Diabetes Pathophysiology and Management Principles

8/24/2013
Dr.Sachin SarpotdarDhanvantari Foundation
Incorporation Chicago
1
Diabetes Patho-physiology and
Principles of management
Dr.Sachin Sarpotdar
BAMS, MSc(Health Science)
Ayurved Physician and Panchakarma
Consultant.
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Diabetes -Historical Aspects
• This term was used first time by Aretaeus of Cappadocia, the Greek
physician.
• Paul Langerhans described Islets in the pancreas in 1869.
• Belgian scientist Jean de Meyer used the term “Insulin" in 1909.
• In 1921 the insulin was purified after the series of experiments, by J.J.R
Macleod, Charles Best, Frederick Banting and James Collip.
• However one of the Ayurvedic classics “Charka Samhita” long back
ago(800-600 BC) has described the term “Madhumeha” which has the
same meaning as that of Diabetes Mellitus.
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• In the year 2007; the diabetes was the 5th leading cause
of mortality.
• 246 million people world wide have diabetes.
• Worldwide;daily 200 children are grabbed by diabetes.
• Worldwide;3 million deaths occur per year due to
diabetes.
• More than 314 millions people have impaired glucose
tolerance.
Problem Estimation
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Prevalence-
o It is projected that by year 2025 the prevalence of DM will be 5.4%
with global diabetic population reaching 300 million.
o Diabetes is prevalent in the age group 45-65 in developing countries
and in developed countries it is in the age group above 65 years.
Mortality Rate-
 1.5 to 2.5 times higher than that of general population.
 Diabetes has recently escalated in all age groups.
Problem Estimation
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Clinical Presentation.
• A 53 years old man
• C/O Burning micturation-since 2 weeks
• Fatigue & pain in the calf muscles since 2 weeks.
• Weight loss of 2 kg in a last 1 month.
• Recurrent boils
• Adv investigation- Haemogram, Urinalysis, BSL-F
& PP, Lipid Profile
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What is Diabetes?
• It is a metabolic disorder, specifically, an
abnormality in the way the body utilizes the
glucose, due to an absolute or relative
deficiency of the hormone insulin or
resistance by the body tissues to the action of
insulin.
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What is Diabetes?
Diabetes is a syndrome of impaired
carbohydrate, fat & protein metabolism.
It is caused by lack of Insulin secretion or
decreased sensitivity of the tissues for
the Insulin.
The characteristic feature is hyperglycemia.
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• Type 1 DM : Insulin Dependent Diabetes
Mellitus. (10%)
• Type 2 DM : Non Insulin Dependent
Diabetes Mellitus. (80%)
• Gestational Diabetes Mellitus
• Malnutrition Related Diabetes Mellitus
• Other Types : Secondary to pancreatic,
hormonal, drug induced & other
abnormalities.
Types of Diabetes Mellitus
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Three modes of Hyperglycemia
• Lack or decrease Insulin production
• Insulin resistance
• Increased Glucose production by Liver.
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Contributory factors
Kapha Dosha (One of the biological humor)
Meda Dhatu (Fatty tissue)
Watery waste products, body components like
urine, sweat, lymph etc.
 Reproductive and regenerative body fluids.
(Various hormones, growth factors and
healing factors)
 Oja (Vital sap)
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Types
Types
Genetic (Sahaja) Life style originated
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Was previously called insulin-dependent
diabetes mellitus (IDDM) or juvenile-onset
diabetes.
Type 1 diabetes develops when the body’s
immune system destroys pancreatic beta cells,
the only cells in the body that make the
hormone insulin that regulates blood glucose.
Type 1 diabetes
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Type 1 diabetes
This form of diabetes usually strikes children
and young adults, although disease onset can
occur at any age.
Type 1 diabetes may account for 5% to 10% of
all diagnosed cases of diabetes.
Risk factors for type 1 diabetes may include
autoimmune, genetic, and environmental
factors.
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Was previously called non-insulin-dependent
diabetes mellitus (NIDDM) or adult-onset
diabetes.
Type 2 diabetes may account for about 90% to
95% of all diagnosed cases of diabetes.
It usually begins as insulin resistance, a disorder
in which the cells do not use insulin properly.
 As the need for insulin rises, the pancreas
gradually loses its ability to produce insulin.
