Complications of Diabetes Mellitus [Chronic] Hasan Aydin, MD Department of Endocrinology and...

CComplications omplications of of

DDiabetesiabetes Mellitus Mellitus[Chronic][Chronic]

Hasan Aydin, MDHasan Aydin, MDDepartment of Endocrinology and MetabolismDepartment of Endocrinology and Metabolism

Yeditepe University Medical FacultyYeditepe University Medical Faculty

Complications of Diabetes Complications of Diabetes MellitusMellitus

Chronic complicationsChronic complications• MicrovascularMicrovascular

– retinopathyretinopathy– NephropathyNephropathy– neuropathyneuropathy

• MacrovascularMacrovascular– cerbrovascular, cardiovascular, peripheral vascular cerbrovascular, cardiovascular, peripheral vascular

diseasedisease

AcuteAcute complicationscomplications– diabetic ketoacidosisdiabetic ketoacidosis

– diabetic nonketotic, hyperosmolar comdiabetic nonketotic, hyperosmolar comaa– hypoglycemiahypoglycemia

IntroductionIntroduction• Adults with diabetes have an annual mortality of Adults with diabetes have an annual mortality of 5.4%5.4%

(double the rate for non-diabetic adults)(double the rate for non-diabetic adults)

• LLife expectancy is decreased on average by ife expectancy is decreased on average by 5-10 years5-10 years

• Although the increased death rate is mainly due to Although the increased death rate is mainly due to cardiovascular diseasecardiovascular disease, deaths from non-cardiovascular , deaths from non-cardiovascular causes are also increased.causes are also increased.

• • A diagnosis of diabetes immediately increases the risk of A diagnosis of diabetes immediately increases the risk of

developing various clinical complications that are developing various clinical complications that are largelylargely irreversibleirreversible and due to microvascular or macrovascular and due to microvascular or macrovascular disease. disease.

MMajorajor D Determiningetermining F Factorsactors

DurationDuration

Glycemic ControlGlycemic Control

Type 1 vs. Type 2Type 1 vs. Type 2

DM Complications

Years

350300250200150100

50

InsulinLevel

Insulin Rasistance

Beta-cell Deficiency

250

200

150

100

50

0

Rela

tive

beta

-cell

fun

cti

on

(%

)

FastingGlucose

PostprandialGlucose

Glu

cose

(mg

/dl)

Diagnosis

ClinicalSigns

Macrovascular Changes

Obesity IGT Diabetes Uncontrolled Hyperglycemia

Prevention OAD Insulin

-10 -5 0 5 10 15 20 25 30

Microvascular Changes

D Kendall, R Bergenstal, International Diabetes Center

Type 2 Diabetes is a Progressive Disease

9.9 - 20.8% of pts have retinopathy Harris MI et al . Diab Care, 21: 1992.

Hamman RF et al. Diabetes, 38: 1989

5 – 10% proteinuria

Haffner SM et al. Diab Care, 12: 1989

At the diagnosis of Type 2 DM

Type 2 DM Starts Years Before Diagnosis

Preventionis more rewarding

thanManagementManagement o of f ComplicationsComplications

Microvascular Complications

Microvascular Complications

• Microvascular complications are Microvascular complications are specific to specific to diabetesdiabetes and do not occur without longstanding and do not occur without longstanding hhyperglycaemiayperglycaemia

• Both T1DM and T2DM are susceptible to Both T1DM and T2DM are susceptible to microvascular complicationsmicrovascular complications

• The duration of diabetes and the quality of The duration of diabetes and the quality of diabetic control are important determinants of diabetic control are important determinants of mmicrovascular diseaseicrovascular disease

Microvascular Microvascular CComplicationsomplications

• A continuous relation exists between A continuous relation exists between

glycaemic controlglycaemic control and the incidence and and the incidence and

progression of microvascular complications. progression of microvascular complications.

• HTN and smokingHTN and smoking also have an adverse effect also have an adverse effect

on microvascular outcomes. on microvascular outcomes.

“Tight Glycemic Control”

reduces microvascular and

macrovascular complications

Reduction of A1c from 8%to 7%

Study N Years Retinop. Renal Neural CV.

