Transcript diabetes - QStation

Systemic Complications of
Diabetes Mellitus
Robert F. Nash D.O.
2006
Diabetes
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“The term diabetes was coined by Aretaeus (81–133 CE)
of Cappadocia. The Greek word diabaínein literally means
"passing through," or "siphon," a reference to one of
diabetes' major symptoms—excessive urine production.
The word became "diabetes" from the English adoption of
the medieval Latin diabetes. In 1675 Thomas Willis added
mellitus from the Latin word for honey (mel in the sense of
"honey sweet") when he noted that the blood and urine of a
diabetic has a sweet taste. This had been noticed long
before in ancient times by the Greeks, Chinese, Egyptians,
and Indians. In 1776 it was confirmed the sweet taste was
because of an excess of a kind of sugar in the urine and
blood of people with diabetes.”
Prevalence (2005)
Total population in US
 20.8 million people (7%)
 Diagnosed 14.6 million
 Undiagnosed 6.2 million
 Age 60 and over
 10.3 million people
 20.9%
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Cost
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Health Care Cost
Other costs
 Disability
 Work Loss
 Premature
Mortality
Total Cost
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$92 BILLION
$40 BILLION
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$132 BILLION
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Mrs. Adams
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Age 51
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New Patient
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Not under any
Physicians care
CC: Check-up
HPI: “ I am just not feeling
well.” Tired, polyuria,
polyphagia, polydypsea, some
weight loss, abdominal pain,
diarrhea, leg pain, sores on feet,
dyspepsia, occasional episodes
of chest pain, difficulty seeing,
ankle edema, and rash.
Diabetes Mellitus
Type I
 Type II
 Gestational
 Other causes
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Type I Diabetes Mellitus
“Juvenille Diabetes”- Misnomer
 Autoimmune process
 Requires Insulin secondary to beta-cell
destruction
 Look for other autoimmune conditions
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Gestational Diabetes Mellitus
Unknown etiology- May be secondary to
maternal hormones
 Resolves with delivery/termination of
pregnancy
 Watch for Hypoglycemia of neonate
 Insulin for management
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Type II Diabetes Mellitus
Decreased insulin sensitivity
 Initial hyperinsulinemia
 “Burn-out of Beta cells”
 Oral and /or Insulin therapy
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Other causes
Chronic pancreatitis
 Endocrine disorders
 Medication induced Diabetes Mellitus
 Genetic Syndromes
 Genetic Defects
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Diabetic Emergencies
Diabetic Ketoacidosis
 Non-ketotic hyperglycemic-hyperosmolar
Coma
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Systemic Complications of
Diabetes Mellitus
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Cardiovascular
Neurologic
Gastrointestinal
Eyes
Oral Cavity
Skin
Genitourinary
Renal
Pathogenesis
Increased glucose levels
 Insulin sensitive cells
 Muscle
 Cells not requiring insulin
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Cardiovascular
Heart disease and stroke incidence
 2-4 times higher than rest of population
 Accelerated atherosclerosis
 Increased cholesterol levels
 Hypertension 73%
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Myocardial infarction
Neurologic
60%-70% with mild to severe neurologic
disease
 Carpal Tunnel Syndrome
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Diabetic Neuropathy
 About 60-70% of people with
diabetes have mild to severe
forms of nervous system damage,
including:
 Impaired sensation or pain in the feet
or hands
 Slowed digestion of food in the
stomach
 Carpal tunnel syndrome
 Other nerve problems
 More than 60% of nontraumatic
lower-limb amputations in the
United States occur among people
with diabetes.
Diabetic neuropathy
Amputations
Major contributing cause of lower extremity
amputations
 82,000 yearly (2000-2001)
 Loss of sensation
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Gastrointestinal
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Polyphagia and Polydyspea
Autonomic Neuropathy
 Decreased peristalsis
 Gastroparesis
 Esophageal
 Diarrhea and Constipation
 Decreased exocrine pancreatic secretions
Lumbar and Thoracic Polyradiculopathy
Skin
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Common complication
Acanthosis Nigricans
Bullosis diabeticorum
Skin Tags
Diabetic dermopathy
Necrobiosis lipoidica diabeticorum
Granuloma annulare
Eyes
Blindness ages 20-74
 12,000 to 24,000 new cases of blindness
yearly
 Retinopathy-late first decade to early
second
 Macular Edema
 Cataracts
 Blurry vision
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Retinopathy
Cataract
Oral Cavity
Periodontal Disease- 1/3 of all diabetics
 Thrush
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Periodontal Disease
Thrush
Genitourinary
Polyuria
 Female Reproduction
 Poorly controlled diabetics
 Prior to conception to end of first 1/3
• 5-10% birth defects
• 15-20% abort
 2/3 to birth causes high birth weight
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Genitourinary
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Female Genitourinary
 Vaginal Candidisis
 Dyspareunia
 UTI’s
 Bladder dysfunction
Male Genitialia
Erectile dysfunction
 Decreased libido
 UTI’s
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Renal
44 % of all End Stage Renal Disease
 Glomerular lesions
 Arteriolosclerosis
 Pyelonephritis
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Five Stages
of Kidney Disease
Nephropathy
Stage 1: Hyperfiltration, or an
increase in glomerular filtration rate
(GFR) occurs. Kidneys increase in
size.