Type 2 diabetes
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Type 2 diabetes
 Type 2 diabetes is associated with older age,
obesity, family history of diabetes, history of
gestational diabetes, impaired glucose metabolism,
physical inactivity, and race/ethnicity.
 Indians are at particularly high risk for type 2
diabetes and metabolic disorder.
 Type 2 diabetes is increasingly being diagnosed in
children and adolescents.
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Etiological and Risk factors.
• Food crazy people.
• Sedentary lifestyle.
• Yogurt / Curd / Dahi.
• Processed food consumption.
• Milk derived products in excess.
• New cereals in excess.
• Carbohydrate rich products.
• Alcohol.
• Genetic predisposition.
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Causes
• Genetic factors
• Obesity
• Viral infections
• Endocrine effect
• Malnutrition
• Maternal diabetes
• Secondary to other diseases
• Other factors
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Pathogenesis
Diabetes occurs when the body does not
produce any Insulin or when the body does
not utilize Insulin effectively.
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 Polyuria
 Polyphagia
 Polydipsia
 Hyperglycemia
 Wasting
 Loss of Libido
 Ketosis
 Dehydration
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• Polyuria : Frequent urination
• Polydypsia, Polyphagia
• Weight loss
• Extreme fatigue & weakness
• Mental weakness & lack of concentration
• Cuts & bruises which heal slowly or not heal properly.
• Tingling or numbness in the extremities.
• Blurred vision
• Infertility
Signs and Symptoms
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Pathogenesis – Phase 1
Diabetes
(PRAMEHA)
Genetic
predisposition
Environmental
factors
Lifestyle factors
Sleep in day
time
Lack of physical
exercise
Sedentary
habits
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Diabetes as a complex phenomenon
The interplay of
Nidana – Etiological & risk factors
Dosha – Biological humors
Dushya – Various contributory body components
in the disease
All above factors make diabetes as a complex
phenomenon
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Dhatvagnimandya
(Low metabolic
conversion)
Fat metabolism
(Meda)
Protein
metabolism
(Mamsa)
Waste product
excretion
(Kleda)
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• Increased production of water soluble waste
products.
• Excess loss of body components through
urine.
• This leads to severe weight loss.
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• Pathological consequences
o Impaired fat metabolism – Weight gain or weight
loss, excess sweating with bad odor and skin
diseases.
o Impaired protein metabolism – Muscle wasting &
nephropathy.
o Waste product excretion – Increased volume of
urine along with loss of some metabolically
important substances like glucose.
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Risk Factors
• Family history of diabetes (i.e., parent or
sibling with type 2 diabetes)
• Obesity (BMI 25 kg/m2)
• Physical inactivity
• Previously identified with IFG, IGT, or an A1C
of 5.7–6.4%
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Risk Factors
• History of GDM or delivery of baby >4 kg (9 lb)
• Hypertension (blood pressure 140/90 mmHg)
• HDL cholesterol level <35 mg/dL (0.90
mmol/L) and/or a triglyceride level >250
mg/dL (2.82 mmol/L)
• Polycystic ovary syndrome.
• History of cardiovascular disease
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 Blood sugar-Fasting & Postprandial.
 Urine test-Urine ®,Urine sugar, Ketone bodies.
 Oral glucose tolerance test-OGTT.
 Glycohemoglobin test.
Diagnostic tests
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 Blood sugar-Fasting & Postprandial.
 Urine test-Urine ®,Urine sugar, Ketone bodies.
 Oral glucose tolerance test-OGTT.
 Glycohemoglobin test.
Diagnostic tests
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Glucose Tolerance Test (OGTT)
• Fasting BSL is measured
• 1gm/kg glucose is given Usually 75gm of
Glucose in 250-300 ml of water on an
empty stomach or overnight fasting
• Each half hour BSL and urine sugar
measured in standard test in modified
version 1 hr, 2hr BSL measured
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Interpretation of OGTT
• Indicated in new diagnosis
• FBSL- 110 – 125 mg/dl i.e. impaired glucose
tolerance test
• Any BSL 200 mg/dl i.e. Diabetic
• 140-200 mg/dl Impaired Glucose Tolerance
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Diagnostic criteria
• Fasting blood glucose if >126 mg/dl.
