Materi Diabetes Dan Komplikasinya

DIABETES DAN KOMPLIKASI

Dr. Zaharita bt BujangKlinik Kesihatan Pekan Nenas

Pontian

SUDAH BERSEDIA NAK SUDAH BERSEDIA NAK DENGAR CERAMAH ?DENGAR CERAMAH ?

Sunday Star-26Sunday Star-26thth March March 20062006

DIABETES MELITUS

Penyakit yang tinggi morbiditi dan mortaliti

Komplikasi diabetes

* Retinopathy : 14.6% NIDDM > 40 thn

* Nephropathy : 10% selepas 25 thn DM

* Neurologi : 50% selepas 50 thn

Risiko co-morbiditiRisiko co-morbiditiCVSCVS 2-4 2-4

StrokeStroke 5X5X

AmputasiAmputasi 27.7X27.7X

ImpotenceImpotence 1/3 lelaki 1/3 lelaki diabetesdiabetes

PATHOGENESIS PATHOGENESIS

Hyperglycaemia

Increased hepaticglucose production Decreased

muscle glucoseuptake

Impaired insulin secretion

DIAGNOSISDIAGNOSIS• Pemeriksaan darahPemeriksaan darah

- FBS , RBS , MGTT- FBS , RBS , MGTT• Gejala – gejala diabetesGejala – gejala diabetes

DIAGNOSTIC CRITERIA FOR DIAGNOSTIC CRITERIA FOR DIABETES (75 G ORAL GLUCOSE DIABETES (75 G ORAL GLUCOSE TOLERANCE TEST)TOLERANCE TEST)Fasting Plasma Fasting Plasma Glucose (mmol/l)Glucose (mmol/l)

< 6.1< 6.1 NormalNormal

>> 6.1 - 6.1 - << 7.0 7.0 Impaired Fasting Impaired Fasting GlucoseGlucose

> 7.0> 7.0 DiabetesDiabetes

2 hour Plasma 2 hour Plasma Glucose (mmol/l)Glucose (mmol/l)

< 7.8< 7.8 NormalNormal

>> 7.8 - 7.8 - << 11.1 11.1 Impaired Glucose Impaired Glucose ToleranceTolerance

> 11.1> 11.1 DiabetesDiabetes

JENIS-JENIS PENYAKIT DIABETES

JENIS-JENIS PENYAKIT DIABETES

PRIMARY SECONDARY

Type 1 (IDDM)

Type 2 (NIDDM)

TYPE 1 VS TYPE 2TYPE 1 VS TYPE 2• Younger: Age< 30 yrsYounger: Age< 30 yrs• LeanLean• HLA DR3 or DR4HLA DR3 or DR4• Autoimune disease.Autoimune disease.• Present of Islet cell Present of Islet cell

antibodies.antibodies.• Insulin deficiency.Insulin deficiency.• May devel. May devel.

Ketoacidosis.Ketoacidosis.• Always need insulin.Always need insulin.• Dissapearance of C-Dissapearance of C-

peptide.peptide.

• Older onsetOlder onset• OverweightOverweight• No HLA linksNo HLA links• No immune No immune

disturbancedisturbance• Insulin resistance.Insulin resistance.• Partial insulin def.Partial insulin def.• May devel. May devel.

Hyperosmolar state.Hyperosmolar state.• 50% need insulin after 50% need insulin after

many years.many years.• C- peptide persist.C- peptide persist.

COULD DIABETES COULD DIABETES PREVENTED ?????PREVENTED ?????

• Lifestyle modification;Lifestyle modification;– Weight loss >5%.Weight loss >5%.– Reduce fat and increase dietary fibre .Reduce fat and increase dietary fibre .– Exercise > 30 min daily.Exercise > 30 min daily.

• ?? Lifestyle modification could prevent ?? Lifestyle modification could prevent diabetes almost 100%.diabetes almost 100%.

