PRAMEHAV.Srujan B.A.M.S III ProfS.V.Ayurveda College

Nidana: आस्यासुखं स्वप्नसुखं दधीनि� ग्राम्यौदका�ूपरसाः पयांसिस | �वान्नपा�ं गुडवैकृतं च प्रमेहहेतुः कफकृच्च सव'म् || (Ca.ci : 6:4)

दिदवास्वप्नाव्यायामालस्यप्रसकं्त शीतस्निस्�ग्ध मधुरमेद्यद्रवान्नपा�सेनिव�ं पुरुषं जानि�यात् प्रमेही भनिवष्यतीनित || (Su.ni : 6:3)

vagbhata mentioned Mutrajanaka anna,paana,kriya also a main cause for prameha.

Poorvaroopa: “स्वेदोऽङ्गगन्धः सिशसि<लाङ्गता च शय्यास�स्वप्नसुखे रनितश्च| हृन्नेत्रजिजह्वाश्रवणोपदेहो घ�ाङ्गता केश�खानितवृजिFः|| शीतनिप्रयत्वं गलतालुशोषो माधुय'मास्ये करपाददाहः| भनिवष्यतो मेहगदस्य रूपं मूते्रऽभिभधावन्तिKत निपपीसिलकाश्च|| (Ca.Ci : 6:13,14)

Pūrvarūpa According to Suśr̥ta : “तेषां तु पूव'रूपाभिण- हस्तपादतलदाहः स्निस्�ग्धनिपच्छिMलगुरुता गात्राणां मधुरशुक्लमूत्रता तKद्रा सादः

निपपासा दुग'न्धश्च श्वासस्तालुगल जिजह्वादKतेषु मलोत्पभिQज'दिRलीभावः केशा�ां वृजिFश्च �खा�ाम् || (Su.Ni : 6:5)

 

Rūpa :

तत्रानिवलप्रभूतमूत्रलक्षणाः सव' एव प्रमेहा भवन्तिKत ॥ (Su.ni : 6:6) सामKय लक्षणं तेषां प्रभूतानिवलमूत्रता ॥ (Ah.ni : 10:7) General symptoms seen in all types of Pramēhas are Prabhūta mūtrata : Increased quantity of urine Āvila mūtrata : Increased turbidity of urine

Saṁ�prāpti : Kapha

vititatesMedas ,mamsa, kleda

vitiates

Pitta vitiates

Reaches basti

Kaphaja prameha

Pittaja prameha

Vata vitiates Ojas, majja,lasika vitiates

Reaches basti Vataja prameha

Saṁprāpti Ghatakas

Dōṣas : Kapha, Pitta,Vāta Dūṣya : Mēdas,Śukra, Ambu, Rasa,Vasā,Ōjas,Majjā,Lasikā Śrōtas : Mūtravaha,Māṁsavaha Śrōtōduṣṭi : Vimārgagamana, Ati pravritti Adhiṣṭhāṇa : Mūtrāśaya Rōgamārga : Maadhyama Sādhyata and Asādhyata : Kaphaja-Sādhya

Pittaja -Yāpya Vātaja-Asādhya

Types of pramehaKaphaja,pittaja and vataja pramehas KAPHAJA PRAMEHAS

ACCORDING TO CHARAKA ACCORDING TO SUSRUTA

Udakamēha-water like Urine Udakamēha (Hydruria)Ikśuvālikamēha-resembles sugar cane juice

Ikśuvālikamēha (Glycosuria)

Sāndramēha-greater viscosity Surāmēha-Urine resembles Sura *Sāndraprasādamēha-partly viscous & clear

Sikatamēha (Graveluria)

Sikatamēha-small and hard crystals ŚanairmēhaSuklamēha-urine resembling flour Lavaṇamēha-urine with Salty taste *Śukramēha-urine resembling semen Pista mehaŚītamēha-Urine will be excessively cold

Sāndramēha

Śanairmēha-small quantity,dec force ŚukramēhaĀlālamēha- resembling saliva (pyuria) Phēnamēha-Urine with froath *

PITTAJA PRAMEHAS-ACCORDING TO CHARAKA ACCORDING TO SUSRUTAKṣāramēha-resembling Kṣāra in smell, colour, touch

Nīlamēha

Kālamēha- black urine HāridramēhaNīlamēha-feathers of cāṣabird(color)

