HELLENIC DIABETES ASSOCIATION

2013


HELLENIC DIABETES ASSOCIATION

2013


2009-2010

:

:

. :

:

:

.
.
.
.
.
.
.
.
.

2010-2011

:

:

. :

:

:

.
.
.
.
.
.
.
.
.

2012-2013

:

:

. :

:

:

.
.
.
.
.
.
.
.
.

 iv

2011

() .


.

.
2009 , ,
.
,
, .
:
, , ,
, .
2011
. .

.

, .

2010-2011

2009-2010

 vi

2013

, , .

.
. . ,

,
.
, , ,
.

2012-2013

vii

 viii



, 2011 ().
.
, ,
(Evidence Based Medicine).

, ,


.

, .
, .

.
.


2013.
,
,
.
.

ADA (American Diabetes Association). ADA
A, B, C E
1.
ix

 1. ADA

, , , ,

- ,
.

(cohort studies),
(case-control studies)
O

,
(case reports)
,

(consensus)



consensus

2. SIGN

IIa

Ib

,
,

IV


SIGN (Scottish Intercollegiate Guidelines Network). SIGN
6
A, B C, ,
, 2.
,
(-SPC - Summary of
Product Characteristics). ,
,
,
SPC .
,
SPC ,
.

.
SPC . SPC ,
:
http://www.ema.europa.eu/ema/index.

28/02/2013

xi

 M
AGEs

Advanced Glycosylation Endproducts

Ankle-Brachial Index

ADA

American Diabetes Assosiation

Body Mass Index

CGM

Continuous Glucose Monitoring

dl

Deciliter
(100 )

DPP-4

Dipeptyl-peptidase-4
--4

DSA

Digital Substractive Angiography

Gram

GFR

Glomerular Filtration Rate

GLP-1

Glucagon Like Peptide-1

-1

HbA1c

Glycosylated Haemoglobin A1c

A1c

IDF

International Diabetes Federation

IFG

Impaired Fasting Glucose

IGT

Impaired Glucose Tolerance

IRMA

Intra Retinal Microvascular Abnormalities

xii

IU

International Units

Kcal

Kilocalorie
()

kg

Kilogram

Liter

Meter

mEq/L

Milliequivalent per Liter

/

mg

Milligram

mg/dl

Milligram per Deciliter

/

min

Minute

ml

Milliliter

mmHg

Millimeter Mercury

mmol/L

Millimole per Liter

MODY

Maturity Onset Diabetes in the Young

msm

Milliosmole

MUFA

Monounsaturated Fatty Acids

NGSP

National Glycohemoglobin Standardization Program

NGT

Normal Glucose Tolerance

xiii

OGTT

Oral Glucose Tolerance Test

PUFA

Polyunsaturated Fatty Acids

RCT

Randomized Controlled Trial

SAFA

Saturated Fatty Acids

SBGM

Self Blood Glucose Monitoring

SPC

Summary of Product Characterstics

STEMI

ST Elevated Myocardial Infarction

ST

SU

Sulfonylurea

TcpO2

Transcutaneous Pressure of Oxygen

TIA

Transient Ischemic Attack

TZD

Thiazolidinediones (Glitazones)
()

TG

Triglycerides

TSPI

Toe Systolic Pressure Index

VEGF

Vascular Endothelial Growth Factor

xiv

xv

xvi


1. , .................... 1
2. 2 ............................................................ 7
3. .
...................................................... 9
4. . ................................................................................................. 13
5. ............................................................................................... 21
6. 2 ....... 25
7.
1 . ............................................................................................................................................. 33
8.
2 . ............................................................................................................................................. 35
9.
.............................................................................................................. 41
10. . ........... 47
11.

. .................................................................................