DCCT Primary

726 6.5 38 % 22 % 35 %

DCCT Secondary

751 6.5 27 % 28 % 29 % 40 %

Kumamoto Primary 55 6 38 % 50 %

Kumamoto Secondary 55 6 28 % 50 %

NCV increased

25 %

UKPDS 4209 9 19 % 26 % 18 % 18 %

Glycemic Control and Glycemic Control and ComplicationsComplications

Mo

rtal

ity

(%)

UK Prospective Study Group.

yıl0

40

1 2 3 4 5 6 7 8 9

20

0

30

10

convetional tight control

Risk- reduction 32%P=0.019

Mortality due to Diabetes

Possible molecular mechanisms Possible molecular mechanisms of diabetes-related complications. of diabetes-related complications.

Harrison's Principles of Internal Medicine, 16th Edn

Consequences of hyperglycemia-Consequences of hyperglycemia-induced activation of protein kinase C induced activation of protein kinase C

(PKC)(PKC)

Vascular Health and Risk Management 2007:3(6):823-832

Mechanisms of AGE Action Mechanisms of AGE Action

Pathophysiology of Pathophysiology of MiMicrovascular crovascular DDiseaseisease

• Structural changesStructural changes– thickening of the capillary basement membranethickening of the capillary basement membrane

• Functional changesFunctional changes– increased capillary permeabilityincreased capillary permeability– increased increased blood flow and viscosityblood flow and viscosity– disturbed platelet functiondisturbed platelet function

• Chemical changes in basement membrane Chemical changes in basement membrane compositioncomposition– increased type IV collagen and its glycosylation increased type IV collagen and its glycosylation

productsproducts

Diabetic RetinopathyDiabetic Retinopathy

RetinopathyRetinopathy• Diabetic retinopathy is a Diabetic retinopathy is a progressive disorderprogressive disorder

• It is the commonest cause of blindness in age It is the commonest cause of blindness in age 30-30-6969..

• Damage to the retina arises from a combination of Damage to the retina arises from a combination of microvascular leakage and microvascular microvascular leakage and microvascular occlusionocclusion

• A A fifthfifth of p of p’’ts with newly discovered ts with newly discovered type 2 type 2 diabetesdiabetes have retinopathy at the time of diagnosis. have retinopathy at the time of diagnosis.

RetinopathyRetinopathy

• In In type 1 diabetestype 1 diabetes, vision threatening , vision threatening retinopathy almost retinopathy almost never occurs in the never occurs in the first first five yearsfive years after diagnosis or before puberty. after diagnosis or before puberty.

• After After 15 years15 years, however, almost all type 1 , however, almost all type 1 diabetes and two thirds of type 2 diabetes diabetes and two thirds of type 2 diabetes have background retinopathyhave background retinopathy

• Vision threatening retinopathy is usually Vision threatening retinopathy is usually due to due to neovascularisationneovascularisation in type 1 diabetes in type 1 diabetes and and maculopathy maculopathy in type 2 diabetes. in type 2 diabetes.

RetinopathyRetinopathy• Depending on the relative contribution of Depending on the relative contribution of

leakage or capillary occlusion, leakage or capillary occlusion, maculopathymaculopathy is is divided into three types: divided into three types: – exudativeexudative maculopathy (when hard exudates maculopathy (when hard exudates

appear in the region of the macula),appear in the region of the macula), – ischaemicischaemic maculopathy (characterised by a maculopathy (characterised by a

predominance of capillary occlusion which results predominance of capillary occlusion which results in clusters of haemorrhages)in clusters of haemorrhages)

– edematousedematous maculopathy (extensive leakage gives maculopathy (extensive leakage gives rise to macular rise to macular eedema). dema).

Classification of Diabetic Classification of Diabetic RetinopathyRetinopathy

• Neovascularization (4 categories)Neovascularization (4 categories)–– Nonproliferative (NPDR)Nonproliferative (NPDR)

1. Early to moderate NPDR1. Early to moderate NPDR2. Severe NPDR (preproliferative)2. Severe NPDR (preproliferative)

–– Proliferative (PDR)Proliferative (PDR)1. 1. Non-high-risk PDRNon-high-risk PDR2. High-risk PDR2. High-risk PDR

Non-Proliferative Diabetic Non-Proliferative Diabetic RetinopathyRetinopathy

Severe NPDR (Pre-Severe NPDR (Pre-Proliferative)Proliferative)

