DIABETES MILLITUS AND COMPLICATION พ.ญ. วิภาจรี เสน่ห์ลักษณา

Classification of DM Diagnosis Risk factors Complication Management

DIABETES MILLITUS Common metabolic disorder Hyperglycemia Pathophysiologic changes in multiple organ system

Classification of DM 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

Diagnosis 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)

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

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

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

MECHANISMS OF COMPLICATION Unknown Chronic hyperglycemia = etiologic factor Hypothesis hyperglycemia activate substance atherosclerosis endothelial dysfunction glomerular dysfunction

GLYCEMIC CONTROL AND COMPLICATIONS 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

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

retinal ischemia appearance of neovascularization rupture easily vitreous hemorrhage , fibrosis and retinal detachment

TREATMENT Prevention most effective therapy Intensive glycemic and BP control Eye examination by ophthalmologist Laser photocoagulation

RENAL COMPLICATION Albuminuria associated risk of CVD Commonly have diabetic retinopathy Smoking accelerates the decline in renal function Chronic hyperglycemia alter renal microcirculation

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

TREATMENT 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

NEUROPATHY 50 percent of patient with long standing DM Correlate with glycemic control Additional risk factors are BMI ,smoking ,HT hypertriglyceride

Polyneuropathy Polyradiculopathy Mononeuropathy Autonomic neuropathy

POLYNEUROPATHY Most common is distal symmetric polyneuropathy Numbness , tingling , sharpness or burning Lower extremities Worsen at night Progression ; the pain subsides sensory deficit

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

MONONEUROPATHY Cranial and peripheral nerve Cranial nerve 3 diplopia

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

TREATMENT Glycemic control improve autonomic neuropathy Avoidance alcohol and smoking Vitamin B 12 and folate supplement Symptomatic treatment Antidepressants , anticonvulsants Foot wear

MACROVASCULAR COMPLICATIONS Cardiovascular disease Cerebrovascular disease Peripheral artery disease

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

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

LOWER EXTREMITIES COMPLICATION DM the leading cause of non traumatic lower extremity amputation Pathologic factors ; neuropathy abnormal foot biomechanics PAD poor wound healing

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

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

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

THANK YOU