Amlameha-sour taste & smell *

Raktamēha-red colour,raw flesh KṣāramēhaManjiṣṭamēha-colour of Manjiṣṭajuice

Manjiṣṭamēha

Hāridramēha-colour of Hāridra juice

LohitamehaVATAJA PRAMEHAS-ACCORDING TO CHARAKA ACCORDING TO SUSRUTAVasāmēha- urine along with Vasā VasāmēhaMajjāmēha-urine along with majja Sarpimeha-resembles gheeHastimēha-Large quantities of urine

Hastimēha

Madhumēha-sweet,astringent,pale

Ksaudrameha-resembles honey

Sādhyāsādhyata In Kaphaja pramehas the vitiated dosa and dusyas have similar attributes drugs prescribed in this condition allievate both dosa and dusya,easily curable. In Pittaja pramehas the vitiated dosa and dusyas have different

attributes ,so there is difficulty in managing the disease,it is said to be Yapya{manageable} Pittajapramēhas are generally Yāpya, but, if Mēdas is not affected much they become Sādhya.

In Vataja pramehas the vitiated dusya is deeper dhatus i.e majja, ojas. many complications and serious in nature.so Asadhya. Patient who suffers with Pramēha right from the time of birth and those

who are born of parents having Pramēha(hereditary) are not curable because of the morbidity in their bīja.

CHIKITSA स्थूलः प्रमेही बलवानि�हैकः कृशस्त<ैकः परिरदुब'लश्च । सम्बृंहणं तत्र कृशस्य कायZ संशोध�ं दोषबलाधिधकस्य ॥ (Ca.Ci : 6:15)

Gulma, Kṣaya, Mēhanaśūla,Bastiśūla, Mūtragraha Krś̥a and durbala people Brm̥hanaVISESHA CHIKITSA Kaphaja Pramēha Cikitsa : Ullēkhana(vamana), LanghanaPittaja Pramēha Cikitsa : Virēcana, santarpana, saṁśamana Patients who are contraindicated for sodhana then samana therapy followed. Susruta-100yojana, carving brahmaratha, digging wells

Sthula & balavan

Oleation therapy Sodhana Santarpan

a

Apatarpana

UPADRAVAS ACCORDING TO SUSRUTA- (Su.Ni : 6:13) Mākṣikōpasarpanaṁ, Ālasya,

Māṁsōpacaya ,Pratisyāya ,Śaithilya ,Ārōcaka ,Avipāka, Cchardi, Nidrā, Kāsa, Svāsa are complications of kapha prameha.

Vr̥ṣanayōravadaranaṁ,Bastibhēdaṁ,Mēḍhratōda,Hr̥dśūla,Amlikā,Jvara,Atisāra,Ārōcaka,Vamathu,Paridhūpanaṁ,Dāha,Mūrccha,Pipāsa,Pāṇḍurōga,Nidrānāśa,Pītavinmūtranētratvam are diseases of pitta origin.

Hr̥dgraha,Laulya,Anidra,Stamba,Kampa,Śūla,Baddhapurīśam are complications of vata origin.

In persons whose body filled with vasa and medas,dhatus get invaded by 3dosas gives rise to prameha pidakas-Śarāvika,Kacchapika,Jālini,Sarṣapī,Alaji,Vinata,Vidhradi,Masūrika,Putrinī, Vidārika

Pathya-apathya Patya  Āhāra Yavaudāna Sarodakam Kusodakam Triphala rasa Madhudakam Sidhu Barley soaked in the decoction of Triphala and kept overnight should be

mixed with honey.Vihāra: Different types of Exercises, bath , Application of ointment made of uśīra,Tvak, Ēla, Aguru, Candana etc.

[Ca.ci.6:46-50]

Apatya Sauvīraka Tuṣōdaka Śukta Mairēya Surā Āsava Pānaka Ikṣuvikāra Piṣṭānna Āmlapadārta Anūpaudakamāṁsa 

Su.ci. 11/5

Importance of barley Oldest grain on earth. Principal ingredient in food of prameha patient. Kaphaja prameha Barley mixed with honey.

Barley soaked overnight in triphala, mixed with honeyTarpana

Barley soaked in prescribed decoctions and taken in form of saktu(roasted flour), apupa(pancakes), dhana(fried barley).

Barley contains a soluble fibre called beta-glucan. It slows the gastric emptying and tempering blood glucose level.

In a placebo barley, oats,wheat are given to people as breakfast. People who are taking barley have less blood glucose levels compared to others.

Yogas Niśāmalaki Cūrṇam,Navāyāsa Cūrṇam,Taikanṭakadyam Ghrt̥am,Daśamūla Ghrt̥am,

Madhvāsavam,Bhallātakāsavam,Dantyāsavam,Lōdhrāsavam,Ayaskrt̥i are importrant yogas mentioned in classics.