Proliferative Diabetic Proliferative Diabetic RetinopathyRetinopathy

Retinal NeovascularizationRetinal Neovascularization

NVEvitreous

hemorrhage

BDR with Clinically SignificantBDR with Clinically SignificantMacular Edema (CSME)Macular Edema (CSME)

Treatment of Diabetic Treatment of Diabetic Retinopathy (Systemic)Retinopathy (Systemic)

• Control– Blood sugar

– Blood pressure

– Cholesterol

• Treat– Heart failure

– Kidney failure

– Avoid smoking

Treatment of Diabetic Treatment of Diabetic Retinopathy (Ocular)Retinopathy (Ocular)

• LaserLaser– Focal for macular edemaFocal for macular edema– Pan-retinal for neovascularizationPan-retinal for neovascularization

– VitrectomyVitrectomy– MedicationMedication

ss

Laser Treatment for Diabetic Laser Treatment for Diabetic Macular EdemaMacular Edema

Vitrectomy Surgery Vitrectomy Surgery

Diabetic Diabetic NephropathyNephropathy

Diabetic NephropathyDiabetic Nephropathy

Over 40% of new cases

of end-stage renal

disease (ESRD) are

attributed to diabetes.

Incidence of ESRD Resulting from Primary

Diseases (1998)

43%

23%

12%

3%

19%

Diabetes

Hypertension

Glomerulonephritis

Cystic Kidney

Other Causes

NephropathyNephropathy • Diabetic nephropathy is characterised by Diabetic nephropathy is characterised by

proteinuria proteinuria >300 mg/24 h>300 mg/24 h, increased BP, and a , increased BP, and a progressive decline in renal function. progressive decline in renal function.

• IIn the early stagesn the early stages,, overt disease is preceded by overt disease is preceded by a phase known as a phase known as incipient nephropathy (or incipient nephropathy (or microalbuminuria)microalbuminuria), in which the urine contains , in which the urine contains trace quantities of protein (not detectable by trace quantities of protein (not detectable by traditional dipstick testing). traditional dipstick testing).

• Microalbuminuria Microalbuminuria is defined as an albumin is defined as an albumin excretion rate of excretion rate of 330-300 mg/24 h0-300 mg/24 h and is highly and is highly predictive of overt diabetic nephropathypredictive of overt diabetic nephropathy

Treatment of DiabeticTreatment of Diabetic NephropathyNephropathy

• Hypertension Control Hypertension Control • Goal: lower blood pressure to <1Goal: lower blood pressure to <14040//9090

mmHg mmHg – Antihypertensive agentsAntihypertensive agents

• Angiotensin-converting enzyme (ACE) inhibitorsAngiotensin-converting enzyme (ACE) inhibitors– captopril, enalapril, lisinopril, benazepril, fosinopril, captopril, enalapril, lisinopril, benazepril, fosinopril,

ramipril, quinapril, perindopril, trandolapril, moexiprilramipril, quinapril, perindopril, trandolapril, moexipril

• Angiotensin receptor blocker (ARB) therapy Angiotensin receptor blocker (ARB) therapy – candesartan cilexetil, irbesartan, losartan potassium, candesartan cilexetil, irbesartan, losartan potassium,

telmisartan, valsartan, esprosartantelmisartan, valsartan, esprosartan

• Calcium channel Calcium channel blockersblockers

• Glycemic Control Glycemic Control – Preprandial Preprandial bloodblood glucose glucose 880-10-1220 mg/dl0 mg/dl– A1C <A1C <6.56.5%%– Postprandial Postprandial bloodblood glucose <1 glucose <1440 mg/dl0 mg/dl– Self-monitoring of blood glucose (SMBG)Self-monitoring of blood glucose (SMBG)– Medical Nutrition TherapyMedical Nutrition Therapy

• Restrict dietary protein to RDA of 0.8 Restrict dietary protein to RDA of 0.8 g/kg body weight per day g/kg body weight per day

Treatment of DiabeticTreatment of Diabetic NephropathyNephropathy

Treatment of End-Stage Renal Treatment of End-Stage Renal DiseaseDisease

There are three primary treatment There are three primary treatment options for individuals who options for individuals who experience ESRD:experience ESRD:

1. Hemodialysis1. Hemodialysis

2. Peritoneal Dialysis2. Peritoneal Dialysis

3. Kidney Transplantation3. Kidney Transplantation

Diabetic Neuropathy

Diabetic NeuropathyDiabetic Neuropathy About About 60-70%60-70% of people with of people with

diabetes have mild to severe forms of diabetes have mild to severe forms of nervous system damage, including: nervous system damage, including: Impaired sensation or pain in the Impaired sensation or pain in the

feet or handsfeet or hands Slowed digestion of food in the Slowed digestion of food in the

stomachstomach Carpal tunnel syndromeCarpal tunnel syndrome Other nerve problemsOther nerve problems

More than 60% of nontraumatic More than 60% of nontraumatic lower-limb amputationslower-limb amputations in the United in the United States occur among people with States occur among people with diabetes. diabetes.