• Blood glucose if >200 mg/dl after 2 hours of
OGTT.
• Symptoms of Diabetes plus Random blood
sugar if above 200 mg/dl.
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Screening test
• After 45 years of age screening test should be
performed annually.
• BP monitoring.
• Ophthalmic checkup.
• Renal function test.
• Examination of feet
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1. Coronary artery &
peripheral vascular
diseases.
2. Diabetic nephropathy
3. Diabetic neuropathy
4. Diabetic ketoacidosis
5. Diabetic coma
6. Problems in Diabetic
retinopathy
7. matrimonial relations
Diabetic complications
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Diabetic foot
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Dhanvantari Foundation Incorporation
Chicago
41
Diabetic Complications
in Ayurvedic Perspective.
• All the complications of Diabetes are due to early
degeneration.
• Vata and Pitta are the two biological humors which are
responsible for early degeneration and emaciation.
• Both of these bioenergies are light & sharp and are
responsible for altered sensory and motor functions.

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Dhanvantari Foundation Incorporation
Chicago
42
Diabetic Complications
in Ayurvedic Perspective.
• These are also responsible for low immune mechanism, altered
immunity & autoimmune mechanism.
• These are directly or indirectly responsible for recurrent infections and
give inflammatory response.
• Due to the dryness of Vata and it’s obstructive nature the blood flow
get affected; which, deteriorate the tissue perfusion.
• Pitta leads to faster degenerative & metabolic transformations in the
body tissues; which leads to tissue destruction i.e. “Dhatu Pak”

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Treatment of DM
• Should be Started with non drug therapy
• It include diet control
• Regular exercise
• Normalizing life style
• Alcohol abstinence
• Vegetarian diet
• Reducing stress
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Treatment of DM
• Start with non drug therapy
• It include diet control
• Regular exercise
• Normalizing life style
• Alcohol abstinence
• Vegetarian diet
• Reducing stress
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Insulin
 It is must in certain cases
• Type I DM
• Infection
• Pregnancy
• Operative procedure
• Short term treatment
• Complications like keto acidosis
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Insulin Formulations
• Human ACTRAPID – 40 U/ ml (Regular Insulin)
• Human MONOTARD – 40 U/ ml (Lenteinsulin)
• Human MIXTARD 30/70 - 40 U/ ml (30 %
soluble insulin + 70% isophane insulin)
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Preparations of insulin
• Insulin is mainly divided into short acting and long
acting
• Short acting (regular) is always clear and long acting
(ultra lente) is turbid
• Two can be mixed together for treatment
• Insulin may be from animal source i.e. Pork or
beef.But now-a-day human insulin is used, which is
less antigenic
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Appear
ance
Onset Peak Dur
Short
acting
clear 1 2-4 6-8
Long
acting
turbid 4-6 14-18 24-36
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Clinical Use of Insulin
• 0.6 -1.2 IU/Kg/day
• 2/3 dose should be given in morning before
breakfast
• 1/3 dose should be given in evening before
dinner
• Morning dose should be split as 1/3 neutral
and 2/3 Isophane (NPH)
• Evening dose should be split 50-50% in
combination
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Adverse effect of insulin
• Hypoglycemia
• Local reaction like swelling, erythema, or
stinging sensation at site of injection
• Allergic reactions which are uncommon to
human insulin
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1. Glibenclamide (Glyburide)
Generic Name Glibenclamide
Brand name DAONIL,
EUGLUCON
Size of tablet 2.5, 5 mg Tab
Doses 2.5 – 15 mg
OD
When taken Before meal
Duration of
action
18 – 24 hr
Price 5.25, 9.50 INR
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2. Glipizide
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Generic
Name
Glipizide
Brand name GLYNASE, GLIPI,
GLIDE
Size of tablet 5 mg
Doses 5 – 20 mg OD/BD
When taken Before Meal
Duration of
action
12 – 18 hr
Price 5, 6 INR
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3. Gliclazide
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Generic Name Gliclazide
Brand name Diamicron,
Dianorm,
Reglide
Size of tablet 30, 40, 80 mg
Doses 40 – 240 mg
OD/BD
When taken Before Meal
Duration of
action
12 -24 hr
Price 70 INR
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4. Glimepiride
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Generic Name Glimepiride
Brand name GLYPRIDE, GLIMY,
GLIMER,AMARYL
Size of tablet 1,2,3,4 mg
Doses 1 – 6 mg OD
When taken Before first meal
Duration of action 24 hr
Price 46, 74, 101 INR
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1. Repaglinide
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Generic Name Repaglinide
Brand name EUREPA, RAPLIN
Size of tablet 0.5,1,2 mg
Doses 1.5 – 8 mg q.d.