Yogas in sahasra yogamKaṣāya Pramēhī-niśā katakādi kaṣāya Palāśapuṣpa kaṣāyaGhr̥tam Pancatiktaka guggulu ghrt̥am Svadamstrādi ghrt̥amChūrṇas Prt̥hu nimba pancaka cūrṇa Nimbādi cūrṇa Vyōṣādi cūrṇa Aśvagandhādi cūrṇa Kalyāṇa kṣāra cūrṇa

Asava Arista• Daśamūlariṣṭa• Aśōkāriṣṭa• Dārvāriṣṭa• Uśīrāsava• Śatāvari guḍaLehyam• Daśamūla harītakī lēhya• Daśamūlādi lēhya• Madhusnūhi rasāyana• Agastya rasāyanaVaṭi • Abhaya mōdaka• Kaiśōra guggulu• Nīlakanṭa ras• Bahumūtrāntaka ras 

Visesha yogas:Udakamēha :Pārijāta

Ikśuvālikamēha:Vaijayanti

Sāndramēha :Saptaparna

Surāmēha :Nimba

Piṣṭamēha:Haridra, Dāruharidra

Śukramēha :Dūrva, Śaivala, Plava, Haṭha, Karanja, Kaśēruka/Kākubha, Candana

Phēnamēha:āragvadha,MrD̥vīkŚanairmēha :KhadiraLavaṇamēha:PāṭhaAguruHaridraSikatamēha:Citraka

Nīlamēha :SālasarādiGaṇa

Hāridramēha :RājavrK̥ṣa

Āmlamēha :NyagrōdhādiGaṇa

Kṣāramēha :Triphalā

Manjiṣṭamēha:Manjiśṭa,Candana

Śōnitamēha :Guḍūci, seeds of Tindūka, Kaśmarya, Kharjūra added with honey

Sarpimēha :Kalka of Kuṣṭa, Kuṭaja, Pāṭha, Hingu, Kaṭukarōhini added with Guḍūci & Citraka Kaṣāyās

Vasāmēha:Agnimantha/Simśapa

Kṣaudramēha:Kadara,Kramuka

Hastimēha :Tindūka, Kapittha,Sirīṣa, Palāśa, Pāṭha, Mūrva, Duhsparśa added with honey and sugar/jiggery and ash of bones of elephant, horse, boar, donkey and camel 

DIABETES MELLITUS

DIABETES Diabetes is a common life-long health condition. Diabetes is a condition where the amount of glucose in your blood is

too high because the body cannot use it properly. This is because your pancreas doesn’t produce any insulin, or not

enough insulin, to help glucose enter your body’s cells – or the insulin that is produced does not work properly (known as insulin resistance).

As of 2013, 382 million people have diabetes worldwide. Type 2 makes up about 90% of the cases

In 2014, the International Diabetes Federation (IDF) estimated that diabetes resulted in 4.9 million deaths. TheWorld Health Organization (WHO) estimated that diabetes resulted in 1.5 million deaths in 2012, making it the 8th leading cause of death.

CLASSIFICATION TYPE 1 DIABETES MELLITUS TYPE 2 DIABETES MELLITUS GESTATIONAL DIABETES OTHER SPECIFIC TYPES a. MODY {MATURITY ONSET DIABETES OF THE YOUNG}b. LADA {LATENT AUTOIMMUNE DIABETES OF ADULT}c. NEONATAL DIABETES MELLITUS[NDM] WOLFRAM SYNDROME ALSTROM SYNDROME

TYPE 1 – {IDDM,JUVENILE DIABESTES} It occurs when the individuals own immune system acts against pancreatic β-cell and destroys it.

TYPE 2 – {NIDDM} It is a disorder of metabolism of carbohydrate , protein and fat due to absolute or relative deficiency of insulin secretion and with varying degree of insulin resistance. GESTATIONAL DIABETES {GDM} Gestational diabetes is a type of diabetes that affects pregnant women, usually during the second or third trimester. Placenta human placental lactogen(hpl) growth & development of fetus

Insulin receptor activity is diminished

hyperglycemia

MODY – MODY is a rare form of diabetes which is different from both Type 1 and Type 2 diabetes, and runs strongly in families. MODY is caused by a mutation (or change) in a single gene. If a parent has this gene mutation, any child they have, has a 50% chance of inheriting it from them.  If a child does inherit the mutation they will generally go on to develop MODY before they’re 25, whatever their weight, lifestyle, ethnic group etc.

