1. DIABETES MILLITUS AND COMPLICATION
พ.ญ. วิภาจรี เสน่ห์ลักษณา

2. Classification of DM
Diagnosis
Risk factors
Complication
Management

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

4. 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

5. 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)

6. Risk factors

7. 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

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

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

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

11. 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

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

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

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

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

22. Type 1 DM
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

23. 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

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

25. Polyneuropathy
Polyradiculopathy
Mononeuropathy
Autonomic neuropathy

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

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

28. MONONEUROPATHY
Cranial and peripheral nerve
Cranial nerve diplopia

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

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

36. MACROVASCULAR COMPLICATIONS
Cardiovascular disease
Cerebrovascular disease
Peripheral artery disease

37. DM marked increase in CHF , CHD , MI ,
sudden death , PAD
CHD risk equivalent
Additional risk factors DLP , HT , obesity
smoking ,reduced physical
activity

38. insulin resistance
activated PAI -1 and fibrinogen
coagulation process and impairs fibrinolysis
thrombosis

48. 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

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

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

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

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

71. THANK YOU