• Prof J. Toumiletho Univ. HelsinkiProf J. Toumiletho Univ. Helsinki

EDUCATION ON EDUCATION ON DIABETESDIABETES• A common chronic disorderA common chronic disorder• Chronic hyperglycaemiaChronic hyperglycaemia• Currently no known cure BUT can be Currently no known cure BUT can be

controlled for a healthy & productive lifecontrolled for a healthy & productive life• Symptoms: Polyuria, polydipsia, Symptoms: Polyuria, polydipsia,

tiredness, lethargy, wt losstiredness, lethargy, wt loss• 50% not aware they are diabetic50% not aware they are diabetic• Majority are asymptomaticMajority are asymptomatic

Causes of Death Among Causes of Death Among People With DiabetesPeople With Diabetes

Ischemic heart diseaseIschemic heart diseaseOther heart diseaseOther heart diseaseDiabetes (acute complications)Diabetes (acute complications)CancerCancerCerebrovascular diseaseCerebrovascular diseasePneumonia/influenzaPneumonia/influenzaAll other causesAll other causes

4040

1515

1313

1313

1010

44

55

CAUSES % of Deaths% of Deaths

Geiss LS et al. In: Geiss LS et al. In: Diabetes in America. Diabetes in America. 2nd ed.2nd ed. 1995:233-257.1995:233-257.

KOMPLIKASI DIABETES

CAD, PVDCVA

Dyslipidemia

Hypertension

Smoking

microvascular

macrovascular

Genetics

KOMPLIKASI DIABETES

AKUT KRONIK

KOMPLIKASI AKUT

Hiperglisemia Koma

(Gula terlalu tinggi)

Hipoglisemia Koma

(Gula terlalu rendah)

Tanda amaranTerlalu dahagaKencing banyak

LetihLemah

Rasa mengantuk

Tanda amaranRasa lapar

Sakit kepalaKetar tangan

BerdebarBerpeluh

Tingkahlaku agresif

KOMPLIKASI KRONIK

Rosak

Salurdarah kecil

Rosak

Salurdarah besar

MataBuah pinggang

Saraf

JantungSalur darah anggota

Kaki diabetes

DIABETIC COMPLICATIONSDIABETIC COMPLICATIONS

RETINOPATHYRETINOPATHY NEPHROPATHYNEPHROPATHY NEUROPATHYNEUROPATHY DIABETIC FOOTDIABETIC FOOT CARDIOVASCULAR DISEASECARDIOVASCULAR DISEASE

MATA

Mudah dapat katarak ( selaput mata )

Glaukoma

Retinopathy

Cataracts of the crystalline lens with opacification, as shown here, are more frequent in persons with diabetes mellitus.

Glaucoma with marked cupping of the optic disk is seen on funduscopic examination. The incidence of glaucoma is higher in the diabetic population.

Diabetic retinopathy is shown here on funduscopic examination.

Proliferative diabetic retinopathy on funduscopic examination is shown here. This is a particularly serious complication in diabetics that can lead to blindness.



Diabetic Nephropathy- Diabetic Nephropathy- Natural HistoryNatural History

Screening for Diabetic Screening for Diabetic NephropathyNephropathy

DARAH TINGGI



TREATMENT

SARAF

Kehilangan rasa pada anggota kaki

Saraf Autonomik-

Tekanan darah rendah bila bangun - pening

Kembung perut

Impotence

Mononeuropati

Diabetic neuropathyDiabetic neuropathyPemeriksaan neurologi

DiagnosisAda gejala

Touch and pin prickVibration sensePosition sense

Ankle jerkMuscle wasting

Autonomic neuropathy

Diabetic controlTreat pain/parassthesia

footcare

TYPES OF NEUROPATHYTYPES OF NEUROPATHY

• PERIPHERAL NEUROPATHYPERIPHERAL NEUROPATHY - Distal Symmetrical Polyneuropathy- Distal Symmetrical Polyneuropathy - Mononeuritis ( Amyotrophy )- Mononeuritis ( Amyotrophy ) - Painful Neuropathy ( Acute )- Painful Neuropathy ( Acute )• AUTONOMIC NEUROPATHYAUTONOMIC NEUROPATHY - Gastroperesis, ED, Diabetic Diarrhoea- Gastroperesis, ED, Diabetic Diarrhoea Neuropathic Bladder, etcNeuropathic Bladder, etc