51

12. . ............................................................................................. 57
13. ................................................................................... 63
14. ............. 65
15. . ................................................... 69
16. . .......................................................................................................................... 73
17. . .............................................................................................. 77
18. ................................................................... 79
19. .......................................................................... 83
20. ................................... 89

xvii

21. . .......................................... 93
22. ............................................................................................................................ 97
23. ................................................................................................................................................ 105
24. Charcot ........................................................... 109
25. ............................................................................................... 111
26. ............................................ 117
27. ..................................... 121

xviii

1. ,

()
, , .
. , , , ,
( )

.

1997
:

1 (1):
-, . 0.6 - 2.6 ,
15 , 9.7 - 49.0/100000 / .
9.7/100000/
2 (2): - .


.
5-10%.
35 8%
(): O
>92 mg/dl, 2 ( >126
1

mg/dl), OGTT 24-28

. 18%

: ,

- ,
, , , ..

MODY (Maturity Onset Diabetes of the Young)
,
, 2
(.. , )
. , ,
25 , .
MODY .
1-2% .
MODY -
, ,
. ,
11
MODY. 2 3.
MODY :
25
,
/

2, ,

1
,
,
.

1.1.
2

 1.1.
1. 200 mg/dl
,
.
.

2. 126 mg/dl
8 .

3.
2 75 g 200 mg/dl.
.

,
,

(Oral Glucose Toler
ance Test - OGTT)
, , ,
, (>140 mg/dl).

, ,

,
150 .
.
, . 75 g ( 1.75 g/kg ,
75 g), 250-350 ml ,
3-5 . 2 . , () .
.
60 ,
.
, (
..)

C-
3

,

.
(Normal
Glucose Tolerance - NGT) , ,
, ,

(Impaired Fasting Glucose
- IFG), 1.2
OGTT,
(Impaired
Glucose Tolerance - IGT), 1.2
(IFG IGT) ,

.

1.2.
1. :
/

2 OGTT
2.
(IFG):



2 OGTT

OGTT*
3.
(IGT):



2 OGTT

126 mg/dl
200 mg/dl
100-125 mg/dl
< 140 mg/dl

< 126 mg/dl

140 <200 mg/dl

* OGTT IFG IGT.

(HbA1c) ,

DCCT (National Glycohemoglobin
Standardization Program - NGSP),
NGSP
HbA1c 6.5%

HbA1c 5.7 - 6.4%


B
HbA1c

HbA1c, , ,
,
.
,
HbA1c ( - ), .

(screening),
, ,
2

(International Diabetes Federation-IDF), 1.3

1.3.
45
102 cm () 88 cm ()
30 kg/m2
, ,


>4 kg

,


1.4 OGTT IGT .

1.4. OGTT
,
(>140 mg/dl)
(IFG)

2.
2

2 . ,

: (
) ,
2.
, 2 ( IFG IGT)
IDF,

,
, IGT


. 2.1.

5%,

30 -

<30%

( trans
) <10%

( 25-35 g )
7

IGT , >35
<65 . (SPC)

.
2.1. 2

OGTT

< 100 mg/dl

> 125 mg/dl

100-125 mg/dl

IFG

IGT

3.
.

:
H , ,
H ,
, , , ,
()


, HbA1c, , . HbA1c
, HbA1c,
7%,
( )
HbA1c
, , HbA1c.
IFG, IGT HbA1c ,
HbA1c 6.5-8.5%

, ,
(Advanced Glucosylation Endproducts-AGEs),
( stress),

HbA1c
7% .
(Randomized Control Trials-RCT) 10 , 1 2. HbA1c 7%
HbA1c 7.0%


1 2
10 :

,
10 , 10

10 , 10 , ,

,
,

.

(RCT)
HbA1c 6.5%

HbA1c
7.0%.

HbA1c 6.5%

.
,

HbA1c 6.5%
10


.
( 60 ) (
)

(
),
, (HbA1c < 6.5%),
:

, -

, ,

,
, ,
(, ..). ,

6.5% HbA1c, 7.0%, 7.0 - 7.5%.

HbA1c 7.0%, ,
, .

HbA1c 7.0%

HbA1c 7.0% ( ),
130 mg/dl (2 ) 180 mg/dl
HbA1c (7.0%)

HbA1c ,

.