• Damage to nerve fibres and capillariesDamage to nerve fibres and capillaries• Symptoms depend on nerves involvedSymptoms depend on nerves involved

– Motor fibres Motor fibres →→ Muscular weakness Muscular weakness– Sensory fibres Sensory fibres →→ Loss of sensation Loss of sensation

• also prickling, tingling, aching and painalso prickling, tingling, aching and pain

– Autonomic fibres Autonomic fibres →→ loss of function loss of function• functions not under conscious control such as functions not under conscious control such as

digestion, bladder, genitals, cardiovascular.digestion, bladder, genitals, cardiovascular.

Diabetic NeuropathyDiabetic Neuropathy

• Other ConsequencesOther Consequences– Diabetic foot (15% of all diabetics)Diabetic foot (15% of all diabetics)– Compression neuropathiesCompression neuropathies

• eg carpal tunnel syndromeeg carpal tunnel syndrome

• Risk factorsRisk factors– Smoking, >40 years old, poor glucose Smoking, >40 years old, poor glucose

controlcontrol– Affects Type 1 and Type 2Affects Type 1 and Type 2

Diabetic NeuropathyDiabetic Neuropathy

Classification of DiabeticClassification of Diabetic NeuropathyNeuropathy

•Symmetric polyneuropathySymmetric polyneuropathy

•Autonomic neuropathyAutonomic neuropathy

•PolyradiculopathyPolyradiculopathy

•MononeuropathyMononeuropathy

Symmetric Symmetric PolyneuropathyPolyneuropathy

• Most common form of diabetic Most common form of diabetic neuropathy neuropathy

• Affects distal lower extremities and Affects distal lower extremities and hands (hands (““stocking-glovestocking-glove”” sensory loss sensory loss) )

• Symptoms/SignsSymptoms/Signs– PainPain– Paresthesia/dysesthesiaParesthesia/dysesthesia– Loss of vibratory sensationLoss of vibratory sensation

Complications of Complications of PolyneuropathyPolyneuropathy

•UlcersUlcers

•Charcot arthropathyCharcot arthropathy

•Dislocation and stress fracturesDislocation and stress fractures

•Amputation Amputation

Treatment of SymmetricTreatment of Symmetric PolyneuropathyPolyneuropathy

• Glucose controlGlucose control

• Pain controlPain control– Alphalipoic acidAlphalipoic acid– AnticonvulsantsAnticonvulsants (gabapentin, (gabapentin,

pregabalin)pregabalin)– Tricyclic antidepressantsTricyclic antidepressants– Topical creamsTopical creams

• Foot careFoot care

Autonomic neuropathyAutonomic neuropathy

• Affects the autonomic nerves Affects the autonomic nerves controlling internal organs controlling internal organs – PeripheralPeripheral– GenitourinaryGenitourinary– GastrointestinalGastrointestinal– CardiovascularCardiovascular

• Is classified as clinical or subclinical Is classified as clinical or subclinical based on the presence or absence of based on the presence or absence of symptomssymptoms

Peripheral Autonomic Peripheral Autonomic DysfunctionDysfunction

• Contributes to the following Contributes to the following symptoms/signs:symptoms/signs:– Neuropathic arthropathy (Charcot foot)Neuropathic arthropathy (Charcot foot)– Aching, pulsation, tightness, cramping, dry Aching, pulsation, tightness, cramping, dry

skin, pruritus, edema, sweating skin, pruritus, edema, sweating abnormalitiesabnormalities

– Weakening of the bones in the foot leading Weakening of the bones in the foot leading to fracturesto fractures

