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Complications of Diabetes

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May be diet controlled or use oral medications and/or insulin. Diabetes Statistics-2007 ... sedentary lifestyle, age 35 and plans to begin a vigorous exercise program ... – PowerPoint PPT presentation

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Title: Complications of Diabetes


1
Complications of Diabetes
  • 31st Annual NDAPA Primary Care Seminar
  • April 30, 2009

2
Diabetes Mellitus
  • Syndrome of abnormal carbohydrate metabolism
    characterized by hyperglycemia
  • Associated with relative or absolute impairment
    in insulin secretion
  • Related to varying degrees of peripheral
    resistance to the action of insulin

3
Type 1 Diabetes Characteristics
  • Destruction of the beta pancreatic cells
  • Absolute insulin deficiency

4
Type 1 Diabetes Etiologies
  • Usually due to autoimmune process
  • Multiple genetic predispositions
  • Environmental factors may play a role
  • Associated with HLA

5
Type 1 Diabetes
  • Generally develops at a younger age but can occur
    at any age
  • Accounts for 10 to 20 of diabetes
  • Requires insulin for survival

6
Type 1 Diabetes-- Idiopathic Form
  • No evidence of autoimmunity
  • Strongly inherited unlike more common autoimmune
    Type 1

7
Type 2 Diabetes Characteristics
  • Variable degrees of insulin deficiency and
    resistance
  • Autoimmune destruction of beta cells does not
    occur

8
Type 2 Diabetes Etiologies
  • Many different causes
  • Often associated with a strong genetic
    predisposition
  • Risk increases with age, obesity, lack of
    physical activity and BMI gt25kg/m2

9
Type 2 Diabetes
  • Generally develops at an older age
  • Marked increase in younger population as obesity
    rises
  • Accounts for 80 to 90 of diabetes
  • May be diet controlled or use oral medications
    and/or insulin

10
Diabetes Statistics-2007
  • Prevalence- 23.6 million or 7.8 of population
  • Age 20 and older -23.5 million or 10.5
  • Age 60 and older-12 million or 23.1
  • Men 12 million or 11.2 -20 and older
  • Women -11.5 million or 10.2 20 and older
  • CDC National Diabetes fact sheet, 2007

11
Diabetes Statistics Youth
  • 186,300 younger than age 20 or 0.2 of population
    Type 1 and Type 2 -2007
  • 2002-2003
  • 15,000 newly diagnosed Type 1
  • 3700 newly diagnosed Type 2
  • Rate of new cases 19 per 100,000 Type 1
  • Type 2- 5.3 per 100,000
  • CDC National Diabetes fact sheet, 2007

12
Diabetes Statistics Youth
  • Non-Hispanic white youth- highest rate of new
    cases of Type 1 DM
  • Type 2 extremely rare among youth lt10
  • CDC National Diabetes fact sheet, 2007

13
Diabetes Statistics Youth
  • Ages 10-19
  • Asian/Pacific Islander and American Indian youth
    -rate of new cases of type 2 greater than rate
    for type 1
  • Non Hispanic white - rate of new cases of type 1
    gt type 2
  • African American and Hispanic- rates of new cases
    of type 1 and type 2 DM similar
  • CDC National Diabetes fact sheet, 2007

14
Pre Diabetes Impaired fasting glucose
  • 1999-2000- 7.0 adolescents aged 12-19
  • 2003-2006 -25.9 aged 20 and older with 35.4 60
    and older
  • CDC National Diabetes fact sheet, 2007

15
Complications Heart Disease and Stroke
  • 2004-heart disease noted on death certificates
    with diabetes 68 age 65 and older
  • 2004-stroke noted on death certificates with
    diabetes 16 age 65 and older
  • Adults with diabetes have heart disease and
    stroke risk 2 to 4 times higher
  • CDC National Diabetes fact sheet, 2007

16
Complications
  • 2003-2004
  • 75 of adults with diabetes had high blood
    pressure
  • Retinopathy causes 12,000 to 24,000 new cases of
    blindness per year
  • 2005
  • Diabetes accounted for 44 of new cases of kidney
    failure
  • CDC National Diabetes fact sheet, 2007

17
Diabetes complications
  • 60 to 70 of people with diabetes have mild to
    severe forms of nervous system damage
  • Peripheral neuropathy of hands and feet
  • Gastroparesis
  • Carpal tunnel syndrome
  • Erectile dysfunction and other nerve problems
  • 30 of people with DM aged 40 and older have
    impaired sensation in the feet
  • CDC National Diabetes fact sheet, 2007