11

,
,

,
, HbA1c <6.5%,


HbA1c
,
,




, , ..,
HbA1c 7.0 - 7.5%
C
,
,
,
.
,
,
HbA1c
, 
C

12

4.

. ,
, ,
.

2
*
2 

,
5%
<30%
( trans ) <10%
( 25-35 g ).

:
, ,
,
, .

( [] >25
kg/m2), 500-1000 kcal/ ( 4.1) 25 kg/m2

* SIGN. A, B C
A, B, C E ADA. 2

13

 4.1.

(Kcal/)

< 30

(15.4 ) (0.27 ) + (717)

30-60

(11.3 ) + (0.16 ) + (901)

60

(8.8 ) + (11.28 ) (1071)

< 30

(13.3 ) + (3.34 ) + (35)

30-60

(8.7 ) (0.25 ) + (865)

60

(9.2 ) + (6.37 ) (302)

= , =
(Kcal/).

, 1.3, 1.5 1.7, ,
, .

()
5 - 10%. , 



C



,

C

(18.5 - 25 kg/m2), ,
24
C

45% 60%

C
14

, ,
1 2. ,


, ,


C




40 g/ ( 20 g/1000 kcal/
), . 30 g/,


, 3 4 ,

C



, 50 g/,
, 1
2,


10%

C

(),
15

(
) 0 120
50 g ,
50 g . ,
, ,
,
.

,
10-20% 

1 , (0.8
g/kg /)

1 (),
2 ,


C


C

35% 
C
trans-
10% . (<8% ) ,
LDL- 

(MUFA), ,
10% 20% 

(PUFA) 10%

C
, 30% 
C
16

( ) 

300 mg/
LDL- 

, ,

(, , C,
, , ), ,

C
6 g/
.


( 10 g/
20 g/ )


, ,



,  C


C

, , , 17

, , ,
, . (Stevia)
.
,
, , , ,
.
().
, ,
.
.

, , ,
,
, ,
, 1950-60,


, ,
, , , ,
, ,
, ( ) .
,

. ,
,
.
18

(Lyon Heart Study)

, -

(PREDIMED),
50% , ( extra virgin oil) ,
(, ).
.
,

.

19

 20

5.
2

2,
IGT
( 5.1), 30 ( ), 5 .

5.1.

50-70%
10
*

>70%

* : = 220
. = 205 (0.5 )

, ,
.

( 5.1), 150
. 75-90
. 3
21

, 2


HbA1c

(, )
( 5.2) ,
.
( )
2-3 .
8-10 8-10
.
2-3 ,
3-5 . ,
10-15 
5.2. (, )


-
-

2-3


-
.

8-10

1,
( )

(> 250 mg/dl)
,
,
22

,
()
.

,
,

,
,
.

<100 mg/dl .

,
,
, , (
), (
)

:

> 40


> 30 :
1 >15

23

 2 >10

.
.

, ,
, .

24

6.
2

2.
.
,


,
:

(SU), -

, GLP-1 (Glucagon Like peptide-1) DPP-4 (--4)

, -

, :







, -

25

,
,
,
,
,
2
,
10 - 15 ,
, ,
.
, , , , , , , , , ( 6.1- 6.2)


(-), .
HbA1c

,
,
.
, , , ,
,
6.1. HbA1c

, 6.2.


, ,
, , 6.1.
HbA1c

,
,
26

,
, :


, , -

DPP-4 GLP-1 -

HbA1c >8.5%,
, , ,
,
, (.. HbA1c >9%),

, .
,

.
10-15 , , 4

,



HbA1c 2-3

HbA1c
, NGSP, , HbA1c

27

 6.1. 2.

HbA1c 8,5%

&
+

HbA1c
2-3

HbA1c > 8,5%

( )

HbA1c > 9%
( )

&
+

+
2

&
+

( )

HbA1c
2-3

HbA1c < 8,5%

6.2

HbA1c > 8,5%

&
+
+ 2


+
3

HbA1c
2-3

&
+

( )
+

8.1

28

 6.2.
2.