LADA- Latent autoimmune diabetes of adults is a form of type 1 diabetes that occurs in adults, often with a slower course of onset. Adults with LADA may initially be diagnosed as type 2 based on their age.NEONATAL DIABETES MELLITUS- Neonatal diabetes is a form of diabetes that is diagnosed under the age of 6months.change in gene affects insulin production.It is different type of diabetes than the more common type 1 as its not an autoimmune and type 1 doesn’t affect anyone under 6months.a) Transient neonatal diabetes mellitus(TNDM)b) Permanent neonatal diabetes mellitus(PNDM)

WOLFRAM SYNDROME- Wolfram Syndrome is a rare genetic disorder which is also known as -DIDMOAD syndrome after its four most common features (Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness).

ALSTROM SYNDROME- Alström Syndrome is a rare genetically inherited syndrome which has a number of features-Retinal degeneration,Type 2DM, Hearing loss, Cardiomyopathy, Renal (kidney) failure, Orthopaedic and rheumatology problems

INCIDENCE

TYPE 2 DM TYPE 1 DM GDM OTHERS

AETIOLOGY

TYPE 1 DM βcell destruction(auto-immune)

absolute insulin deficiency & deficiency of c peptide TYPE 2 DM 1.Impaired insulin secretion by pancreas 2.Insulin resistance by peripheral tissues 3.Increased glucose production by liver 4.Incretins are not working properly{not significant} Over weight and sedentary lifestyle are the primary causes to typ 2

dm which leads to these conditions.

MATURITY ONSET DIABETES OF THE YOUNG HNF4-alpha mutation on chromosome 20—MODY1 Glucokinase gene mutation on chromosome 7—MODY2 HNF1-alpha. This gene causes about 70% of cases of MODY.—MODY3 Insulin promoter factor 1 mutation on chromosome 13---MODY4 HNF1-Beta mutation on chromosome 17----MODY5

GESTATIONAL DIABETES is caused by – overweight gestational diabetes before very large baby in a previous pregnancy (4.5kg/10lb or over) have a family history of diabetes (parent, brother or sister)

NEONATAL DIABETES MELLITUS is caused by- Infants with NDM do not produce enough insulin leading to increase in blood glucose.caused by change in a gene which affects insulin production.This is not autoimmune like typ1. MODY & NDM are monogenic forms of diabetes.

Clinical features Unexplained weight loss  Polyuria(increased urination) Polydipsia (increased thirst) Polyphagia(increased hunger) Fatigue Slow healing of cuts Ketosis [Type 1] Prolonged high blood glucose can cause glucose absorption in the lens of the

eye, which leads to changes in its shape, resulting in vision changes. A number of skin rashes that can occur in diabetes are collectively known as

diabetic dermadromes. Symptoms may develop rapidly (weeks or months) in type 1 diabetes, while

they usually develop much more slowly and may be subtle or absent in type 2 diabetes.

What is Insulin?Insulin is a hormone secreted by pancreatic beta cells. It works as a chemical messenger that helps your body use the glucose in your blood to give you energy. You can think of it as the key that unlocks the door to the body’s cells. Once the door is unlocked, glucose can enter the cells where it is used as fuel.

INSULIN SECRETION

1. Glucose from blood stream enters into beta cell by GLUT2(transporter) mechanism.

2. Glucose gets converted into pyruvic acid and then undergoes citric acid cycle &oxidative phosphorylation.

3. End product ATP is obtained.4. Due to ATP formation ATP sensitive

potassium channels gets closed.5. Membrane depolarization occurs,by

that voltage gated calcium channels are opened.

6. Influx of calcium takes place.7. These calcium triggers the storage

granules and by exocytosis insulin,c-peptide,amylin very little amount of proinsulin is released into the blood stream.

