DIABETES MELLITUS

1-INTRODUCTION Diabetes mellitus (DM) is a chronic syndrome caused by inherited and acquired
deficiency in a production of insulin by the pancreas, or by the infectiveness of the insulin produced. Such a deficiency result in increase concentration of glucose in the blood which in turn damage many of body system in particular the blood vessels and nerves. Diabetes affect about 5% of the global population a and management of the diabetes without any side effect is still challenge to medical system. The therapeutic management includes use of insulin and other agent like amyl in analogue, alpha glycosidase inhibitor like acaerbose, miglitol and voglibiose, sulphonyl urea, biguanide for treatment of hypoglycemia.

These drugs also have certain adverse effect like causing hypoglycemia at higher dose, liver problems, lactic acidosis and diarrhea, a part from currently available therapeutic option, many herbal medicine have been recommended for the treatment of diabetes. Traditional plant medicines are used through the world range for diabetic presentation. Herbal drug are prescribed widely because of their effectiveness, less side effect and relatively low cost (venkatesh et. 2003). India has rich history of using various potent works and herbal component for treating diabetes many Indian plants have been investigated for their beneficial use in different type of diabetes are reported in numerous scientific journals. The present reviews, deal with some selective Indian medicinal plant having pharmacologically established hypoglycemic potential. 1.1-TYPES OF DIABETES: TYPE-1: if the diagnosis is not made when the common feature of hypoglycemic present, diabetes ketoacidosis may develop. Lower plasma volume produces dizziness and weakness due to postural hypertension total body potassium loss and general catabolism of muscle protein further contribute to the weakness when the insulin deficiency is severe and of acute onset, all of this system in progress in an accelerated manner. Ketoacidosis excebrates the dehydration and hyper asmolarity by producing anorexia, nausea and vomiting. As the plasma amorality rise, imparted consciousness insure with progression of the acidosis, deep breathing with rapid ventilator

rate as the body attempt to correct the acidosis. The patient breath may have the fruity odor of acetone. TYPE-2: the clinical presentation of type-2 diabetes may occur in a number 0f different ways. Many patient with diabetes 2 have an insidious onset of hyperglycemia and they may have few or non of the classical symptoms .this is a particulary true in obes in indivusal,whose diabetes may only be deducted during routine investigation chromic infection are as sustained hyperglycemia can result in severe impartment of phagocyte function genralised prorates and symptom of vaginites are frequently the initial complaints of the women with type 2 .retinopathy may be routine ophthalmologic examination or the combination of neuropathy, peripheral vascular disease and infection may manifest as foot ulceration or gangrene. GESTATIONAL DIABETES: Gestational diabetes also involve a combination of inadequate insulin secretion and responsive ness, resembling type 2 diabetes in several respect. it develop during several in several respect I develop during pregnant and may improve and disappear after delivery. Even though it may be transient, gestational diabetes may damage the health fotus or mother, and about 2050% of women with diabetes develop type 2 diabetes later in life. 1.2 CAUSES OF DIABETES MELLITUS Glucose metabolism Since insulin is the principle hormone that regulate uptake of glucose into most of the cells from the blood (primarily muscle and fat cell, but not central nervous system, cells), deficiency of insulin or the insensitivity of its receptor plays a central in all form of diabetes mellitus most of the carbohydrate in food is converted within the first two hour to the monosaccharides glucose the principal carbohydrate in the blood insulin is produced by beta cells in the pancreases in response to rising level of glucose in the blood insulin most enables to absorb the glucose for the blood used as fuel for the conversion to another molecule. or for storage. Insulin is also the principle control signal for conversion to other needed molecule or for storage .insulin is also the principle control signal for conversion of glucose to glycogen for storage in lever and muscle cells. Lower insulin in result in reverse the conversion of glycogen to glucose when glucose level is fall, all though only glucose produced this way by the liver reenter the blood stream. higher insulin level in increase many

anabolic process such as cell growth and duplication, protein synthesis ,and fat storage . Insulin is the principle signal in converting many of the bio-directional process from metabolism from a catabolic to an anabolic direction ,and vice versa if the amount of insulin quibble is insufficient ,if cells respond poorly to the effect of insulin or insulin itself is reactive glucose is not handle poorly by body cells or strode properly in the liver and nucles.the net effect is persistent high level of blood glucose, protein synthesis ,&other metabolic detergents, such as acidosis. 1.3 DIAGNOSIS OF DIABETES MELLITUS: Signs and symptoms: The classical trial of diabetes symptoms is polyuria,poly dipsia and unexplained weight loss plus. a random venous plasma glucose concentration >7.0 mmol(whole blood >6.1m mol/1-2 hrs after 75g anhydrous glucose in oral glucose tolerance test. With no symptom, diagnosis should not be based on a single glucose determination but requires confirmatory plasma venous determination. At least one additional glucose test result, on another day with the value in diabetes range, is essential ,either fasting from a random sample is essential either fasting from random sample is essential, either fasting from a random sample or from the 2 hrs post glucose load if the fasting and random value are not dianogstic,the 2 hrs value should be used current recommendation are that the diagnosis is confirmed by glucose measurement is performed in acrediotary labotary on a venous plasma sample. the biochemical diagnosis of ketoacidosis is usually made at beside 7confirmed in the libratory a blood glucose test strip will usually blood glucose level of more than 22 m mol/1.formal libratory measurement of glucose, urea cretonne ,electrolyte arterial ph, po2& pco2 should be carried out. Treatment aim to initially to receive the immediate signs and symptoms of diabetes .in the longer term, the main aim of treatment is to prevent the development of diabetes complication. Persistent hyperglycemia (DCCT 1993, UKPDS 1998a. UKPDS 1998a.UKPDS 1998b) and hypertension (UKPDS 1998c) are the two major controllable factor that influence the development of diabetic complication. 1. Eye disease:

Blurring of vision is usually a benign occurrence associated with the rapid change in the blood glucose control open angle glaucoma is more common in patients with diabetes than in the general population, for reason that are unclear .cataracts are laso common in patients with diabetes past middle age. Once deducted careful attention should be paid to blood glucose and blood pressure control. 2. Disease of the urinary tract: Urinary tract infection common in diabetes .management is no different to that in the population who did not have diabetes, except the recurrence is common. The role of prophylactic antibiotic is preventing chronic renal damage in ulcer. MANAGEMENT OF DIABETES MELLITUS: Management of the patient with type 2: Many of the patients with type 2 diabetes are: Overweight and need advice on calorie
Restriction in addition to the general healthy Eating advice, in order to lose weight Achieve a body and weight

DRUG USE EVALUATION:

Define the term drug use evaluation (DUE) List the objectives of DUE Describe the step in DUE cycle Describe ways in which drug use problem can be identified Drug use is a complex process. Uncertainties in diagnosis, treatment and medication adherence to contribute to wide variation in the way drug are used for any given condition. What is drug use evaluation?

Drug use evaluation (DUE) in an ongoing authorized and systemic quality and improvement process, which is designed to: Review drug use or prescribe pattern. Provide back of result to clinicians and other relevant groups. Develop criteria and standard which describe optimal drug use. Permeate appropriate drug use through education and other intervention. TABLE: phase and step involved in conducting a drug use evaluation Phase 1: planning STEP 1 identify drug or areas of practice for possible study STEP 2 design of study STEP 3 define criteria and standards STEP 4 design the data collection form Phase 2: data collection STEP 5: collect data Phase 3: evaluation STEP 6: collate data and evaluate result Phase 4: feedback of result STEP 7: feedback result to clinicians and other hospital staff Phase 5: interventions STEP 8: develop and implement interventions Phase 6: re-evaluation STEP 9: reevaluate to determine if drug use has improved STEP 10: reassess and revise DUE program as needed Phase 7: feedback of results STEP 11: feedback result to clinicians and other hospital staff

Drug use evaluation (DUE) was originally known as drug utilization review (DUR) in the 1970s and early 1980s. The term drug utilization review (DUR) and drug use evaluation (DUE) are interchangeable. Types of DUE: DUE studies are often drug focused, where the use of single drug or class of drug is examined. Less commonly DUE studies are indication focused; wherw the use of drug for a specific indication is examined. Quantitative studies Qualitative studies Quantities studies: involves the collection, organization and display of estimate or measurement of drug use. This type data is often used for making purchasing desiccation or other financial activates such as preparing drug budgets. Qualitative DUE studies: on the other hand, are multidisciplinary operations, which collect organize, analyse and report information on actual drug use. Establishment of a DUE program: Although individuals may conduct DUEs in both hospital and community settings, a more usual approach in hospital is to develop a coordinated DUE program. The administration of a DUE program should be multidisciplinary to avoid some common problems, which can occur if the DUE committee is administered by the pharmacy department.

Medical staff may be more likely to perceive the DUE programs as a pharmacy budget measure rather than a tool for improving clinical care. The involvement of medical and nursing staff may be more rusticated which may reduce the effectiveness of the DUE program. DUE may be given a lower priority than other pharmacy department and DUE staff may be forced to relinquish their DUE activates when the department is short staffed.

Step involve in conducting a drug use evaluation:

Step 1: identify drug and therapeutic area of practice of possible inclusion in the program.

Commonly prescribed drug , e.g. antibiotic ,proton pump inhibitors Drug associated with potential significantly drug interaction, e.g. warfarin, theophylline phenoytyoin. Expensive drugs, e.g. low molecular weight heparins ,broad spectrum cephalosporins . New drugs Drug with narrow therapeutic index,e.g. digitoxin,theophylline Drug which upon withdrawal may cause problems, e.g. antidepressant,carbamazepine Step 2: design of study: a variety of research has been used in DUE studies. the repost design where drug use is examined before and intervention to improve prescribe is another commonly used observational method. Step 3: define criteria and standards:
Perform an exhaustive literature search for the chosen drug or

therapeutic area, using more than such mechanism( e.g. Medline) and one or more pharmacy based system
Assemble full copies of all the reverent original research papers

Step 4 : design the data collection from : Just as to impossible to monitor and evaluate all use drug in hospital, it is also impossible to address all accept of use for individual drugs

Table : common accept of drug use study in DUEs Patient demographics Prescriber detail

Disease severity Indication for drug Cost of therapy

Step 5: data collection : data collection should be chosen carefully, and should be familiar with how information is arranged in the patient case notes.knoldge of drugs names, strength and the way order to written is also important . Depending upon their availability, physican, pharmacist, and nurse make ideal data collectors. Step 6: evaluate results: Data evaluation is more critical step in DUE. The data obtained should be collected using available source such as spreadsheet and word processing. Drug being used for new indication Outdated procedures Inadequate resources

Step 7: provide feedback of results: The success of any DUE strategy depends on feedback of the result to prescribes, other hospital staff involved in the study and to adminstritative heads. Step 8: develop and implement interventions: If a drug use problem was identified the next step is to consider how the problem can be addressed. Intravenous to improve drug use can be educational and operation, and can target group, or only those prescribe who did not meet drug use criteria.

2. REVIEW OF LITERATURE:
Many students are instructed, as part of their research program, to perform a literature review, without always understanding what a literature is. A literature review is a critical and in depth evaluation of previous research. it is a summary and synopsis of particular area of research, allowing anybody reading the paper to establish why you are pursuing this particular research program.