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Aims  of management

►    To achieve near normal glycaemia

-    Short term- to prevent symptoms of hyper & hypo

-    Long term- to prevent complications

►    Good quality of life, near normal life expectancy







Types of Insulin

►      Short acting -      Soluble / Neutral insulin

                       Insulin aspart

                     Insulin lispro

►     Intermediate acting - Isophane

►     Long acting - Insulin Zinc suspension

                  new insulin analogue - Glargine

                                 Detemir 

►      Biphasic- mixture of short and intermediate

                     Biphasic lispro

                     Biphasic Isophane





Types of Insulin

Insulin	Lispro Aspart	Neutral/ regular	Isophane	ultratard	Glargine
Onset	10-20′	30′	1h	4h	2-4h
Peak	1h	1-3h	4-6h	6-18h	peak less
Duration	3-5h	4-8h	8-14h	24h	20-24h

Soluble insulin / neutral /clear

►    Names - Human actrapid/ Humulin S

►    Species- Bovine, porcine, human

►    Following s/c injection

        Onset of action – 30 min

           Peak- 1-3 hours

           Duration- 4-8 hours

►    Only insulin suitable for intravenous route –plasma half life < 5 min, required continuous infusion

►    Used in diabetes Ketoacidosis





Sites of injections - Subcutaneous

►    Thighs

►    Upper buttocks

►    Abdomen

►    Arms

Important to rotate the site

Rate of absorption may be significantly different – faster from arm and abdomen than from thigh and buttock





Routes of Administration

►    Subcutaneous for long term regular use

►    Intravenous infusion in acute conditions- diabetes Ketoacidosis, Perioperative period, Hyperosmolar Nonketotic state  ONLY NEUTRAL/ CLEAR INSULIN CAN BE USED

►    Continuous subcutaneous insulin infusion via pump – neutral

►    Intraperitoneal – Peritoneal dialysis patients

►    Inhaled insulin- experimental





Untoward effect of insulin

►    Hypoglycaemia

►    Weight gain- anabolic hormone

►    Lipohypertrophy- injection to same site

►    Insulin oedema

►    Transient deterioration in retinopathy

►    Insulin neuritis – actively regenerating neurone, uncommon

►    Postural hypotension







Recurrent Hypo

►    ? Required dose adjustment

►    ? Right insulin/ injection technique

►    ? Meal/ fasting related

►    ? Injections sites

►    ? Exercise

►    Unexplained - ?autonomic neuropathy





Sick day rules

    never stop insulin

    monitor more frequently

    maintain your hydration

    Check for ketones

    Know when & how to call for help





Oral Medications to Treat Type 2 Diabetes

Major Classes of Medications

    sensitize   the body to insulin +/- control hepatic glucose production



    stimulate the pancreas to make more insulin



    slow the absorption of starches



Thiazolidinediones

Biguanides





Sulfonylureas

Meglitinides





Alpha-glucosidase

 inhibitors







Thiazolidinediones

►    ↓ insulin resistance by making muscle and adipose cells more sensitive to insulin. They also suppress hepatic glucose production.

►    Efficacy

    ↓ fasting plasma glucose ~1.9-2.2 mmol/L

    Reduce A1C ~0.5-1.0%

    6 weeks for maximum effect

►    Other Effects

    Weight gain, oedema

    Hypoglycemia (if taken with insulin or agents that stimulate insulin release)

    Contraindicated in patients with abnormal LFT or CHF

    Improves HDL cholesterol and plasma triglycerides; usually LDL neutral

►    Medications in this Class: pioglitazone (Actos), rosiglitazone (Avandia), [troglitazone (Rezulin) - taken off market due to liver toxicity]





Biguanides

►    Biguanides ↓ hepatic glucose production and increase insulin-mediated peripheral glucose uptake.