NEUROPATHYNEUROPATHY

PERIPHERAL NEUROPATHYPERIPHERAL NEUROPATHY SYMPTOMATICS SYMPTOMATICS ANTIEPILEPTICSANTIEPILEPTICS : : Clonoazepam, Gabapentin,Clonoazepam, Gabapentin,

CarbamazipineCarbamazipine TRICYCLICS TRICYCLICS :: Amitriptyline, ImipramineAmitriptyline, Imipramine OTHERS :OTHERS : Pentoxifylline, TENS, AcupuncturePentoxifylline, TENS, Acupuncture

TREATMENT

AUTONOMIC DYSFUNCTIONAUTONOMIC DYSFUNCTION SEXUAL DYSFUNCTIONSEXUAL DYSFUNCTION GASTROPERESISGASTROPERESIS

TREATMENTTREATMENT

SEXUAL DYSFUNCTIONSEXUAL DYSFUNCTION

SEXUAL DYSFUCTION

NEUROLOGICASSESSMENT

VASCULARASSESSMENT

HORMONALASSESSMENT

PIHORMONAL NON HORMONAL

I/CAVERNOSALINJ

VACUUMPENILE

PROTHESIS

TREATMENT



DIABETIC FOOTDIABETIC FOOT

NEUROPATHYPERIPHERALAUTONOMICULCER

INFECTIONGANGRANE

W OUND DEBRID

ANTIBIOTICSAVOID WT BEARING

REVASCULAR SURGERYANTIPLATELET

PENTOXYFYLINEAMPUTATION

PVDDM

PREVENTION

OPTIMAL GLYCEMIAGOOD FOOT CARE FOOT EVALUATION

PODIATRIC VISIT

TREATMENT

DIABETIC FOOTDIABETIC FOOTScreening

Pemeriksaan kaki 6 -12 M

DM controlSpecific intensive care

Emphasize self care

Foot Ulcers and Amputations Foot Ulcers and Amputations & DM& DM

– >50% of lower limb amputations in the >50% of lower limb amputations in the USUS

– Foot ulcers occur in Foot ulcers occur in 15%15% of diabetes of diabetes patients over a lifetimepatients over a lifetime

– Cost of diabetes-related amputation: Cost of diabetes-related amputation: $27,000$27,000

National Diabetes Fact Sheet. National Diabetes Fact Sheet. November 1, 1997:1-8.November 1, 1997:1-8.Reiber GE et al. In: Reiber GE et al. In: Diabetes in America. Diabetes in America. 2nd ed. 1995:409-4282nd ed. 1995:409-428..


• Foot problem ( esp. infection )Foot problem ( esp. infection )• Major reason for hospitalizationMajor reason for hospitalization• Leading cause of nontraumatic foot Leading cause of nontraumatic foot

amputation.amputation.• Disorder of foot in Diabetic patient;Disorder of foot in Diabetic patient;• a) peripheral neuropathya) peripheral neuropathy• b) Ischemiab) Ischemia


• Common presentation:Common presentation:• a) Infectiona) Infection• b) Gangreneb) Gangrene• c) Skin ulcersc) Skin ulcers• d) Neuropathic joint disorder d) Neuropathic joint disorder

( Charcot fracture).( Charcot fracture).

PATHOPHYSIOLOGYPATHOPHYSIOLOGY• MULTIFACTORIAL:MULTIFACTORIAL:• a) Diabetic neuropathya) Diabetic neuropathy• b) Vascular diseaseb) Vascular disease• c) Susceptibility to infectionc) Susceptibility to infection• d) Traumad) Trauma• All these predispose the diabetic foot All these predispose the diabetic foot

to ulcerations.to ulcerations.

WHY ALL THE FUSS ABOUT WHY ALL THE FUSS ABOUT FOOT IN DIABETES FOOT IN DIABETES MELLITUS?MELLITUS?• Although the various system failures Although the various system failures

associated with DM are more life associated with DM are more life threatening, it is noted that diabetic threatening, it is noted that diabetic foot ulcer is more emotional and foot ulcer is more emotional and more disablingmore disabling

Risiko amputasi 15X lebih Risiko amputasi 15X lebih tinggi untuk pesakit tinggi untuk pesakit diabetes berbanding diabetes berbanding dengan orang lain.dengan orang lain.