18
Diabetes Complications
  • More than 60 of nontraumatic lower-limb
    amputations occur in people with diabetes
  • 2004- 71,000 nontraumatic lower-limb amputations
    in people with DM
  • Periodontal disease -2 times the risk of those
    without DM
  • Poorly controlled DM (A1C gt9)- 3 times more
    likely to have severe periodontitis
  • CDC National Diabetes fact sheet, 2007

19
Diabetes-related risk factors
  • Macrovascular complications
  • Microvascular complications
  • Neuropathic complications

20
Diabetic Retinopathy
  • Most frequent cause of new cases of blindness
    among adults aged 20-74 years
  • Prevalence strongly related to the duration of
    diabetes
  • Screening very important

21
Diabetic Retinopathy Other risk factors
  • Presence of nephropathy
  • High blood pressure - associated with
    proliferative diabetic retinopathy
  • Pregnancy in Type 1 DM may aggravate retinopathy

22
Diabetic Retinopathy
  • Intensive diabetes management with goal of near
    normoglycemia delays or prevents the onset of
    diabetic retinopathy
  • Lowering blood pressure decreases risk
  • Need more frequent eye exams during pregnancy if
    had pre-existing diabetes-need close followup one
    year postpartum

23
Diabetic Retinopathy
  • Screening recommended yearly
  • Less frequent eye exams may be considered with
    advice of eye care professional if has had normal
    eye exams and control is good

24
Diabetic Retinopathy
  • Laser therapy can reduce risk of vision loss
  • Promptly refer patients with any level of macular
    edema, severe nonproliferative diabetic
    retinopathy and proliferative diabetic retinopathy

25
Neovascularization
26
Retinal Fibrosis
27
Cardiovascular disease
  • Major cause of mortality for individuals with
    diabetes
  • Major contributor to morbidity and direct and
    indirect costs of diabetes
  • Type 2 DM is independent risk factor of
    macrovascular disease

28
Cardiovascular disease other risk factors
  • Hypertension
  • Dyslipidemia
  • Kidney disease
  • Smoking
  • All of the above are more common in people with
    diabetes.

29
Cardiovascular System
  • Hypertension
  • Coronary artery disease-2.5 xs more frequent
  • CAD may be present at 25-30 yrs of age in Type 1
    DM
  • Cardiomyopathy

30
Cardiovascular System
  • Peripheral vascular disease -5-10 xs as common
  • MI 2-10xs more frequent
  • Cardiac autonomic neuropathy (CAN

31
Coronary Artery Disease
  • Type 2 diabetes associated with a two to four
    fold excess risk
  • Greater increase in women than men
  • Recommend aggressive treatment of dyslipidemia

32
Screening for CVD
  • Annually (or more often) assess CV risk factors
  • dyslipidemia
  • hypertension
  • smoking
  • positive family history of premature
    coronary disease
  • Presence of micro- or macroalbuminuria

33
Cardiac stress testing candidates
  • Diagnostic-Typical or atypical cardiac symptoms
    and abnormal resting electrocardiogram
  • Screening -Those with history of peripheral or
    carotid occlusive disease
  • sedentary lifestyle, age gt35 and plans to begin a
    vigorous exercise program
  • 2 or more of the CV risk factors

34
Recommendation
  • Patients gt55 years of age with CV risk factor ACE
    should be considered
  • Asymptomatic patients-consider a risk factor
    evaluation to stratify patients
  • Treat risk factors aggressively
  • Consider screening as outlined in previous slide

35
Cardiovascular disease Decreasing Risk
  • Treat blood pressure aggressively - goal blood
    pressure is lt130/80.
  • Blood pressure should be checked on every visit
  • Lifestyle changes - diet (low sodium, increase
    fresh fruits and vegetables)
  • Exercise
  • Lipid control

36
CV risk factors
  • SMOKING CESSATION

37
Standards of Care
  • Lipids
  • LDL lt 100 mg/dl
  • Triglycerides lt150 mg/dl
  • HDL gt 40 mg/dl

38
Standards of Care
  • In people with diabetes over the age of 40 with a
    total cholesterol gt 135 mg/dl, statin therapy to
    achieve an LDL reduction of approximately 30
    regardless of baseline LDL level may be
    appropriate

39
Antiplatelet therapy
  • Anti-platelet agents
  • Use ASA therapy as secondary prevention in all
    with history of CAD, PVD or CAD
  • Use ASA therapy as primary prevention in those
    with increased CV risk, including those over 40
    years of age or have additional risk factors

40
Antiplatelet therapy
  • Many trials have shown a 30 decrease in
    myocardial infarction and a 20 decrease in
    stroke in patients with diabetes.