SU

TZD

DPP-4

GLP-1

, ,

SU

TZD

DPP-4

GLP-1

SU
TZD

SU
TZD

TZD
DPP-4
GLP-1

SU
DPP-4
GLP-1

29

+
TZD
DPP-4
GLP-1

 6.1. , , ,

HbA1c %

&

&

1.0-2.0

1.0-2.0

. (GFR <30 ml/

min)

0.5-0.8

(GFR <25 ml/min)

1.0-2.0

1.
2. MR
3.

.
( > >
MR). (GFR <30 ml/min)

( >
)


(GFR <15 ml/min)

. . .
. .
. :
,
(GFR <5 ml/min),

0.5-1.5

1.
2.

0.5-1.4

DPP-4
1.
2.
3.

0.5-0.8

GFR <50
ml/min
, ,

25 mg GFR <30 ml/min

GLP-1

0.5-1.0

. .
.
:
GFR <30 ml/min (
GFR 50-30 ml/min 5 g).
GFR <60 ml/min

1.
2.

30

 31

0.6 - 1.8 mg

0.6/1.2/ 1.8 mg

10 - 20 g

2.

1.

5 / 10 g

GLP-1

45 - 60 min
2

6 .

100
50
5

1.
2.
3.
100
100
5

DPP-4

15 - 45

15/30/45

1 - 16
120 - 540

0.5 /1/2
60/120/180

1.
2.

12 24

2.5 - 20
30 - 120
1-6

5
30
1/2/3/4

150-300

500-3000

mg/

1.
2. MR
3.

50/100

850/1000

mg/

,
DPP-4,
GLP-1,

DPP-4
GLP-1,

,
DPP-4,

,
,
DPP-4
GLP-1, ,

6.2. ,

.


,

 32

7.

1

.
, ,
.
, 24, , ( )
.
,
,
(basal)
( ), ,
,
, .
,
(bolus)
( ).



( ), ,
,

2-3
80-120 mg/dl.
33

,
:
:
,


:
A
.
:

A

.


80-130 mg/dl 140160 mg/dl
1, , ..
,

,

24 .
.

34

8.

2

,
6, .

2:

: ,
, 8.1.

( , )
( , ).

: 10 (International Units, IU)
.
: 80-120 mg/dl.
:
. ( < 70 mg/dl).

:
180 mg/dl
4
120 - 180 mg/dl
2
80 - 120 mg/dl

< 80 mg/dl


2 - 4

.
35

 2

, , .
, , 1, 2 3, 8.1.

1:
()
. HbA1c >7.0%,
(
) 3
2:
( )

. (
HbA1c >7.0%) 2 3

3:
,
( ) ,
, , .

1, 2 3
1
: , ,
.
: 80120 mg/dl.
:
.
:

36

 8.1. 2.

&
+

( )
+



HbA1c
2-3

()
-
+

( )

HbA1c
2-3

+


+

( )

+

3
+

HbA1c
2-3

()
-
+

()

+

2
+

HbA1c
2-3


HbA1c
2-3

37

 >120 mg/dl:
80 - 120 mg/dl:
< 80 mg/dl:

2 - 4

2 - 4

.
,
.
:
-

( ).

2-3 ,
.
2 3
,
( ).
1-3 ( )
( ) , .

. ,
.

,
38

 + ,
, ,

8.1.
8.1.

+ 1-2

+ 3

( , ),


, 8.2.
,
, .

39

 8.2. ( )*

()

Humulin Regular

30-45 min 1-3

Actrapid

30 min

5-7
6-8

(Lispro), Humalog

0-15 min

3-4

(Aspart) Novorapid

10 min

1-3

3-5

(Glulisine) Apidra

1-3

10-20 min -1 3-4

()
Humulin NPH

Protaphane

2-8 16-18

1.5 4-12 24

(Glargine) Lantus

1-4

24

(Detemir) Levemir

1-4

24

30/70 (30% -70% ), Mixtard 30

30 min

2-8 24

30/70 (30% -70% ), Humulin M3 30-45 min 1-8 14-15

40/60 (40% -60% ), Mixtard 40

30 min

2-8 24

50/50 (50% -50% ), Mixtard 50

30 min

2-8 24

10 min

1-8 24

Aspart 30/70, Novomix 30

Lispro 25/75, Humalogmix 25 0-15 min

14-16

Lispro 50/50, Humalogmix 50 0-15 min

14-16

* (SPC)

40

9.