Peripheral Autonomic Peripheral Autonomic DysfunctionDysfunction

• TreatmentTreatment– Foot care/elevate feet when sittingFoot care/elevate feet when sitting– Eliminate aggravating drugs Eliminate aggravating drugs

((tranquilizers, antidepressants, diureticstranquilizers, antidepressants, diuretics))

– Reduce edemaReduce edema•midodrinemidodrine•diureticsdiuretics

– Support stockingsSupport stockings– Screen for CVDScreen for CVD

Genitourinary Autonomic Genitourinary Autonomic NeuropathyNeuropathy

Sign/Symptom Treatment Bladder dysfunction Voluntary urination;

catheterization

Retrograde ejaculation Antihistamine

Erectile dysfunction Sildenafil, tadalafil

Dyspareunia Lubricants; estrogen creams

Gastrointestinal AutonomicGastrointestinal Autonomic NeuropathyNeuropathy

• Symptoms/SignsSymptoms/Signs– Gastroparesis resulting in anorexia, nausea, Gastroparesis resulting in anorexia, nausea,

vomiting, and early satietyvomiting, and early satiety– Diabetic enteropathy resulting in diarrhea and Diabetic enteropathy resulting in diarrhea and

constipationconstipation

• TreatmentTreatment– Other causes of gastroparesis or enteropathy Other causes of gastroparesis or enteropathy

should first be ruled outshould first be ruled out– Gastroparesis - Small, frequent meals,Gastroparesis - Small, frequent meals,

mmetoclopramide, erythromycinetoclopramide, erythromycin– Enteropathy - loperamide, antibiotics, stool Enteropathy - loperamide, antibiotics, stool

softeners or dietary fibersofteners or dietary fiber

Cardiovascular Autonomic Cardiovascular Autonomic NeuropathyNeuropathy

• Symptoms/SignsSymptoms/Signs– Exercise intoleranceExercise intolerance– Postural hypotensionPostural hypotension

• TreatmentTreatment– Discontinue aggravating drugsDiscontinue aggravating drugs– Change posture (make postural changes Change posture (make postural changes

slowly, elevate bed)slowly, elevate bed)– Increase plasma volumeIncrease plasma volume

PolyradiculopathyPolyradiculopathy

• Lumbar polyradiculopathy (diabetic amyotrophy) Lumbar polyradiculopathy (diabetic amyotrophy) – Thigh pain followed by muscle weakness and atrophyThigh pain followed by muscle weakness and atrophy

• Thoracic polyradiculopathy Thoracic polyradiculopathy – Severe pain on one or both sides of the abdomen, possibly Severe pain on one or both sides of the abdomen, possibly

in a band-like patternin a band-like pattern

• Diabetic neuropathic cachexiaDiabetic neuropathic cachexia– Polyradiculopathy + peripheral neuropathyPolyradiculopathy + peripheral neuropathy– Associated with weight loss and depressionAssociated with weight loss and depression

MononeuropathyMononeuropathy

• Peripheral mononeuropathyPeripheral mononeuropathy– Single nerve damage due to compression or Single nerve damage due to compression or

ischemia ischemia – Occurs in wrist (carpal tunnel syndrome), Occurs in wrist (carpal tunnel syndrome),

elbow, or foot (unilateral foot drop)elbow, or foot (unilateral foot drop)– Symptoms/SignsSymptoms/Signs

• numbnessnumbness• edemaedema• painpain• pricklingprickling

• Cranial mononeuropathyCranial mononeuropathy– Affects the 12 pairs of nerves that are Affects the 12 pairs of nerves that are

connected with the brain and control connected with the brain and control sight, eye movement, hearing, and tastesight, eye movement, hearing, and taste

– Symptoms/SignsSymptoms/Signs• unilateral pain near the affected eyeunilateral pain near the affected eye• paralysis of the eye muscle paralysis of the eye muscle • double visiondouble vision

• Mononeuropathy multiplexMononeuropathy multiplex

MononeuropathyMononeuropathy

MACROVASCULAMACROVASCULARR

COMPLICATIONSCOMPLICATIONS

Macrovascular Macrovascular CComplicationsomplications

• Angina.Angina.

• Myocardial infarction.Myocardial infarction.

• Transient ischaemic attacks.Transient ischaemic attacks.

• Cerebrovascular accident.Cerebrovascular accident.

• Claudication lower limb.Claudication lower limb.

• Neuropathy / infection.Neuropathy / infection.