When taken Before each meal
Duration of
action
2-3 hr
Price 56, 92. 142 INR
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2. Nateglinide
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Generic Name Nateglinide
Brand name GLINATE
Size of tablet 60, 120 mg
Doses 180 – 240 mg q.d.
Duration of action 2-3 hr
Price 55, 91 INR
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a. Metformin
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Generic Name Metformin
Brand name GLYCIPHAGE,
GLYCOMET
Size of tablet 250,500, 850 mg
Doses 0.5 - 2 gm q.d.
Duration of
action
6 – 8 hr
Price 5.5, 11, 14 INR
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Pioglitazone
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Generic Name Pioglitazone
Brand name PIONORM
Doses 15 – 45 mg OD
When taken Before dinner
Duration of action 24 hr
Price 35.5, 51 INR
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a. Acarbose
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Generic Name Acarbose
Brand name GLUCOBAY
Doses 25 – 100 mg TID
Duration of action 4 – 6 hr
Price 42, 50 INR
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b. Miglitol
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Generic Name Miglitol
Brand name MIGLIT, MIGNAR
Doses 25 – 100 mg TID
Duration of
action
4 – 6 hr
Price 60, 108 INR
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Anti Diabetic Herbs- Minerals
& Compound Drugs
• Most of the anti diabetic herbs are astringent and bitter.
They contain tannins & flavonoids.
• These have Anti-Kapha properties.
• Drugs are metabolic regulators( Deepan)
• Drugs with Pachan quality are beneficial.
• Drugs with cleansing property are preferred.
• Drugs reduce the Kleda i.e watery waste product by
decreasing its production or eliminating it through urine.
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Anti Diabetic Herbs- Minerals &
Compound Drugs
• Research work across the world have focused
on their -
• cytoprotective, anti inflammatory, immune
boosting and antimicrobial actions.
• Stimulate insulin secretion.
• Inhibit auto antibodies.
• Inhibit hepatic gluconeogenesis and regulate
the FBS.
• Increase the glucose utilization and reduce the
insulin resistance.
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Anti Diabetic Herbs- Minerals &
Compound Drugs
• These herbs improve the lipid profile and used
as metabolic regulators.
• Some of these herbs are Nephro protective.
• These herbs inhibit the new abnormal growth
of the vessels and inhibit the platelets sticking
• Minerals are used to induce the enzymes and
regulate the metabolism. This is done by
regulating the transcription process.
• Compound products improve the nutritional
status.
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Important Pancreatic Stimulants & Insulin
Sensitizers.
• Amalaki-.Emblica officinalis
• Bibhitak-Terminalis belerica.
• Haritaki-Terminalia chebula.
• Shunthi-Dry ginger
• Marich-Piper nigrum.
• Pimpali-Piper longum.
• Turmeric.
• Daruhalad-Berberis aristata
• Guduchi-Tinospora cordifolia.
• Lodhra-Symplocos
recemosa.
• Nimba-Azadirachta indica.
• Chandan-Santalum
album.
• Usheer-Vetiveria
zizanioidis.
• Khadir.-Acacia catechu.
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Herbs for Prevention of Insulin
Resistance.
• Amalaki-.Emblica officinalis
• Bibhitak-Terminalis belerica.
• Haritaki-Terminalia chebula.
• Shunthi-Dry ginger
• Marich-Piper nigrum.
• Pimpali-Piper longum.
• Turmeric.
• Daruhalad-Berberis aristata
• Guduchi-Tinospora cordifolia.
• Karela (Bitter Gourd)- Momordica charantia.
• Meshshringi- Gymnema sylvestre.