EVALUATION OF ULCERSEVALUATION OF ULCERS

• Evidence of infection in adjacent Evidence of infection in adjacent soft tissue.soft tissue.

• Probe – involvement of deeper Probe – involvement of deeper structures, tendons, bone and joint.structures, tendons, bone and joint.

WAGNER CLASSIFICATIONWAGNER CLASSIFICATION

• Stage 0 - Pressure area on the foot aggravated Stage 0 - Pressure area on the foot aggravated by footwearby footwear

• Stage 1 - Superficial ulcer Stage 1 - Superficial ulcer • Stage 2 - Full-thickness ulcer.Stage 2 - Full-thickness ulcer.• Stage 3 - Full-thickness ulcer with abscess orStage 3 - Full-thickness ulcer with abscess or osteomyelitisosteomyelitis Stage 4 - Infected area with local gangrene Stage 4 - Infected area with local gangrene

( forefoot )( forefoot ) Stage 5 - Extensive gangrene, foot and legStage 5 - Extensive gangrene, foot and leg

RISK STATUS RISK STATUS CLASSIFICATIONCLASSIFICATION 1) Normal sensation with no deformity.1) Normal sensation with no deformity. 2) Normal sensation with deformity.2) Normal sensation with deformity. 3) Insensitivity without deformity.3) Insensitivity without deformity. 4) Ischemia without deformity.4) Ischemia without deformity. 5) Complicated:5) Complicated: combination insensitivity/ ischemia/ combination insensitivity/ ischemia/

deformity; Charcot joint, previous deformity; Charcot joint, previous ulceration, ulceration.ulceration, ulceration.

TREATMENTTREATMENT GRADE 0 – skin intact, bony GRADE 0 – skin intact, bony

deformity, foot at risk.deformity, foot at risk.

• Proper foot wear with padding.Proper foot wear with padding.• Patient education.Patient education.• Surgical correction of claw toes & Surgical correction of claw toes &

prominent PIP joint.prominent PIP joint.

TREATMENTTREATMENT GRADE 1 – superficial ulcers.GRADE 1 – superficial ulcers.

• Outpatient dressing changes.Outpatient dressing changes.• Total contact cast.Total contact cast.• Antibiotics.Antibiotics.

TREATMENTTREATMENT GRADE 2 – Deep ulcersGRADE 2 – Deep ulcers

• Hospitilazation.Hospitilazation.• Wound debridement/ aggressive.Wound debridement/ aggressive.• Wound care and IV antibiotics.Wound care and IV antibiotics.• Goal to correct to Grade 1 ulcer. Goal to correct to Grade 1 ulcer.

TREATMENT TREATMENT GRADE 3 – Abscess and osteomylitisGRADE 3 – Abscess and osteomylitis

• Emergency drainage.Emergency drainage.• Wound left open for daily dressing till Wound left open for daily dressing till

definite closure.definite closure.• IV antibioticIV antibiotic• If failed, amputation.If failed, amputation.

TREATMENTTREATMENT

GRADE 4 - Gangrene of toes/ GRADE 4 - Gangrene of toes/

forefootforefoot

AMPUTATIONAMPUTATION

TREATMENT TREATMENT GRADE 5 - whole foot gangreneGRADE 5 - whole foot gangrene

AMPUTATIONAMPUTATION

Foot ulcerFoot ulcer

Foot ulcerFoot ulcer

DIABETIC COMPLICATIONSDIABETIC COMPLICATIONS RETINOPATHYRETINOPATHY NEPHROPATHYNEPHROPATHY NEUROPATHYNEUROPATHY DIABETIC FOOTDIABETIC FOOT CARDIOVASCULAR DISEASECARDIOVASCULAR DISEASE