41
Cerebrovascular Disease
  • Two to four times risk
  • Greater risk in women than men
  • Mortality from CVA is 3 times higher in patients
    with diabetes than those without
  • Estimated nearly 13 of patients over age 65 with
    diabetes have had a cerebrovascular event.

42
Peripheral Vascular Disease
  • Claudication
  • Combined with neuropathy it can lead to serious
    infections and amputations

43
Diabetic Foot Ulcer
44
Genitourinary System
  • Nephropathy
  • Chronic renal failure
  • Diabetic patients have 10-fold greater risk for
    renal deterioration during hypovolemic episodes
    than nondiabetics.

45
Diabetic Nephropathy
  • Diabetes is the most common cause of end-stage
    renal disease
  • In the United States, accounts for gt40 of cases
    of end stage renal disease
  • 20-30 of Type 1 develop kidney disease
  • Smaller fraction of Type 2

46
Screening
  • Annual microalbuminuria test - random urine for
    microalbumin/creatinine ratio
  • result should be lt30

47
Reducing Nephropathy Risk
  • Optimize glucose control
  • Optimize blood pressure control

48
Treatment
  • ACE (angiotensin converting enzyme) inhibitors or
    ARB (angiotensin receptor blockers) in patients
    with albuminuria
  • Use as first line in treatment of hypertension
  • Some recommending treatment of all people with
    diabetes with ACE inhibitor

49
Gastrointestinal System
  • Gastroparesis-May ? risk of aspiration pneumonia
  • Nocturnal diarrhea

50
Autonomic Neuropathy
  • Loss of beat-beat variability of heart rate
  • Prolonged QT interval on ECG
  • Orthostatic hypotension
  • Tachycardia

51
Neuropathy
  • Frequency parallels duration and severity of
    hyperglycemia in both Type 1 and Type 2 diabetes
  • Several syndromes
  • Polyneuropathy
  • Autonomic neuropathy

52
Autonomic Neuropathy
  • Early satiety
  • Anhidrosis
  • Impotence
  • Peripheral neuropathy
  • Nighttime diarrhea

53
Autonomic Neuropathy
  • Presence of autonomic neuropathy increases risk
    of perioperative cardiovascular instability.
  • Life-threatening bradycardia and hypotension may
    occur

54
Miscellaneous
  • Infections
  • Venous thrombosis

55
Standards of Care
  • Glycemic control- A1C lt 7.0
  • More stringent control -A1C lt 6.0- may be
    considered in individual patients
  • Preprandial plasma glucose 90-130 mg/dl
  • Postprandial plasma glucose lt180 mg/dl
  • Blood Pressure - lt130/80

56
  • DCCT data showed continuous relationship between
    the risk of complications and mean HbA1c

57
Acute Complications
  • Hypoglycemia
  • Diabetic Ketoacidosis
  • Hyperosmolar coma

58
Hypoglycemia in children
  • Risk of severe hypoglycemia appears to be higher
    in children and adolescents than in adults with
    prevalence rates of up to 85.7 episodes per 100
    patients
  • It is true for asymptomatic nocturnal
    hypoglycemia, prevalence rates of 45-55
  • Hypoglycemic episodes in children are profound
    and prolonged
  • Diabetes Care, volume 31, supplement 2, 2/2008

59
Hypoglycemia in children
  • Heightened risk is at partly attributable to
    inability of children to recognize autonomic
    symptoms or (at younger ages) relay the symptoms
    to caregivers
  • It is worsened by the tendency of children and
    adolescents for unpredicted eating and exercise
  • Diabetes Care, volume 31, supplement 2, 2/2008

60
Hypoglycemia in children
  • Repeated severe hypoglycemia starting before age
    5 years may be harmful to long-term memory
    functioning
  • Brain of very young children may be more
    vulnerable than the brain of older children to
    negative effects of severe hypoglycemia on
    long-term spatial memory
  • Diabetes Care, Volume 28, Number 10, October 2005

61
Hypoglycemia in children
  • Current recommendation is to avoid recurrent or
    severe hypoglycemia in children less than 5 even
    if it means running their HgbA1C slightly higher.
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