PATHOPHYSIOLOGY:

HYPERGLYCEMIA INCREASED BLOOD GLUCOSE LEVELS

Reduced insulin secretion by

pancreatic βcellsIncreased glucose

output by liver

Insulin resistance by peripheral

tissue[decreased glucose uptake]

Insulin

Mixture of peptide harmones secreted when we take food, by epithelium of GIT-Glucagon like peptide 1 [GLP1] Gastric inhibitory peptide Secretin IncretinsGastrinCholecystokinin

Intravenous glucose

Glucose orally Insulin

Intake of food

GLP-1,GIP etc secreted

Stimulate Gstimulatory

protein in βcell

Stimulate Adenylyl cyclase

Conversion of ATP into cAMP

Increase in intracellular cAMP also leads to release

of insulinInsulin

DPP-4[dipeptidyl peptidase-4] enzyme. {Breaks down the aminoacid chain of GLP-1 & GIP and insulin secretion is inhibited}

Management Lifestyle monitoring Oral hypoglycemics Insulin Surgery

Life style monitoring Diet Physical activity Stress management single diet plan exists for people with diabetes is no longer valid. The Plate Method is the recommended diet plan for people with diabetes. carbohydrate counting is another method. Physical activity promotes weight reduction and improves insulin sensitivity, thus lowering blood glucose levels.Approximately 150min of aerobic exercise is needed in 1week for diabetic person. Though a person follow strict diet and physical activity, stress can hamper the diabetic care.

Stressful condition

SNS is stimulated

Norepinephrine is released

Inhibits insulin secretion

Insulin mediated glucose uptake by

peripheral tissue is lessMore glucose to CNS

oral hypoglycemic

Insulin secretogogues

They help in closure of ATP sensitive potassium channels and there by secretion of insulin.

s.no

category Generic name

1 Sulfonylureals Glymepiride,Glyburide 2 Meglitinide Repaglinide

Thiazolidinediones [TZD’S]

Rosiglitazonepioglitazone

Decreases peripheral insulin resistance

Biguanide Metformin Reduces hepatic glucose production

GLP-1 analog Liraglutide,Exanatide

Produce insulin

DPP4 inhibitors Sitagliptin,saxagliptin

Increases the life of INCRETINS

Side effects

Metformin Safest in oral hypoglycemics

Causes abdominal distension,nausea in higher

dose

Lactic acidosis

category effect Sulphonylureals Hypoglycemia Meglitinide{short acting secretogogues}

Weight gain, Hypoglycemia

Thiazolidinediones {TZD’s} Hepatitis,edema,bladder cancer

GLP-1 analog Weight loss,GIT problemsPramlinitide{amylin analogue} Nausea

INSULIN Insulin is usually given subcutaneously, either by injections or by an insulin pump. They are rapid acting insulins, intermediate acting insulins and long acting insulins.

Overdose of insulin causes insulin shock-low blood sugar,weakness,convulsions,coma. Insulin shock therapy or insulin coma therapy[ICT] was a form of psychiatric treatment

in which patients were repeatedly injected large doses to produce daily comas,each coma lasts upto an hour and terminated by intravenous glucose.

Inhalable insulin is available in 1mg and 3mg,should be given 10min before meal faster than regular insulin. Contraindicated in smokers, pulmonary disorders.

Rapid acting insulins Regular insulin Insulin lispro Insulin aspart Insulin glulisine Prompt insulin zinc ,

Slightly slower acting

Intermediate acting insulins Isophane insulin Neutral protamine

Hagedorn (NPH) Insulin zinc

Long acting insulins

Insulin glargine Insulin detemir Extended insulin zinc

Surgery Bariatric surgery (weight loss surgery) includes a variety of procedures performed on

people who have obesity. Weight loss is achieved by reducing the size of the stomach Long-term studies show the procedures cause significant long-term loss of weight,

recovery from diabetes, improvement in cardiovascular risk factors A pancreas transplant is occasionally considered for people with type 1 diabetes who

have severe complications of their disease. Vertical banded gastroplasty,Sleeve gastrectomy,Gastric bypass surgery are

some of the techniques. Surgery improves type 2 diabetes in nearly 90 percent of patients by:a) Lowering blood sugarb) Reducing the dosage and type of medication requiredc) Improving diabetes-related health problems Many are able to maintain normal blood sugar levels with little or no medications following surgery. Islet cell transplantation will be soon available to persons having TYPE 1.

Prediabetes Pre-diabetes is a term used for people who are at increased risk for developing

diabetes. People with pre-diabetes have blood glucose levels that are higher than normal but not high enough to be diagnosed with diabetes.

Fasting blood glucose level of 100-125 mg/dL 2-hour post-oral glucose tolerance test (post-OGTT) glucose level of 140-200 mg/dL. Haemoglobin A1C of 5.7 to 6.4%. Persons with prediabetes are at increased risk for macrovascular disease, as

well as diabetes If a person is diagnosed with pre-diabetes, they can still make lifestyle changes

to prevent the type 2 diabetes- keeping a healthy weight (or losing weight if overweight), eating lowfat meals that contain many fruits, vegetables and whole grain foods.