Macrovascular Macrovascular CComplicationsomplications• Atherosclerotic disease accounts for most of the Atherosclerotic disease accounts for most of the

excess mortality in diabetes. excess mortality in diabetes.

• In the UKPDS, fatal cardiovascular events were In the UKPDS, fatal cardiovascular events were 70 70 timestimes more common than deaths from microvascular more common than deaths from microvascular complications. complications.

• The relation between glucose concentrations and The relation between glucose concentrations and macrovascular events is less macrovascular events is less powerfulpowerful than for than for microvascular disease; microvascular disease;

• SSmoking, BP, proteinuria, and cholesterol moking, BP, proteinuria, and cholesterol concentrationconcentration are more important risk factors for are more important risk factors for atheromatous large vessel disease in diabetes. atheromatous large vessel disease in diabetes.

Macrovascular Macrovascular CComplicationsomplications

• Hyperlipidaemia is no more common in Hyperlipidaemia is no more common in well controlled well controlled type 1 diabetestype 1 diabetes than it is than it is in the general population. in the general population.

• In type 2 diabetes, total and LDL In type 2 diabetes, total and LDL concentrations are also similar to those concentrations are also similar to those found in non-diabetic people, but type 2 found in non-diabetic people, but type 2 diabetes is associated with a more diabetes is associated with a more atherogenic lipid profile, in particular atherogenic lipid profile, in particular low low HDLHDL and and high small, dense, LDL particles. high small, dense, LDL particles.

Macrovascular Macrovascular CComplicationsomplications

• HTN affects at least HTN affects at least halfhalf of diabetes. of diabetes.

• In UKPDS, tight BP control (mean In UKPDS, tight BP control (mean 144/82144/82 mm Hg) mm Hg) achieved significant reductions in the risk of stroke achieved significant reductions in the risk of stroke (44%)(44%), , heart failure heart failure (56%)(56%), and diabetes related deaths , and diabetes related deaths (32%)(32%), as , as well as reductions in microvascular complications (for well as reductions in microvascular complications (for example, example, 34%34% reduction in progression of retinopathy). reduction in progression of retinopathy). One thirdOne third of p of p’’ts required ts required three or morethree or more antihypertensive antihypertensive drugs to maintain a target BP drugs to maintain a target BP <150/85<150/85 mm Hg. mm Hg.

• In another recent study (hypertension optimal treatment In another recent study (hypertension optimal treatment study) rates of CV events in type 2 diabetes were reduced study) rates of CV events in type 2 diabetes were reduced even further when combination treatment was used to aim even further when combination treatment was used to aim for target for target diastolic BP <80 mm Hg. diastolic BP <80 mm Hg.

Unmodifiable Unmodifiable RRisk isk FFactorsactors

• Age >50Age >50

• GenderGender

• HereditaryHereditary

Modifiable Modifiable RRisk isk FFactorsactors

• SmokingSmoking

• InactivityInactivity

• NutritionNutrition

• Obesity (BMI > 30)Obesity (BMI > 30)

• Excessive smoking & alcohol Excessive smoking & alcohol intakeintake

Medical Medical RRisk isk FFactorsactors

• Hypertension (BP>130/80mmHg)Hypertension (BP>130/80mmHg)

• High cholesterolHigh cholesterol

• Poor glycemic control (HbA1c>7%)Poor glycemic control (HbA1c>7%)

• MicroalbuminuriaMicroalbuminuria

Coronary Coronary HHeart eart DDiseaseisease • The incidence and severity of coronary The incidence and severity of coronary

heart disease events areheart disease events are higher higher in diabetes, in diabetes, and several clinical features are worth and several clinical features are worth noting. noting.

• The diabetes subgroups in the major The diabetes subgroups in the major secondary prevention studies of cholesterol secondary prevention studies of cholesterol reduction (Scandinavian simvastatin reduction (Scandinavian simvastatin survival study survival study (4S)(4S) and cholesterol and and cholesterol and recurrent events recurrent events (CARE)(CARE) trial) show a trial) show a beneficial effect of beneficial effect of statinsstatins. .

Peripheral Peripheral VVascular ascular DDisease isease

• Atheromatous disease in the legs, as in Atheromatous disease in the legs, as in the heart, tends to affect more distal the heart, tends to affect more distal vesselsvessels——for example, the for example, the tibial arteriestibial arteries——producing producing multiple, diffuse lesionsmultiple, diffuse lesions that are less straightforward to bypass that are less straightforward to bypass or dilate by angioplasty. or dilate by angioplasty.