Stage 2: Glomeruli begin to show
damage and microalbuminurea
occurs.
Stage 3: Albumin excretion rate (AER)
exceeds 200 micrograms/minute, and
blood levels of creatinine and ureanitrogen rise. Blood pressure may
rise during this stage.
Five Stages of Kidney Disease
(con’t.)
Stage 4: GFR decreases to less than 75 ml/min, large
amounts of protein pass into the urine, and high blood
pressure almost always occurs. Levels of creatinine and
urea-nitrogen in the blood rise further.
Stage 5: Kidney failure, or end stage renal disease
(ESRD). GFR is less than 10 ml/min. The average length
of time to progress from Stage 1 to Stage 4 kidney
disease is 17 years for a person with type 1 diabetes.
The average length of time to progress to Stage 5, kidney
failure, is 23 years.
Treatment
Diabetes Type II
 Weight loss and dietary change
 Adjust medications to keep Fasting
Glucose between 90 and 130
 HGBa1c Below 7.0
 Pain management
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Treatment of Diabetic
Nephropathy
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Hypertension Control - Goal: lower blood pressure to <130/80
mmHg
 Antihypertensive agents
 Angiotensin-converting enzyme (ACE) inhibitors
• captopril, enalapril, lisinopril, benazepril,
fosinopril, ramipril, quinapril, perindopril,
trandolapril, moexipril
 Angiotensin receptor blocker (ARB) therapy
• candesartan cilexetil, irbesartan, losartan
potassium, telmisartan, valsartan, esprosartan
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Beta-blockers
Prevention of Diabetic Retinopathy
Associated Vision Loss
 Intensive
glycemic control
 Tight blood pressure control
(<130/80 mmHg)
 Comprehensive eye examinations
Treatment
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GI
Metoclopramide or erythromycin
 Loperamide or stool softners
Polyneuropathy
 Antidepressant
 Anticonvulsants
 Regular foot exams
Erectile Dysfunction
Dyspareunia
 Lubricants
 Estrogen Cream
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References
American Diabetes Association: Preventive Foot Care in Diabetes
(Position Statement). Diabetes Care 27 (Suppl.1): S63-S64, 2004
Feldman, EL: Classification of diabetic neuropathy. In UpToDate.
Wellesley, MA, UpToDate, 2003
National Diabetes Information Clearinghouse. Diabetic Neuropathies:
The Nerve Damage of Diabetes. Bethesda, MD: National Institute of
Diabetes and Digestive and Kidney Diseases, National Institutes of
Health (NIH), DHHS; 2002
National Diabetes Information Clearinghouse. Prevent Diabetes
Problems: Keep Your Feet and Skin Healthy. Bethesda, MD: National
Institute of Diabetes and Digestive and Kidney Diseases, National
Institutes of Health (NIH), DHHS; 2003
References, cont.
Feldman, EL: Pathogenesis and prevention of diabetic
polyneuropathy. In UpToDate. Wellesley, MA, UpToDate, 2003.
Feldman, EL, McCulloch, DK: Treatment of diabetic neuropathy. In
UpToDate. Wellesley, MA, UpToDate, 2003.
Stevens, MJ: Diabetic autonomic neuropathy. In UpToDate.
Wellesley, MA, UpToDate, 2003.
Feldman, EL: Clinical manifestations and diagnosis of diabetic
polyneuropathy. In UpToDate. Wellesley, MA, UpToDate, 2003.
References
American Diabetes Association: Nephropathy in Diabetes (Position
Statement). Diabetes Care 27 (Suppl.1): S79-S83, 2004
National Kidney and Urologic Diseases Information Clearinghouse.
Kidney Disease of Diabetes. Bethesda, MD: National Institute of
Diabetes and Digestive and Kidney Diseases, National Institutes of
Health (NIH), DHHS; 2003.
United States Renal Data System. USRDS 2003 Annual Data
Report. Bethesda, MD: National Institute of Diabetes and Digestive
and Kidney Diseases, National Institutes of Health (NIH), DHHS;
2003.
DeFronzo RA: Diabetic nephropathy: etiologic and therapeutic
considerations. Diabetes Reviews 3:510-547, 1995
National Kidney and Urologic Diseases Information Clearinghouse.
Kidney Failure: Choosing a Treatment That’s Right For You.
Bethesda, MD: National Institute of Diabetes and Digestive and
Kidney Diseases, National Institutes of Health (NIH), DHHS; 2003.
References
American Diabetes Association: Retinopathy in Diabetes (Position
Statement). Diabetes Care 27 (Suppl.1): S84-S87, 2004
Diabetic Retinopathy: What you should know. Bethesda, MD: National
Eye Institute, National Institutes of Health (NIH), DHHS; 2004.
Aiello LP, Gardner TW, King GL, Blankenship G, Cavallerano JD,
Ferris FL 3rd, Klein R: Diabetic Retinopathy. Diabetes Care 21 (1):
143-156,1998.
Mrs. Adams
Hypertension
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73%