1 (1) 90%

2 (2) ,
(MODY )
1, 2
. 1 , 2
2 , , ,
, , .

(
)
, /
.
HbA1c 9.1.
9.1.

HbA1c %
(mg/dl)
(mg/dl)
(mg/dl)

< 7.5%
90-145
90-180
120-180

7.0%
80-130
80-140
120-150

41

,



:
( ), .
, . ,

,
.

:
( )
, ( )
(
) .
( ),
, , .

(basal) (bolus): 40-60%
( ),
. ,
. H
,
,
42

 : -

, . ( )
(basal)
(bolus).

,

,
(basal-bolus) ,
, ,
, :



,

:
,

,
(.. )

43

lispro aspart
2 , glulisine 6
, glargine levemir, 2

.
,
,
8.2 8.

, ,
.
,
, 
C

: -

, 
B

: : .
. glargine

:
44

. .

glargine

2

:

(30 , 5 )
:

.

( ) .
2 9.1.

45

 9.1. 2

: 80-130 mg/dl
: < 140 mg/dl
HbA1c < 7 %

> 250 mg/dl, HbA1c > 9%,

/,

HbA1c
2-3

: 80-130 mg/dl
: < 140 mg/dl
HbA1c < 7 %

HbA1c
2-3

: 80-130 mg/dl
: < 140 mg/dl
HbA1c < 7 %

: 80-130 mg/dl
: < 140 mg/dl
HbA1c < 7 %

HbA1c
2-3

/,
,

HbA1c
2-3

46

10.
.

.
:

24, ( 8
), (2 ) (
).
24

2-3 HbA1c
( , Self Blood Glucose Monitoring-SBGM)
(),


, . / 

, :

,

47

,
/ , .

/
, ,


, ,
/
,


,
, 

1 2
(basal) (bolus) , 3-7 24 (, , ,
)

2
24,
. ,
, HbA1c 2-3

2,

, 3
(, , )


48

 , , 4-7

( 2
, 2-3 ), , :

(, Continuous Glucose Monitoring

- CGM) ,
.
2-4 ,

, (Real time),

.
:

1 25
( ) 

1, ,

C

,
.
49

, 180 mg/dl,

,
,

, , .


3-4 ,

,
, 180 mg/dl


2,
HbA1c >7.0%.

50

11.

.

.
:
70 mg/dl

, , , , , , .

(autonomic),
.

, , , , , , , .

.

, , .
.

(, ), : , , , .

70-60 mg/dl.

, .
.
51

60 mg/dl. -

. . 50 mg/dl
.
.

40 mg/dl. .
.

(hypo
glycemia unawareness).

, -

60 mg/dl,
.
.

, , , .

.
, , ,
,
.

,
.

1
. 50% - 60% 1 , 10% 10% 10
. 2
.
52

2
. 2 .

, ,
,
,








/


, ,

,
,
.

,
,
,
53

, ,



()
. + Ca++
Q
. ,


,

,


( Somogyi) /
.
:

, .

,
, ,

54

( 70-60 mg/dl).

, -

10-20 g 
15
< 80 mg/dl 10-20 g 

20-50 g

()

, , -

, , ,
.

10-30 g , 35% (calorose)

1 mg .
20 . ,

,
.

,
.
5% 12 .

55

.
, (CGM),


CGM , ,

.

56

12.
1.

()

, , ,


(- )

pH .

>250 mg/dl.

: pH <7.3 / HCO3 <18 mmol/l.

