DIABETES MILLITUSAND COMPLICATION

พ.ญ. วิ�ภาจรี เสน่ ห์�ลั�กษณา

Classification of DM Diagnosis Risk factors Complication Management

Common metabolic disorder Hyperglycemia Pathophysiologic changes in

multiple organ system

DIABETES MILLITUS

1. Type 1 diabetes ; betacell destruction absolute insulin deficiency

2. Type 2 diabetes ; insulin resistance impaired insulin secretion 3. Other specific types of diabetes 4. Gestational DM

Classification of DM

Symptoms plus random blood glucose > or = 200 mg/dl

Fasting plasma glucose > or = 126 mg/dl

A1C > 6.5 % 2-hr plasma glucose > or = 200

mg/dl ( OGTT)

Diagnosis of DM

Risk factors

Family history of diabetes Obesity ( BMI > 25 kg/m2 ) Physical inactivity Race Previous IFG History of GDM or delivery of baby > 4

kg Hypertension HDL < 35 mg/dl and/or TG >250 mg/dl History of CVD

Acute complication - relative insulin deficiency and volume depletion 1. Diabetic ketoacidosis 2. Hyperglycemic hyperosmolar state Chronic complication

COMPLICATION

Vascular Microvascular - retinopathy - neuropathy - nephropathy Macrovascular - coronary heart disease - peripheral arterial disease - cerebrovascular disease Nonvascular

CHRONIC COMPLICATION

Unknown Chronic hyperglycemia = etiologic factor Hypothesis hyperglycemia activate substance

atherosclerosis endothelial dysfunction glomerular dysfunction

MECHANISMS OF COMPLICATION

UKPDS - reduction in A1C associated with reduction

in microvascular complication - strictly BP control reduce both macro and microvascular complication DCCT - improved glycemic control associated

with reduce TG and increase HDL

GLYCEMIC CONTROL AND COMPLICATIONS

Diabetic retinopathy retinal vascular microaneurysm change in venous vessel caliber vasc hemorrhage alter retinal permeability blood flow

EYE DISEASE COMPLICATION

retinal ischemia appearance of neovascularization

rupture easily vitreous hemorrhage , fibrosis and retinal detachment

Prevention most effective therapy

Intensive glycemic and BP control

Eye examination by ophthalmologist

Laser photocoagulation

TREATMENT

Albuminuria associated risk of CVD Commonly have diabetic retinopathy Smoking accelerates the decline in

renal function Chronic hyperglycemia

alter renal microcirculation

RENAL COMPLICATION

Type 1 DM - 5-10 yrs ; 40 percent microalbuminuria - next 10 yrs ; 50 percent macroalbuminuria - macroalbuminuria reach ESRD in 7-10 yrs Type 2 DM - albuminuria may be from other factors such as HT , CHF , prostate disease or infection - less predictive of DN and progression to macroalbuminuria

Glycemic control Strictly BP control < 130/80 mmHg Treatment dyslipidemia ACE I OR ARBs Annual microalbuminuria ,serum Cr

test Nephrology consultation ; GFR < 60

ml/min

TREATMENT

50 percent of patient with long standing DM

Correlate with glycemic control Additional risk factors are

BMI ,smoking ,HT hypertriglyceride

NEUROPATHY

Polyneuropathy Polyradiculopathy Mononeuropathy Autonomic neuropathy

Most common is distal symmetric polyneuropathy

Numbness , tingling , sharpness or burning Lower extremities Worsen at night Progression ; the pain subsides sensory

deficit

POLYNEUROPATHY

Pain in one or more nerve root Thoracic pain , abdominal pain , thigh pain Associated with muscle weakness Self-limited and resolve 6-12 months

DIABETIC POLYRADICULOPATHY

Cranial and peripheral nerve Cranial nerve 3 diplopia

MONONEUROPATHY

Resting tachycardia , orthostatic hypotension Hyperhidrosis of upper extremities Anhidrosis of lower extremities Hypoglycemia unawareness

AUTONOMIC NEUROPATHY

Glycemic control improve autonomic neuropathy

Avoidance alcohol and smoking Vitamin B 12 and folate supplement Symptomatic treatment Antidepressants , anticonvulsants Foot wear

TREATMENT

Cardiovascular disease Cerebrovascular disease Peripheral artery disease

MACROVASCULAR COMPLICATIONS

DM marked increase in CHF , CHD , MI ,

sudden death , PAD CHD risk equivalent Additional risk factors DLP , HT , obesity smoking ,reduced physical activity

insulin resistance

activated PAI -1 and fibrinogen

coagulation process and impairs fibrinolysis

thrombosis

Revascularization procedures Beta blocker ,ACE I or ARB in CHD Anti platelet therapy Control other risk factor - DLP - HT - life style modification - stop smoking

TREATMENT

DM the leading cause of non traumatic lower

extremity amputation Pathologic factors ; neuropathy abnormal foot biomechanics PAD poor wound healing

LOWER EXTREMITIES COMPLICATION

Careful selection of footwear Daily feet inspection Keep feet clean and moist Avoid walking barefoot

TREATMENT

Off – loading Debridement Wound dressing ATB Revascularization Limited amputation Hyperbaric oxygen

Glycemic control BP and DLP control Life style modification diet control Weight control Exercise Stop smoking

TAKE HOME MESSAGE

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