PENYAKIT MACROVASCULARPENYAKIT MACROVASCULAR• 80% KEMATIAN DIABETES ADALAH 80% KEMATIAN DIABETES ADALAH

BERKAITAN DENGAN PENYAKIT BERKAITAN DENGAN PENYAKIT CARDIOVASKULARCARDIOVASKULAR

• ANTARANYA-ANTARANYA-* CORONARY ARTERY DISEASE* CORONARY ARTERY DISEASE*CEREBROVASCULAR – STROKE*CEREBROVASCULAR – STROKE* PERIPHERAL VASCULAR DISEASE* PERIPHERAL VASCULAR DISEASE

PENGURUSAN KOMPLIKASI PENGURUSAN KOMPLIKASI MACROVASCULARMACROVASCULAR

SARINGAN CARDIOVASCULAR YEARLY / GEJALA

SEJARAH ANGINA , CLAUDICATIONSTROKE

CHECK BPCAROTID BRUIT

PERPHERAL PULSE

ECG , CXR, STRESS TESTECHO

KardiovaskularKardiovaskular• Untuk mengurangkan komplikasi Untuk mengurangkan komplikasi

makrovaskular ,selain hyperglisemia makrovaskular ,selain hyperglisemia semua faktor risiko harus dirawatsemua faktor risiko harus dirawat

• Merokok , dyslipidemia , kawal HPT, Merokok , dyslipidemia , kawal HPT, ubah gaya hidupubah gaya hidup

CV DISEASE & DIABETES

SILENTISCHAEMIA

AMI

ANGINA

CARDIOMYOPATHY

INSULINRESISTANCE

HT

VASCULARDYSFUNCTION

HYPERGLYCAEMIA

DYSLIPID-AEMIA

CLOTTING ABNSMOKING

OBESE

CV COMPLICATIONSCV COMPLICATIONS

• CORONARY ARTERY DISEASECORONARY ARTERY DISEASE -ASYMPTOMATIC -ASYMPTOMATIC SUDDEN DEATH SUDDEN DEATH

• PERIPHERAL ARTERY DISEASEPERIPHERAL ARTERY DISEASE• CEREBROVASCULAR DISEASECEREBROVASCULAR DISEASE

CHD mortality according to CHD mortality according to degree of glucose tolerancedegree of glucose tolerance

1.4

2.73.2

0

1

2

3

4

Normal glucosetolerance (n = 6055)

IGT (n = 690) Newly diagnosed + known diabetes

(n = 293)

Ann

ual C

HD

mor

talit

y pe

r 100

0 pe

rson

s

Adapted from Eschwege E et al. Horm Metab Res Suppl 1985; 15: 41–6.

CORONARY ARTERY CORONARY ARTERY DISEASEDISEASE

TREATMENTTREATMENT MEDICALMEDICAL INVASIVE/SURGICALINVASIVE/SURGICAL

PREVENTIONPREVENTION

MEDICAL TREATMENTMEDICAL TREATMENT

THROMBOLYTIC THERAPYTHROMBOLYTIC THERAPY ANTIPLATELETANTIPLATELET BETA BLOCKERBETA BLOCKER ACE INHIBITORACE INHIBITOR TIGHT GLYCAEMIC CONTROLTIGHT GLYCAEMIC CONTROL CORRECT CVS RISK FACTORSCORRECT CVS RISK FACTORS

INVASIVE/SURGICAL INVASIVE/SURGICAL PERCUTANEOUS CORONARY PERCUTANEOUS CORONARY

INTERVENTION ( PCI )INTERVENTION ( PCI ) ANGIOPLASTY +/- STENTINGANGIOPLASTY +/- STENTING SURGICAL BYPASS ( CABG )SURGICAL BYPASS ( CABG ) HIGH RATE OF RESTENOSIS IN ANGIOPLASTYHIGH RATE OF RESTENOSIS IN ANGIOPLASTY USE OF IIa/IIIb Platelet Inhibitor prevent restenosis USE OF IIa/IIIb Platelet Inhibitor prevent restenosis post stenting ( EPISTENT Study )post stenting ( EPISTENT Study )

• SEKIAN TERIMAKASIHSEKIAN TERIMAKASIH

ATAS PERHATIAN ANDA.ATAS PERHATIAN ANDA.

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Materi Diabetes Dan Komplikasinya