: - >3 mmol/l
>2+ ( )

( ) .

, , , , ,
,
shock

( Kussmaul),

.

(
,
)
57

( , ).

:




.
:

(, , , ),
, , , ..

1 (
, )

pH: 7.25-7.30
HCO3: 15-18 mmol/l
: >10 mmol/l.

pH: 7.00-7.24

HCO3: 10-15 mmol/l

: >12 mmol/l.

pH: <7.00
HCO3: <10 mmol/l

: >14 mmol/l.
(: : [Na+] [Cl+ HCO3]
58

 10-14 mmol/l. >14 mmol/l

, .
,
, ).

,
, .
1000 ml
NaCl , 15-20 ml/kg
2 1000 ml NaCl , 8-10 ml/kg
4 1000 ml NaCl , 4-5 ml/kg
, 6-12
24.

, :
( , bolus) 10 0.15 /kg.
5-10
/ (100 250 ml NaCl 0.9%,
12.5-25 ml/, )
50-70 mg/dl/
50-70 mg/dl 1 ,

250 mg/dl, NaCl 5% 150-250 ml/. 2-4 /,
150-200 mg/dl.
59

o . ,
. , ,
,
, .
>5.5 mEq/l, 2
3.5-5.5 mEq/l, 20-30 mEq/l KCL,
, , +

<3.5 mEq/l 40 mEq/l KCL, ,
, +

(HCO3) pH <7.0.
, .
pH 6.9-7.0 44 mmol HCO3 3060
pH <6.9 88 mmol HCO3
30-60
,
.

.

, 2-3 , , : ,
, ,



, , pH
0, 2, 6, 10, 24
HCO3, pCO2,
2-4
-
0, 6, 12, 24
60

, pH,
,
6,
30-60
. 1-2
24
.

2.

() ,
,
2, ,
.
: ,
, , ..

( >600 mg/dl).
(1+ 2+ , -
<3 mmol/l ) pH >7.30
( >320 mosm/l)

(mosm/l)= 2[Na+ (mEq/l)] + (mg/dl)/18 +
(mg/dl)/6.

,
. (, , ,
Babinski ). , 40%.

9-10 . NaCl (0.9%) Na >155 mEq/l NaCl (0.45%). 0.45% 61

NaCl
(water for injection)
, .

, ,
. 3-5
(
150 mg/dl ) .

. ,
. , ,
, , .

>5.5 mEq/l, 2.

A 3.5-5.5 mEq/l, 20-30 mEq/l KCL,

, ,

<3.5 mEq/l 40 mEq/l KCL, ,

, .

,
, , , ..

,
, .. .
.
62

13.

(Body Mass Index, ) 30 kg/m2,

25 29.9 kg/m2.
=

[ ]2

,
, ,
. E , 2
( >40 kg/m2) 93 42 . 2 80 85%
2. 80% 2
(
/ ), 5-7%
150 , (.. 30 , 5 ),
2 50%
2


(
).
500-1000 kcal/ ,
4.1 4.
.
.

2 >28 kg/

m 3-6 (5-10% ).
,
63

5% ,
,

()

, (
, ) ( )

2 BMI >35 kg/m2

/
( 95% , 80%
58% )

:
BMI >35 kg/m2

,

18-60
(<5 )

,

.

64

14.

2 ()

2 HDL
. LDL ,
LDL
H LDL
, HDL
() 2
1 2


. LDL <100 mg/dl, HDL > 50 mg/dl < 150 mg/dl 

1 2
LDL

LDL :
: LDL <100 mg/dl
: LDL <70 mg/dl

, LDL 30-40%


LDL HDL
:
: < 150 mg/dl
C
HDL
> 40 mg/dl
> 50 mg/dl
C

65

LDL

trans
-3
.
,

LDL:


:

> 40

( , , , )

<40 

LDL >100 mg/dl

>40 .
<40 .