►    Efficacy

    Decrease fasting plasma glucose 60-70 mg/dl (3.3-3.9 mmol/L)

    Reduce A1C 1.0-2.0%

►    Other Effects

    Diarrhea and abdominal discomfort

    Lactic acidosis if improperly prescribed

    Cause small decrease in LDL cholesterol level and triglycerides

    No specific effect on blood pressure

    No weight gain, with possible modest weight loss

    Contraindicated in patients with impaired renal function

    Medications in this Class: metformin (Glucophage), metformin hydrochloride extended release (Glucophage XR)





Sulfonylureas

►    Sulfonylureas increase endogenous insulin secretion

►    Efficacy

    Decrease fasting plasma glucose 3.3-3.9 mmol/L

    Reduce A1C by 1.0-2.0%

►    Other Effects

    Hypoglycemia

    Weight gain

    No specific effect on plasma lipids or blood pressure

    Generally the least expensive class of medication

►    Medications in this Class:

    First generation : chlorpropamide , tolazamide, acetohexamide , tolbutamide

    Second generation : glyburide , glimepiride , glipizide





Meglitinides

►    stimulate insulin secretion (rapidly and for a short duration) in the presence of glucose.

►    Efficacy

    ↓ peak postprandial glucose

    ↓ plasma glucose 3.3-3.9 mmol/L

    ↓ HbA1C 1.0-2.0%

►    Other Effects

    Hypoglycemia (may be less than with sulfonylureas if patient has a variable eating schedule)

    Weight gain

    No significant effect on plasma lipid levels

    Safe at higher levels of serum Cr than sulfonylureas

►    Medications in this Class: repaglinide , nateglinide





Alpha-glucosidase Inhibitors

►    Alpha-glucosidase inhibitors block the enzymes that digest starches in the small intestine

►    Efficacy

    ↓ peak postprandial glucose 2.2-2.8 mmol/L

    ↓ fasting plasma glucose 1.4-1.7 mmol/L

    Decrease A1C 0.5-1.0%

►    Other Effects

    Flatulence or abdominal discomfort

    No specific effect on lipids or blood pressure

    No weight gain

    Contraindicated in patients with inflammatory bowel disease or cirrhosis

►    Medications in this Class: acarbose , miglitol 









Combination Therapy  for Type 2 Diabetes

Sulfonylurea + Biguanide

    Glyburide  +  Metformin     -  Glucovance

    Glipizide  +  Metformin     -  Metaglip



Thiazolidinedione + Biguanide

   Rosiglitazone + Metformin  -  Avandamet





Chart





Clinic Checklists

►    Glycaemic control- home monitoring, HbA1c, inj site, hypo

►    Diet, exercise, Smoking, alcohol

►    BP

►    Weight

►    Macrovascular- CVA, IHD

►    Microvascular- Retinopathy, microalbuminuria, neuropathy

►    Foot

►    Lipid profile, renal function, TSH





Special circumstances

►    Intercurrent illness

►    Peri-operative period

►    Pregnancy

►    Childhood and adolescents

►    Others- travelling across time zones

                Exercise

                Alcohol

            Driving





Dr K S Myint

Specialist Registrar

Okay, so the obvious selling point of Love and Other Drugs--based on Jamie Reidy's memoir: Hard Sell: The Evolution of a online pharmacy Salesman-- is Anne Hathaway in the altogether. Which is altogether not a bad reason to watch, even if you don't like anything else about the movie. But I think you will.

Introduction
- PLT regulated by 3 categories of substances

• agents outside plt, act on plt membrane receptors - catecholamines, collagen, thrombin, prostacyclin
• agents generated inside plt, act the same - ADP, prostaglandin D2, E2, serotonin
• agents generated inside plt, act inside plt - prostaglandin endoperoxides, Tx A2, cAMP/GMP

- hence the groups of antiplatelet agents

• PG synthesis online pharmacy viagra - aspirin
• ADP-induced plt aggregation inhibitor - clopidogrel, ticlopidine
• glycoprotein IIb/IIIa receptor blockers - abciximab, tirofiban, eptifibatide

ASPIRIN
- Tx A2 - arachidonate product --> plt change shape, degranulate, aggregate
- aspirin --> cyclooxygenase inhibitor irreversibly --> reduce tx A2
- other NSAIDs + salicylates --> do the same but action is reversible hence not used as antiplt


CLOPIDOGREL + TICLOPIDINE
- irreversibly block ADP receptors on plt
- use

• PTI with stent - prevent re-thrombosis
• prevention of vascular events - TIA, completed strokes, unstable angina

