Transcript Diabetes mellitus salma ahi md ,endocrinologist

DIABETES MELLITUS
SALMA AHI MD ,ENDOCRINOLOGIST
JANUARY2015
DM1 OR 2
AGENDA
WHO SHOULD SCREEN
DIAGNOSTIC CRITERIA
DIABETES MANAGEMENT DRUG TREATMENT
DIABETES COMPLICATIONS
HLP
CAD
RETINOPATHY
NEPHROPATHY
NEUROPATHY
DIABETIC FOOT
CASE MANAGEMENT
DM1OR DM2
Obese or Thin
Old or Young
[LADA,MODY,YOUTHS,GDM,CF,HIV]
FH
Ketosis
[DKA OF DM1 , KETOSIS PRONE DM2]
SMBG results may help guide treatment decisions and/or
self-management for patients using less frequent insulin
injections or noninsulin therapies
When prescribing SMBG, ensure that patients receive ongoing
instruction and regular evaluation of SMBG technique, SMBG results,
and their ability to use SMBG data to adjust therapy
CORONARY HEART DISEASE
Recommendations
Screening
In asymptomatic patients, routine screening for coronary artery
disease(CAD) is not recommended
because it does not improve outcomes as long as CVD risk factors are
treated. A
RETINOPATHY
Recommendations
Optimize glycemic control to reduce the risk or slow the progression of
retinopathy. A
Optimize blood pressure control to reduce the risk or slow the
progression of retinopathy. A
Screening Adults with type 1 diabetes should have an initial dilated and
comprehensive eye examination by an ophthalmologist or optometrist
within 5 years after the onsetof diabetes. B
Patients with type 2 diabetes should have an initial dilated and
comprehensive eye examination by an ophthalmologist shortly after the
diagnosis of diabetes. B
NEPHROPATHY
Recommendations
Optimize glucose control to reduce the risk or slow the progression of diabetic
kidney disease. A
Optimize blood pressure control to reduce the risk or slow the progression of
diabetic kidney disease. A
At least once a year, assess urinary albumin [UACR]) and estimated glomerular
filtration rate (eGFR) in patients with type 1 diabetes duration of5 years and in all
patients with type 2 diabetes. B
HYPERTENSION/BLOOD PRESSURE CONTROL
Recommendations
Screening and Diagnosis
 Blood pressure should be measured at every routine visit.
 Patients found to have elevated blood pressure should have blood pressure
confirmed on a separate day. B
One study found that failure to detect pressure from this monofilament at
any of 12 places on the foot (figure) was
the single most practical measurement of risk assessment .
Nylon monofilament test
There is a risk of ulcer formation if the patient is unable to feel the monofilament when it is
pressed against the foot with just enough pressure to bend the filament.
The patient is asked to say "yes" each time he or she feels the filament.
Failure to feel the filament at four of 10 sites is 97 percent sensitive and 83 percent specific for
identifying loss of protective sensation.
"Loss Of Protective Sensation (LOPS)" = Lack21 of perception at 4 out of 10 test sites on foot
Diffuse neuropathies
Focal neropathies
DSPN
Large fiber
neropathy
Small fiber
neuropathy
Proximal
motor
neuropathy
Acute
mononeurop
athies
Entrapment
syndromes
0-+
0-±
+-++±
Sensory
loss
0-++++
0-±
(touch , vibration)
(thermal , allodynia)
pain
+-++±
+-++±
+-++±
+-++±
+-±
Tendon
reflex
N-↓↓↓
N-↓
N-↓↓
N
N
Motor
deficit
0-+++
0
+-++±
+-+++
+-++±
Different clinical presentations of diabetic neuropathies
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Large fiber neropathy
Small fiber neuropathy
Impaired vibration perception
Impaired position sense
Symptoms predominant
Associated with allodynia
Defective warmth sensation
Defective autonomic function:
Decreased sweating,dry skin,impaired vasomotion
and blood flow , a cold foot
Reduced sensitivity to 1.0-g Semmes Weistein
monofilament
Depressed tendon reflexes
Remarkable intactness of reflexes
Deep-seated gnawing,dull,toothache-like in the bones of the feet , or even
crushing or cramp-like pain
Superficial,burning pain
Sensory ataxia(wadeling gait)
Electrophysiologically silent
Wasting of small muscle of feet : hammer toes(intrinsic minus feet and hand)
with weakness of hands and feet
Shortening of Achilles tendon:
pes equinus
Foot ulceration and subsequent gangrene
Risk of charcot´s neuropathy
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DM
Neuropathy
Motor n.