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Ayurvedic Products
• D.B.T= 1-2 BD/TDS
• Diabecon 1-2 BD/TDS
• Vijaysar Ghan =1-2 BD/TDS
• Daruharidra Ghan =1-2 BD/TDS
• Meshashringi cap= 1 BD
• Haridra cap= 1-2 BD
• Karela cap= 1BD/ TDS
• Vrikshamla cap- 1 BD
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Ayurvedic Products
• Lodharasava- 3 tsf BD (After meal) with Warm
Water.
• Beejakarishta- 3tsf BD( After meal) with warm
water.
• Bhallataksava – (Rasashala) 2tsf BD with
water.
• Ayaskruti - 2tsf BD with warm water.
• Mustharishtum- 3tsf BD with warm water.
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Ayurvedic Products
• Methi Ghan
• Maka Ghan
• Gudmar Ghan
• Guduchi Ghan/Cap
• Gokshur
• Punarnava
• Ashwagandha Churna Vati /Cap
• Rasayan Churna
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Ayurvedic Mineral Products
• Jasad Bhasma
• Abhrak Bhasma
• Trivanga Bhasma
• Suvarna Bhasma
• Rajat Bhasma
• Loha Bhasma
• Suvarna Makshik Bhasma
• Shilajeet
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Ayurvedic Compound Products
• Arogyavardhini
• Chandraprabha
• Saptamrut Loha
• Gokshuradi Guggul
• Triphala Guggul
• Navak Guggul (Medohar Guggul)
• Shilajatwadi Vati
• Tapayadi Loha
• Vasant Kusumakar
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Patent & Proprietary Products
• Amree Plus – Amil Pharma – 20 tabs- 84 INR
• Yesaka Liq- Simandhar Herbals- 500-ml-180 INR
• Madhumehari Chrna- Baidyanath- 100Gm- 97
INR
• Madhumehari with Gold Tab- 40 tabs-560 INR
• Jumbola Liq- Luna Pharma- 450ml- 190 INR
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Patent & Proprietary Products
• Ojamin Liq-Everest Pharma Pune- 1lit-450 INR.
• Beejakarishtum Nisha Herblals- 400ml-220
INR.
• Diabecon – Himalaya- 60 Tab-100 INR
• D.B.T- Sharangadhar- 100 Tab- 190 INR.
• Asanad Tablet – Ayurved Rasashala Pune-
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Eye diseases.
• Retinopathy, cataract and glaucoma are more common in
diabetic patients.
• Eye is the sight of Pitta and bleeding tendency is the Pitta
predominant condition.
• In such condition “Bowel cleansing” is recommended.
• Triphala decoction is used to wash the eyes and for
bowel cleansing purpose.
• For the prevention of eye diseases the compound
TRIPHALA can be used in the form of MEDICATED GHEE.
• This can be taken orally as well as locally.
• Saptamrut Loha 2 BD
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Nephropathy.
• Nephro protective herbs can be used.
Some of the Nephro protective herbs are
1)Punarnava-Boerhavia diffusa.
2)Gokshur-Tribulus terrestris.
These herbs can be given in the form of
decoction or herbal tea. Medicated enema
are also given.
3) Chanrprabha, Shilajatawadi Vati in a dose of
2 BD are also used.
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Diabetic foot
• Wound healing is the function of Shukra
Dhatu.
• It is associated with reproduction as well as
regeneration.
• Herbs like Shatavari, Ashwagandha are
recommended in wound healing.
• Dressing with Vrana Ropan oil to take care of
ulcers.
• Pressure relieving modification is essential.
• Tapyadi Loha & Vasant Kusumakar are also
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Neuritis
• Sensory and motor nerves are affected in diabetes.
• As per Ayurveda sensory, cognitive and motor functions
are regulated by Vata.
• The skin is one of the site of Vata.
• Oil is supposed to be the best for the control of Vata
ailments.
• Hence in the prevention of neuritis the oil massage is
recommended.
• Massage improves the local blood supply, lymph
drainage and nerve conduction.
• Massage also stimulate the Neuro-endocrinal system.
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Infections.
• Recurrent infections of skin, urinary and
genital tracts are very common in diabetic
patients.
• Herbal bath ,local wash with herbal
decoctions and herbal powders application to
the skin are very effective in skin care.
• Herbs like Nimba, Khadir, Daruharidra Triphala
are used in the skin care and in its hygiene.
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Diabetes Pathophysiology and Management Principles

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