- SE

• GIT - nausea, dyspepsia, diarrhoea - 20% pt
• hemorrhage - 5%
• neutropenia - 1% (very serious) - regular monitoring WCC in first 3 months

- clopidogrel has fewer SE than ticlopidine - rarely assoc with neutropenia
- clopidogrel - dose dependent efx - hence need loading dose 300mg (80% plt inhibition) - 75mg maintenance - takes 7-10 days to reach antiplt efx hence the same time to wean off


Aspirin + clopidogrel resistance
- no objective studies
- varies from 5%-75% where thrombosis happens despite rx


GLYCOPROTEIN IIb/IIIa RECEPTOR BLOCKERS
- used in acute coronary syndromes
- IIb/IIIa complex acts as receptors for fibrinogen, vitronectin, fibronectin, and vWF --> as final common pathway of plt aggregation
- average plt has 50,000 copies of receptors --> ppl lacking these receptors = Glanzmann's thrombasthenia --> bleeding tendency

- abciximab - monoclonal antibody - used in PTI and ACS
- eptifibatide
- tirofiban - smaller molecule than eptifibatide - inhibit ligand binding to IIb/IIIa receptor


OTHER ANTIPLTs
- dipyridamole

• vasodilator
• inhibit adenoside uptake + cGMP phosphodiesterase activity
• by itself - no beneficial efx - need to combine with aspirin to prevent cerebrovascular ischaemia

- cilostazol - newer phosphodiesterase inhibitor --> promotes vasodilation + (-) plt aggregn


DRUGS USED IN BLEEDING DISORDERS
Vitamin K
- fat soluble, found in leafy green veges
- human get it from veges + gut bactera
- confers biologic activity on factor 2,7,9,10 by modifying them
- 2 forms - K1 and K2 - K1 found in food, K2 found in human tissue + synthesised by bacteria
- requires bile salt for absoprtion
- onset 6 hrs, compete by 24 hrs
- best given IV + po, not sc (erratic)
- given to all newborn to prevent hemorrhagic disease of newborn (common in premature infants)

Plasma fractions
- spontaneous bleeding occurs when factor activity <5-10% of normal
- commonest: hemophilia A and B (christmas disease, IX deficiency)
- preparation

• prepared from large pools of plasma
• viral transmission elimited/reduced by pasteurisation
• but not prion disease
• now uses recombinant technology

- clinical usage

• if hemorrhage to joint --> infuse factor VIII/IX to maintain 30-50% of normal concentration for 24 hrs
• soft tissue hematoma = minimum of 100% factor activity for 7 days
• hematuria = 10% activity for 3 days
• surgery/major trauma = 100% activity for 10 days
• has loading + maintenance dose
• desmopressin acetate - increases VIII activity with mild hemophilia /vWB disease --> can use in minor surgery like tooth extraction - given intranasal

- cryoprecipitate

• plasma protein fraction from whole blood
• treat deficiencies/qualitative abnorm of fibrinogen
• eg DIC/liver disease
• hemophilia A and vWB disease if desporessin not indicated and other stuff not available --> last resort as cryoprecipitate not treated to reduce risk of viral transmission

Fibrinolytic inhibitor
- aminocaproic acid (EACA) - competitively inhibit plasminogen activation - po and rapidly cleared
- tranaxemic acid

• analog of EACA
• 15mg/kg loading, then 30mg/kg QID
• uses - adjunct therapy for hemophilia, bleeding from fibrinolytic therapy, prophylaxis for intracranial aneurysm, postop bleed (GI, prostatectomy, bladder hemorrhage, drug induced cystitis)
• SE: intravascular thrombosis

-

The number of stories I hear about sex in casual conversations boggles the mind. Many times in response to the question “What do you do?” I hear a personal story about sexuality. I could tell stories about where I’ve heard stories –the gym, coffee shop, walking the dogs, parties, meetings, etc. This highlights the need many people have to understand, embrace, and discover their sexuality and sexual viagra.

Often, however, the only venue to seek professional support is through the use of a “problem” model where the individual seeks help because bad things are happening.

What would it look like to develop a cialis based, holistically integrative approach to sexuality? What would it look like if the conversation starts from a place of health versus starting from a problem? In my experience, the more enjoyable conversations occur when a person is experiencing a transformation in their life regarding sexuality.