• Medial calcification of vessels Medial calcification of vessels ( ( MMöönckeberg's sclerosisnckeberg's sclerosis ) is common ) is common

StrokeStroke• 85%85% of acute strokes are atherothrombotic, of acute strokes are atherothrombotic,

and the rest are haemorrhagic (10% primary and the rest are haemorrhagic (10% primary ICH , 5% SAH ). ICH , 5% SAH ).

• The risk of atherothrombotic stroke is The risk of atherothrombotic stroke is two to two to three timesthree times higher in diabetes, but the rates higher in diabetes, but the rates of haemorrhagic stroke and TIA are similar to of haemorrhagic stroke and TIA are similar to those of the non-diabetic population. those of the non-diabetic population.

• Diabetes are more prone to Diabetes are more prone to irreversibleirreversible rather than reversible ischaemic brain rather than reversible ischaemic brain damage, damage, small lacunar infarctssmall lacunar infarcts are common. are common.

StrokeStroke• Stroke pStroke p’’ts with diabetes have a ts with diabetes have a higher higher

death rate death rate and a poorer neurological and a poorer neurological outcome with more severe disability. outcome with more severe disability.

• Maintaining Maintaining good glycaemic controlgood glycaemic control immediately after a stroke is likely to immediately after a stroke is likely to improve outcomeimprove outcome, but the long term survival , but the long term survival is reduced because of a is reduced because of a high rate of high rate of recurrencerecurrence. .

• Antihypertensive treatmentAntihypertensive treatment is effective in is effective in preventing stroke. preventing stroke.

Erectile Erectile DDysfunction ysfunction • A common complication of diabetes, occurring in up to A common complication of diabetes, occurring in up to

half of menhalf of men aged over 50 years (compared with aged over 50 years (compared with 15-20%15-20% in age matched non-diabetic men), although the exact in age matched non-diabetic men), although the exact prevalance is unknown because of likely prevalance is unknown because of likely underreportingunderreporting..

• Pathogenesis is Pathogenesis is multifactorialmultifactorial, with , with autonomic autonomic neuropathyneuropathy, , vascular insufficiencyvascular insufficiency, and , and psychological psychological factorsfactors contributing to the clinical picture. The contributing to the clinical picture. The condition causes appreciable social and psychological condition causes appreciable social and psychological problems for many pproblems for many p’’ts, and its importance should not ts, and its importance should not be underestimated. be underestimated.

• SildenafilSildenafil, Tadalafil, Tadalafil, which is reported to have a , which is reported to have a 50-70%50-70% success rate in diabetes, is an important advance. success rate in diabetes, is an important advance.

DIABETIC FOOT SYNDROME

Foot Problems and DiabetesFoot Problems and Diabetes

• Neuropathy Neuropathy – Peripheral: loss of protective sensation Peripheral: loss of protective sensation – Autonomic: loss of ability to sweat Autonomic: loss of ability to sweat – Motor: loss of structure/muscle toneMotor: loss of structure/muscle tone

• Peripheral Vascular DiseasePeripheral Vascular Disease– Impaired circulation in legs and feet Impaired circulation in legs and feet – Increased incidence of inflammation and infection Increased incidence of inflammation and infection – High risk of ulcers, gangrene and amputations High risk of ulcers, gangrene and amputations

when person also has neuropathywhen person also has neuropathy

Callus formation Subcutaneous hemorrhage

Breakdown of skin Deep foot infection with osteomyelitis

Illustration of ulcer due to Illustration of ulcer due to repetitive stressrepetitive stress

Diabetic Foot UlcersDiabetic Foot Ulcers

Diabetic foot ulcersDiabetic foot ulcers

Diabetic Foot UlcersDiabetic Foot Ulcers

Diabetic foot ulcersDiabetic foot ulcers

PreventionPrevention

• Foot exam by a health professional at Foot exam by a health professional at every medical visit every medical visit

• Comprehensive exam annually Comprehensive exam annually – VascularVascular– MusculoskeletalMusculoskeletal– Skin and soft tissueSkin and soft tissue

• EducationEducation

T h a n k Y T h a n k Y o u !o u !