Dr. SYED SULAIMAN;M.D. (GEN.MED) PHYSICIAN & DIABETOLOGIST

FPG<100 mg% PPPG< 140mg % HbA1C<7% TOTAL CHOLESTEROL< 200mg % LDL CHOLESTEROL< 100mg% TRIGLYCERIDE<150mg% B.P<130/85mm of Hg

100FPG,LDL 150PPPG,TG 200T.C 7HbA1C 130/85B.P

Justify yourself!

Give me reason to negate!

 Management of the disease  Management of the co morbid conditions

 Depression  Erectile Dysfunction  Skin diseases  Endocrine disorders

 At least five symptoms present nearly every day for 2 weeks, including:  Depressed mood  Diminished interest in daily activities  Significant weight loss/gain or decreased appetite  Insomnia or hypersomnia  Psychomotor agitation or retardation  Fatigue or loss of energy  Feelings of worthlessness/guilt  Diminished ability to concentrate/make decisions  Recurrent thoughts of death or suicide

 Feeling sad/depressed mood  Inability to sleep  Early waking  Lack of interest/enjoyment  Tiredness/lack of energy  Loss of appetite  Feelings of guilt/worthlessness  Recurrent thoughts about death/suicide

Depression and Diabetes share many common threads:  Chronic history  Multifactorial pathogenesis  Poorly understood etiology  Multifaceted clinical picture  Frequent exacerbations  Need for patients active participation in management  Ability to be controlled but difficulty in getting cured

 Poor adherence to treatment  Poor glycemic control  Frequent complications  Sexual dysfunction  Poor Quality of life  Less interest in exercise  Lack of physical fitness

 Life time prevalence of major depression in diabetes is 28.5%  DEPRESSION IS TWICE COMMON IN DIABETICS  More frequent in women (28%) than in men(18%)  More in uncontrolled group(30%)than in controlled group(21%)  More in clinical(32%) than in community samples(20%)

36% Depression Female > Male 18% Normal population Female > Male

MYTH  Depression is obvious and easily recognized and expressed by the patient REALITY  Depression disorders are overlapping, hardly expressed by the patient and constitute a major problem in symptom exaggeration

 While depression is significantly more common in people with diabetes compared to those without diabetes, it can be treated effectively.  Depression increases the risk of developing diabetes, Impacts on blood glucose control, and increases the risk of developing diabetes complications.  It is associated with increased body weight or obesity, and poorer diabetes self- management.  It is important to recognize that although diabetes and depression are separate conditions they often co-exist and any treatment offered must reflect this in order to maximize the benefits to the person with diabetes.

“The consistent inability to achieve or sustain an erection of sufficient rigidity to permit sexual intercourse “

 Many men with diabetes also have erectile dysfunction :  ED can be an early sign of diabetes.  A diabetic man is two to five times more likely to develop ED than a man who is not a diabetic.  Men with diabetes tend to develop ED years earlier than men  without diabetes.  More than 50% of men develop diabetic ED within 10 years of gettingdiabetes.¹  50%-60% percent of diabetic men over age 50 have some problem with ED.¹  50%-75% of men with diabetes will experience some degree of ED during their lives.  9% of men with diabetes age experience ED. 95% of men with diabetes experience ED by age 70.¹

Genetics: A family disposition for the disease Diet: High in fat and processed foods Lack of exercise: Getting off the couch

 Neurogenic: Penile autonomic neuropathy  Vasculogenic: Diabetic microangiopathy  Endocrinologic:

 Lesions of medial preoptic nucleus, paraventicular nucleus, hippocampus  Spinal trauma  Myelodisplasia (spina bifida)  Pelvic surgery/radiotherapy  Multiple sclerosis  Intervertebral disc lesion  Peripheral neuropathies  Alcohol  Diabetes  HIV

 Hypertension  Smoking  Diabetes  Hyperlipidaemia  Peripheral vascular disease  Blunt perineal or pelvic trauma  Pelvic irradiation

 Hypogonadism  Low testosterone  Raised SHBG  Raised Prolactin  Thyroid disease

 Antihypertensives  Thiazides  B blockers  Centrally acting drugs  Antidepressants  Tricyclics  MAO inhibitors  SSRI  Anticholinergics  Atropine  Antipsychotics  Phenothiazines  Anxiolytics  Benzodiazepines  Psychotropic drugs  Alcohol  Opiates  Amphetamines  Cocaine

 Generalised atherosclerosis  Penile arteries smaller than coronary arteries  ED pre-dates coronary artery disease  Man with ED and no cardiac symptoms is a cardiac patient until proven otherwise

 Sexual  Medical  Psychosocial history

Cutaneous Infections: 1.Candidiasis 2.Dermatophytosis 3.Phycomycosis 4.Erythrasma 5.Malignant external otitis Nuerologic lesions: 1.Charcot Joint 2.Compensatory hyperhydrosis 3.Neuropathic ulcer Disorders of Collagen: 1.Necrobiosis lipoidica 2.Granuloma annulare 3.Scleroderma diabeticorum 4.Waxy skin 5.Sclerodermalike change of the hand Metabolic diseases: 1.Porphyria cutanea tarda 2.Yellow skin 3.Xanthomatosis 4.Hemochromatosis 5.Glucagonoma syndrome 6.Generalized Pruritus Skin conditions with strong but unexplained association with Diabetes: 1.Acquired icthyosis 2.Diabetic dermopathy 3.Diabetic bullae 4.Rubeosis 5.Vitiligo 6.Acanthosis nigricans 7.Finger ” pebbles” 8.Perforating disorders Cutaneous reactions to diabetes therapy: Insulin induced disorders 1.Insulin allergy 2.Insulin Lypodystrophy 3.Insulin - induced lipohypertrophy Hypoglycemic agents 1.Hypersensitivityreactions 2.Disulfiram reactions

TAENIA PEDIS ONYCHOMYCOSIS

NEUROPATHIC ULCER CHARCOT FOOT

GRANULOMA ANNULARE NECROBIOSIS LIPOIDICA SCLERODERMA DIABETICORUM

ACANTHOSIS NIGRICANS BULLAE DIABETIC DERMOPATHY

xanthomatosisHaemochromatosis Porphyria cutaneatarda

LIPODYSTROPHY LIPOHYPERTROPHY

Type 1 DM,Hypothyroidism & Graves disease– autoimmune association Girls > Boys  Subclinical hypothyroidism (SCH):  TSH, normal FT4 & FT3.  Frequently seen in adults with Type 1 & Type 2 DM

The good physician treats the disease; the great physician treats the patient who has the disease. William Osler