Diabetes MellitusFifth Stage-Medicine

Dr. Sarbast FakhradinMBChB, MSc Diabetes Care & Management

Chronic complications of DM• 1. Macrovascular:

• A. Coronary heart disease

• B. Peripheral arterial disease

• C. Cerebrovascular disease

• 2. Microvascular:

• A. Eye disease: Retinopathy, Maculopathy.

• B. Neuropathy, sensory, motor, autonomic

• C. Nephropathy.

• 3. Other:

• A. GIT (Gastroparesis)

• B. Genitourinary (Uropathy, Sexual dysfunction)

• C. Dermatologic

• D. Infection

• E. Cataract & Glaucoma

• F. Periodontal disease

• G. Hearing loss

Pathophysiology

• Macrovascular: Atherosclerosis occur earlier in life, more

extensive & more sever.

• Microvascular: thickening of the capillary basement

membrane, increased vascular permeability.

• Factors associated with increased mortality and morbidity in people with diabetes

• 1. Duration of diabetes

• 2. Early age at onset of disease

• 3. High glycated haemoglobin (HbA1c)

• 4. Raised blood pressure

• 5. Proteinuria; microalbuminuria

• 6. Dyslipidaemia

• 7. Obesity

Preventing diabetes complications

• 1. Education• 2.Glycemic control• 3. Hypertension (ACEI, AII receptor antagonist)• 4. Dyslipidemia• 5. Smoking• 6. Alcohol

→Silent myocardial infarction (neuropathy)

Diabetic retinopathy• Clinical features :• 1. Microaneurysms

• 2. Retinal haemorrhages (dot and blot)

• 3. Exudates

• 4. Cotton wool spots

• 5. Venous changes

• 6. Neovascularisation (retina and iris)

• 7. Pre-retinal/subhyaloid haemorrhage

• 8. Vitreous haemorrhage

• 9. Fibrosis/gliosis

Types of retinopathy:1. Non-proliferative 'background' retinopathy without maculopathy

2. Pre-proliferative retinopathy

3. Proliferative retinopathy

4. Maculopathy

Diabetic retinopathy

• Management:1. Glycaemic control

2. Blood pressure control

3. Lipid profile control

4. laser photocoagulation

5. Vitrectomy

Diabetic nephropathyStages of diabetic nephropathy:

Random urine sample can estimate urinary Albumin:Creatinine Ratio; normal range (mg/mmol) differs in males (< 2.5) and females (< 3.5)

• Abnormal results

• Exclude recent (24 hrs) vigorous exercise, fever, heart failure, urine

infection, prostatitis, menstruation

• Confirm observation twice within 3-6 months

• Look for blood pressure above target levels.

• Management

• 1. Improved control of blood glucose

• 2. Aggressive reduction of blood pressure

• 3. Aggressive cardiovascular risk factor reduction (ACE inhibitors,

ARB, statins and aspirin)

• 4. Medications: Metformin dose, Insulin, etc

• 5. Renal replacement therapy & transplantation

Screening for diabetic retinopathy & nephropathy

• 1. Patients with type 1 diabetes annually from 5 yrs after diagnosis

• 2. Patients with type 2 diabetes annually from time of diagnosis

Diabetic Neuropathy

• Approximately 30% of diabetic patients.

• Associated with the duration of diabetes and the degree of

metabolic control.

• They can occur in motor, sensory and autonomic nerves, or in

combination.

Classification of diabetic neuropathy

• A. Somatic

• 1. Polyneuropathy

– Symmetrical, mainly sensory and distal

– Asymmetrical, mainly motor and proximal (including amyotrophy)

• 2. Mononeuropathy (including mononeuritis multiplex)

• B. Visceral (autonomic)

• 1. Cardiovascular

• 2. Gastrointestinal

• 3. Genitourinary

• 4. Sudomotor

• 5. Vasomotor

• 6. Pupillary

Clinical features

• Symmetrical sensory polyneuropathy:

• Asymptomatic

• Symptomatic: The most common clinical signs are diminished

perception of vibration sensation distally, 'glove-and-stocking'

impairment of all other modalities of sensation, & loss of

tendon reflexes in the lower limbs.

• Symmetrical sensory polyneuropathy: (Cont)

• Paraesthesiae in the feet, pain in the lower limbs (worse at night

&on the anterior aspect of the legs), burning sensations in the

soles of the feet, hyperaesthesia and an abnormal gait (commonly

wide-based), Muscle weakness and wasting(advanced case), The

toes may be clawed with wasting of the interosseous muscles,

which results in increased pressure on the plantar aspects of the

metatarsal heads (callus formation).

Asymmetrical motor diabetic neuropathy (diabetic amyotrophy)

• Severe & progressive weakness & wasting of the proximal muscles of the limbs (Mainly lower)

• Severe pain (anterior aspect of the leg), hyperaesthesia & paraesthesiae.

• Loss of weight ('neuropathic cachexia').

• The patient may look extremely ill & be unable to get out of bed.

• There may be absent tendon reflexes, extensor plantar responses, & the CSF protein is often raised.

• Some deficits become permanent.

• Management is mainly supportive.

Mononeuropathy • Motor or sensory• Peripheral or cranial nerve• Unlike the gradual progression of distal

symmetrical and autonomic neuropathies, mononeuropathies are severe and of rapid onset but they eventually recover.

• Most commonly affected are the 3rd and 6th cranial nerves (diplopia), the femoral and sciatic nerves, median nerve (carpal tunnel syndrome), ulnar nerve, Lateral popliteal nerve (foot drop).

Autonomic neuropathy• Clinical features • 1. CVS: Postural hypotension, resting tachycardia, fixed heart rate.

• 2. GIT: Dysphagia, abdominal fullness, nausea & vomiting, unstable glycaemia, due to delayed gastric emptying ('gastroparesis'), nocturnal diarrhoea ± faecal incontinence, & Constipation.

• 3. Genitourinary: Difficulty in micturition, urinary incontinence, recurrent infection, erectile dysfunction & retrograde ejaculation,

• 4. Sudomotor: Gustatory sweating, nocturnal sweats without hypoglycaemia, anhidrosis; fissures in the feet

• 5. Vasomotor: Feet feel cold, dependent oedema, & bullous formation

• 6. Pupillary: Decreased pupil size, delayed or absent reflexes to light.

• →The development of autonomic neuropathy is less clearly related to poor metabolic control than somatic neuropathy, and improved control rarely results in amelioration of symptoms.

Management

• Pain and paraesthesiae from peripheral somatic

neuropathies

• 1. Strict glycaemic control

• 2. Anticonvulsants (gabapentin, pregabalin, carbamazepine, phenytoin)

• 3. Antidepressants (amitriptyline, imipramine, duloxetine)

• 4. Opiates (tramadol, oxycodone)

Management

• Postural hypotension: Support stockings, Fludrocortisone, α-

adrenoceptor agonist, NSAIDs

• Gastroparesis: Dopamine antagonists (metoclopramide, domperidone),

Erythromycin.

• Diarrhoea :Loperamide, Broad-spectrum antibiotics

• Constipation: laxatives (senna)

• Erectile dysfunction (impotence): Phosphodiesterase type 5

inhibitors (sildenafil, vardenafil, tadalafil)-oral, vacume, implantation,

psychosexual therapy.

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