Diagnosis & Investigations Diagnosis of diabetes is determined through A1C levels, fasting blood glucose

levels, oral glucose tolerance tests Criteria for diagnosis of diabetes are: A1C levels greater than or equal to 6.5%. Fasting blood glucose levels greater than or equal to 126 mg/dL. Blood glucose levels greater than or equal to 200 mg/dL following an oral glucose

tolerance test[GTT] Random blood glucose levels greater than or equal to 200 mg/dL.Glycated hemoglobin (A1C) test: This blood test indicates your average blood sugar level for the past two to three months. It measures the percentage of blood sugar attached to haemoglobin. The higher your blood sugar levels, the more hemoglobin you'll have with sugar attached. Diabetic 6.5% Prediabetic 5.7-6.5% Normal 5.7%

Random blood sugar test:   Diabetic 200mg/dl {11.1 mmol/L}

Fasting blood sugar test: A blood sample will be taken after an overnight fast Normal 100mg/dl {5.6mmol/L} Prediabetic 100-125mg/dl {5.6 to 6.9 mmol/L} Diabetic 126mg/dl {7mmol/L} on two separate tests.Oral glucose tolerance test: For this test,person fast overnight, and the fasting blood sugar level is measured. Then glucose is given, and blood sugar levels are tested periodically for the next two hours, Normal 140mg/dl Diabetes 200mg/dl Prediabetic 140 to 200mg/dlIn type 1 DM urine is tested for the presence of ketone [ketonuria]. Presence of autoantibodies are tested.

Complications Diabetic complications are broadly two types-

1. Microangiopathy-

Diabetic nephropathy, neuropathy and retinopathy comes under this category.2. Macroangiopathy-

Cerebrovascular disease, Peripheral vascular disease and Coronary artery disease comes under this category.

High blood glucose

Endothelial cells uptake

glucose more

Basement membrane thickens

Slows the blood flow

Long standing DMAccumulation of lipids

and blood clots in large blood vessels

Obstruction to the blood flow

Diabetic retinopathy- PDR{proliferative diabetic retinopathy} NPDR{Non proliferative diabetic retinopathy}

Microangiopathy in bloodvessels

supply retinaLess nutrition to

retinaNeovascularisati

on

Vitreous haemorrhages

Both central and peripheral vision is affected

Scatter photocoagulation, Anti-VEGF drugs are followed.Diabetic neuropathy- Angiopathy of

bloodvessels supply to nerves

Less glucose and oxygen supply to

nerve

Nerves are very sensitive even slight change

Nerve damage and eventually death

Diabetic nephropathy- Tiny blood vessels that supply nephron damages by overtime in diabetic persons .Diminishes the reabsorption and causes loss of protein,glucose and water through urine.Presence of protein(albumin) in urine is first sign.Urinary proteome analysis shows high and Glomerular filtration rate is decreased.*VEGF- vascular endothelial growth factor.

Life threatening complications of diabetes- DKA { Diabetic keto-acidosis} when there is less insulin in blood breakdown of fat and muscle ketones and fatty acids(acidosis) Tachycardia,nausea,vomiting,diarrhea and kussmaul’s breathing are seen in DKA. HYPEROSMOLAR HYPERGLYCEMIC NONKETOTIC SYNDROME {HHNS}

High blood glucose

(longterm)

Diminished reabsorption

process

Glucose along with large amount of water

excreted

No adequate consumption of

water

Blood concentrated[hyperosmolality]

Blood pulls water out of tissues into bloodstream

Severe dehydration Seizures,

coma

HYPOGLYCEMIA- Overdose of hypoglycemic medications Hypoglycemia too much glucose to cells

Nervousness,shakiness Brain needs constant glucose insufficient glucose in blood

Seizures,Diabetic coma

C-peptide Connecting peptide or c-peptide is a polypeptide that connects A chain and B chain. Initially c-peptide was considered as biologically inactive component. Insulin and c-peptide are secreted in equimolar amount. so it acts marker for endogenous insulin secretion. Level of c-peptide is measured in many conditions- a. Insulinase enzyme b. overdose of insulin { exogenous insulin-no cpeptide} c. Differentiate Type 1 DM &Type 2 DMC-peptide will do two things- 1. stimulate k+, Na+ ATPases 2. stimulate endothelial cell to have more nitricoxide synthase enzymeeNOS acts as vasodilator. C-peptide will maintain health of microvasculature. Synthetic c-peptide will be soon available and thereby microangiopathies are reduced.

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