180mg Also three times daily

21. BIGUANIDE Biguanide ; increase isulin sensitivity of both hepatic and peripheral, reduce LDL, triglyceride and increase HDL. ALSO decrease glucose absorption in GIT. Metformin (500,850,1000mg ) Adverse effect ; GIT (stomach upset, abdominal discomfort, anorexia and diarrhea, also lactic acidosis in renal impariment. How to minimized GIT adverse effect? Glucophage XR (extended release ) and take the medicine with food.

22. GLITAZONE Thiozolidinediones (glitazone ); It enhance insulin sensitivity in muscle, liver and fat tissue indirectly and need insulin for their action 1-pioglitazone (Actos )™(15,30,45mg) with duration 24hr, also decrease triglyceride without increase in LDL. 2- rosiglitasone (avandia )™ 2,4,8mg with duration 24hr, an increase in LDL will occur.

23. GLUTAZONE Adverse effect of glitazone ; water retention due to sodium retention, odema, wt gain, hepatic toxicity, increase risk of upper and lower limb.

24. α –glucosidase inhibitor α –glucosidase inhibitor ; inhib. Of breakdown of sucrose and complex carbohydrate to mono succharide Acarbose (precose )™ and miglitol (glycet)™ 25,50,,100mg taken 1-3 times daily. Adverse effect ; flatulence, abdominal discomfort, bloating and diarrhea.

25. DPP-4 -I DPP-4-Inhibitor : dipeptidyl peptidase-4 enzyme – inhibitor(glipitin) ; these agent able to prolong half life of endogenous incretin hr. that required for decrease glucagon level, stimulate insulin secretion. Sitagliptine (januvia)™ 25,50,100mg. Given once daily, reduce dose in renal impairment. Alogliptin (vipidia)™ 6.25, 12.5,25mg also once daily and reduce dose in renal impairment

26. DPP4-I Saxagliptin (onglyza)™ ; 2.5,5mg once daily. linagliptine(trajenta)™ ; 5mg once daily Vildagliptin (galvus )™ ; 50mg twice daily All above group need dose adjusment in case of mixed with sulphonyl urea and insulin, in add. alogliptine + metformin + pioglitazone need adjustment bec. Risk of hypoglycemia.

27. DPP4-I Adverse effect ; mild hypoglycemia if use alone, urticaria, facial oedema, Rare steven – johnson syndrom, pancreatitis, (saxagliptine rare associated with decrease lymphocyte count and cause infection )

28. SOD.GLUCOSE CO-TRANS.2-I Na- glucose co transporter 2 inhibitor ; Inhibit glucose reabsorption in renal and increase urinary glucose excretion. Canagliflozin (invokana)™ ; 100mg, 300mg 1x1 Dapagliflozin(forxiga)™; 5mg, 10mg 1x1 Empagliflozin (jardiance)™ ; 10mg, 25mg 1x1 Most adverse eff. UTI, thirst, polyurea.

29. MIXED PREPARATION ROR TYPE 2 D.M 1- glucovance™ (glibenclamide+metformin)1.25/250,2.5/500,5/500 2- vipdomet ™ 12.5mg of alogliptine+ 1000mg of metformin. 3-jentadueto™ linagliptine 2.5mg/850mg or 1000mg 4-komboglyze™ saxagliptine 2.5mg/850 or 1000mg 5-janumet™ sitagliptine 50mg/500mg, or 1000mg met. 6-galvumet™, eucreas™ vildagliptin 50mg/850 or 1000 mg met.

30. 7-metaglip™ ; glipizide+ metformin 2.5mg/250mg 2.5mg/500mg, 5mg/500mg 8-avandamet™ rosiglitazone 1mg,2mg, 4mg/ metformin 500mg, or 2mg,4mg/1000mg