Over the recent years, there has been the development of a “Life Coaching” movement. What is a Life Coach? Take a sports star, they still have their coaches to help them further improve their skills. Similarly, life coaching is based on your experience, to help you integrate your values and goals and foster empowerment. A life coach is someone who walks along in your journey. The focus is on integration, positive sexuality, and health (instead of the more traditional illness based model).

There is a great need for the integration of life coaching and sexuality. Not all life coaches have the skills in sexuality. I encourage you to seek someone who is skilled in both coaching/counseling and sexuality. The goal will be to help you integrate your life and values to the ultimate goal where you say “I’m living a life I love.”

Sertleşme Sorunu Nasıl Tedavi Edilir? Sertleşme Sorunu Nasıl Tedavi Edilir? penis sertleşmiyor ereksiyon sorunu Penis İçi Enjeksiyon Penis Protezi

Sertleşme Sorunu Nasıl Tedavi Edilir? penis sertleşmiyor ereksiyon sorunu

Psikolojik ve fiziksel sorunlar için farklı tedaviler uygulanır. Psikolojik bir durumda, seks terapisi konusunda uzmanlaşmış psikologların yardımı alınmalıdır. Psikolojik tedavilerin yanında eğer sorunun nedeni fiziksel sorunlar ise, sorunlara yönelik tedaviler uygulanır. Tıbbî müdahalelerden önce doğal yollarla setleşme sorununun önüne geçmek veya etkiyi azaltmak mümkündür.

• Sigara,alkol gibi uyuşturucu madde kullanılmaması,


• Stresten uzuk kalınıp dinlenmeye zaman ayrılması,


• Hafif egzersizler ile kan dolaşımının düzenlenmesi,


• Fazla yağlı ve ağır yiyeceklerin tüketilmesinden kaçınılması…

Gibi genel tedbirler bizlere yardımcı olacaktır. Bunun dışında tıbbî tedaviler de vardır. Genel olarak sertleşme sorunu tedavisinde kullanılan 4 ana tedavi yöntemi vardır:

1. Ağız yoluyla kullanılan ilaçlar

2. Vakum cihazı

3. Penis içine enjeksiyon

4. Penis protezi

1. Ağız yoluyla kullanılan ilaçlar

• Sildenafil (Viagra, Vigrande, Sildegra)

cGMP düzeylerini yükseltmek suretiyle sertleşmeyi sağlar. Sildenafil’in 25, 50 veya 100 mg’lık dozları mevcuttur, doktor tavsiyesine göre seçim yapılabilir. Cinsel birleşmeden bir saat önce alınır. Sertleşme sorununun nedenine göre ilacın etkinsi %65-80 arasında değişmektedir. Sertleşme sorununa neden olan birçok hastalık grubunda (şeker, endokrin, nörolojik, psikolojik, pelvik cerrahi sonrası, arteriojenik, venojenik, idiopatik) etkinliğini kanıtlamıştır. Seksüel arzuyu arttırıcı etkisi yoktur. Etkisi 4 saat sürer. 8-12 saat içinde ilacın tamamı vücuttan atılmış olur. Nitrat grubu ilaç kullanmayan kalp hastalarında sildenafil güvenilir ve etkin bir tedavi seçeneğidir.

• Vardenafil (Levitra)

Vardenafil ve sildenafil arasında bazı farmakolojik benzerlikler bulunmaktadır. Kandaki maksimum seviyeye 0.7-0.9 saatte ulaşılır. 5, 10 ve 20 mg’lık dozlarda kullanılan vardenafil, %80′e varan başarı oranlarına sahiptir. Şeker hastalığı olanlarda ve prostat kanseri nedeniyle ameliyat olmuş hastalarda diğer PDE5 inhibitörlerinden daha üstün izlenimi vermektedir.

Tadalafil (Cialis)

cialis de fosfodiesteraz tip 5 enzimini engelleyerek etki gösterir. Yapısı diğer grup üyelerinden farklıdır. Tadalafil, sildenafil ve vardenafil’den daha yavaş kana karışır. Maksimum kan düzeyine 2 saatte ulaşılır. Ayrıca tadalafil’in yarılanma ömrü, (kan düzeyinin yarı yarıya azalması için gereken süre) rakiplerinden daha uzundur (17.5 saat). Böylelikle tadalafil 36 saat boyunca etkinlik sağlar. Tadalafil’in emilimi yaş, alkol tüketimi veya yemeklerden etkilenmez. Tadalafil 5, 10 ve 20 mg’lık dozlarda kullanılır.