Intrinsic muscle
wasting
Sensory n.
Decreased
pain and
position
sensation
Abnormal
Autonomic n.
Sympathetic
dysfunction
Anhydrosis
Denervation of vessels
machanics of
foot muscles
Structural changes in the
foot(hammer toe/claw Increased foot
circulation
toe appearance,
(Hyperthermia)
prominent metatarsal
heads)
Drying of the skin
Fissure formation
Distended pedal veins
Abnormal pressure on foot Increased bone resorption
Multiple minor painless Fx.
Pounding pulses
(A red and warm foot)
Recurrent
subluxation
Charcot joint
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Case 1:
• A 73-year-old woman, living alone, who was diagnosed
approximately 20 years ago with type T2DM. She has a history
of congestive heart failure, but she remains active and is
completely independent.
• She is not overweight and her blood pressure is within the
normal range.
• Her HbA1c has been running between 5.5-6
• She had several episodes of hypoglycemia every day
Her current diabetes medications
• Insulin NPH of 22 units in the morning and 16
units in the evening.
• Metformin 1g twice a day
• Glibenclamide 5 mg twice a day.
• Furosemide and Lisinopril for her heart failure.
• FBS:260
She had got dizzy and fallen one week ago, she had a snack, and then she was fine.
She had this problem a couple of times before that.
Her main problems?
•
•
•
•
Long-standing T2DM
A history of heart failure
Episodes of recurrent falls
Estimated glomerular filtration rate or "eGFR
is 45
Which of the following treatment goals do
you believe are most important for this
patient?
1- Current level of glycemic control and
occasional hypoglycemic events are
acceptable
2- Prevent further hypoglycemic events and
accept a higher HbA1c of ~9%
3- Reduce the HbA1c to <7% and accept some
hypoglycemic events
4- Prevent further hypoglycemic events and
reduce the HbA1c to ~8%
With respect to the patient's oral medications, what
course of action do you think would be appropriate at
this time?
1- Continue both the Metformin and
Sulfonylurea
2- Discontinue Metformin, continue the
Sulfonylurea
3- Discontinue the Sulfonylurea, continue
Metformin
4- Discontinue both the Metformin and
Sulfonylurea
Case 2:
• A 17 years old boy was diagnosed with type ? diabetes
approximately 8 months ago. He was very healthy and very active
before it. He currently uses Glibenclamide 30 mg to manage his
diabetes but, after several months, his blood glucose is steadily
increasing. He recently had to abuse her mother insulin to control
his hyperglycemia FBS:760 when experienced a ketoacidotic
episode. The patient and his mother are now visiting you one week
after his hospital visit.
• HbA1c has been higher at his last couple of visits, and currently it's
almost 13 per cent.
How concerned would you be about
the patient's level of glycemic control?
1- I would not be concerned at this point
2- This is not unusual, but I would still be
concerned
3- This is unusual, and I would be concerned
4- I would be very concerned
What of the following therapeutic
approaches would you most likely favor in
this patient?
1- Encourage him to continue with OHA
2- Switch to premixed insulin
3-Switch to basal insulin plus rapid acting insulin
4-Switch to NPH insulin plus Regular insulin
What would be a reasonable HbA1c target
for this patient over the next 3-6 months?
1- <8%
2- <7.5%
3- <7.0%
4- <6.5%