2. Vakum Cihazı

Vakum cihazları plastik bir silindir, vakum pompası ve elastik sıkıştırma bandından oluşur.

• Penise kayganlaştırıcı madde uygulanır.


• Penis, silindirin içine sokulur.


• Silindirden dışarı doğru hava pompalanır. Böylelikle vakum etkisi yaratılır ve sertleşme olur.


• Silindirin serbest ucunda bulunan sıkıştırma bandı, sertleşmiş penisin köküne yerleştirilir. Böylelikle sertlik devamlı hâle gelir.


• Silindir penisten ayrılır. Sıkıştırma bandı, yarım saat süreyle penis üzerinde durabilir. Bant çıkarılıncaya kadar sertleşmeyi devam ettirir. Bu teknik kolaylıkla öğrenilebilir ve pek çok kişi tedaviyle başarılı sonuçlar almıştır.

3. Penis İçi Enjeksiyon

Korpora kavernozaya ince bir iğneyle damar genişletici ilaçlar enjekte edilir. Bu ilaçlar penis dokusunu gevşetir ve damarları genişletir. Böylelikle ereksiyon halkalarına gelen kan miktarı artar ve sertleşme gerçekleşir. Hasta cinsel ilişkiden 10-15 dakika önce kendine enjeksiyon yapar ve uygun doz ayarlaması neticesinde yaklaşık yarım saat sürecek sertleşme sağlanabilir.

4. Penis Protezi

Penis protezi cerrahi müdahale ile penis içine yerleştirilen iki adet sentetik silindirden oluşur. 2 çeşit protez kullanılmaktadır. Bükülebilen (malleable), yarı-sert protez ve şişirilebilen protez. Şişirilebilen protezler, penisteki silindirlere ek olarak bir adet pompa ve bir adet rezervuar içerir. Sıvı rezervuarlardan silindirlere pompalanır ve böylelikle penis sertleşir. Pompanın tabanındaki bir düğmeye basmak suretiyle silindirlerdeki sıvı rezervuara geri döner ve penis yumuşar. Penis protezleri daha ziyade yukarıda sıralanan tedavi yöntemlerinden fayda sağlayamayan hasta grubuna ve penis eğriliği olan hastalarda ameliyat çözüm olmadığında uygulanır. Bu grup hastada mutluluk balonu yerleştirilmesi %90′a varan hasta memnuniyeti oranlarıyla sonuçlanmıştır.

See also: cheap cialis | 

by Santosh Kumar Agarwal for Alarm Bells

Four residents of Sikkim, an Indian Province on the Himalayan Mountain, have been arrested for smuggling a hill fungus, known as ‘Yarsagumba’ in local terminology, which is known to have immense medicinal value particularly in respect of treatment of impotence in men.

The arrested persons are, Narayan, Deepak, Arjun and Darsang Bhutia, all being residents of Sikkim. The arrests are part of wider crackdown on the smuggling chain for medicinal plants in the hills, which also resulted in the 'controversial' arrests of Czechs entomologist and his aide Emil Kusera on 22^nd June’08.

As per S.T.Lachunga, Chief Conservator of Forests, the arrested persons named one Ganesh Thapa, on interrogations, as to be the king-pin of the chain. Thapa was picked up from Singtam on 3^rd July’08 and about 15kg of Yarsagumba was recovered from him hidden inside several pillows in his room. The price of dried Yarsagumba is about $8000 in the international markets. The value of ceased goods are therefore about Rs.5000000/- in Indian Currency.

The Scientifically named ‘Cordyceps sinensis’, the fungus is used as an aphrodisiac and has immense medicinal value in traditional Chinese medicines. In pharmaceuticals, it is used to manufacture potent antibiotics, immune system stimulants, anti tumor agents etc.

http://www.groundreport.com/Arts_and_Culture/Arrests-in-Sikkim-for-Smuggling-Himalayan-Viagra-a

pic: Sikkimonline.info