,


C

<40 LDL <100 mg/dl

66

 >40 LDL <100 mg/dl

- LDL (<70 mg/dl <100 mg/dl
)

LDL 30-40% 

, LDL 30%,
,
LDL.
LDL



LDL
LDL 30-40%, 16.1

16.1. LDL
30% - 40%

(mg)

10

40

40
5

20

40

LDL%
39
31
34
39
35
25

LDL 6%

HDL

(> 1000 mg/dl) 67

,
(-3 )

, LDL,
, (>200
mg/dl) HDL (<35 mg/dl),
.
/
.
HDL, -3 .
, -3

68

15.

(), ( ),
()
140 mm Hg / () 80 mm
Hg
() ,


A

140 mm Hg

80 mm Hg

, :

. 1 kg , ,
~5 mm Hg. = [ + (2)] / 3
< 1.5
g, 3.5 g . 1 g
4 mm Hg 2 mm Hg
. .. 30-45 4

69


20 g/
10 g/

, ,
.

()
(1)
C

1
, 1
Ca,

(Glomerular Filtration
Rate-GFR) >30 ml/ /1.73 m2 *
GFR <30 ml//1.73 m2
-
.
. , ,


,

70

24
24
1
. 35% / 5 mEq/L, ,

1 
C

(,

)

* GFR Cockroft-Gault:
GFR =

(140 H) ( kg)
(K mg/dl) 72

0.8.

:
=

( ) ( kg)
3600

GFR 1.73 m2 :
GFR 1.73 m2
GFR/1.73 m2 =

71

 72

16.

()

(20-30%), (), 1, 2, ()
, (),
,

/
24
( 300 mg/g) 

, 16.1

16.1.

, mg/g

< 30
30-300*
> 300

* 2 3
3-6

73

, , 2,
,
, , 

(GFR)
, 16.2.

16.2

GFR ml/min/1.73 m2*

** GFR

> 90

GFR

60 - 89

GFR

30 - 59

GFR

15 - 59

< 15

* GFR ml/min/1.73 m2 15
**
,
> 3

() () <140/80
mmHg
B
<130/80 mmHg

C
<110 mmHg

C
() (-)
(1)

1, ,

()


74

 2, 1


2, ,

( >1.5 mg/dl) 1


1


1

1

,

(SPC).
.

HbA1c <7.0% HbA1c <6.5%

A

(GFR 60-90 ml/

min/1.73m2) 0.8 - 1 g/kg 
C
(GFR <60 ml/min/1.73m2)
0.8 g/kg 
C

75

 76

17.
()
. .
( , ) :

, , , ,
( , Intra Retinal
Microvascular Abnormalities-IRMA)
,
,

,
,
,
20 1 80% 2

6% 30-60 .

2
1 10 ,

, 2-3 ,
2-3

.
77

, 

,


LASER : 

,
(Vascular Endothelial
Growth Factor-VEGF)

78

18.

(macro=, macroangiopathy )
, ,
:

( )
( )

()

.
, ( Mnckeberg)

2-8

, ,
,

2
79

1

( 70%)
.

:
( LDL- , HDL-
)



, HbA1c .

( )

,
.
, ,
, - .

:
, ,

80

,
(100 mg ):

> 50 > 60
:




( -


C

<50 <60 -

, 

<30 

,
.

81

 82

19.

()

()

40-50%.
, 2-4 5

2 ,
IFG IGT

.
, , 3 .

, (stress
echo)
( , ..)
( ST T),
83

( ).





.

()




1,


b1c

.

, ,
,
AGEs .
OM
()
.

( ,
) , .
84

, , , .
ST,
STEMI (ST Elevated Myocardial Infarction)
ST,
NON-STEMI

. , .

.
, ,



-, MEA,
,

,
.



, ,

18 :
85

(100 mg/)

(75 mg/)
B

(100 mg/) (75 mg/) 
B

,

C
-

B

C
H ,

C

.

,

A

:
86

 , -

> 40

.
> 30 :
1 >15
2 >10

-

87

 88

20. E

() 24
24

(-Transient Ischemic Attack)
(80% )
(20%)
:

( )

. 40%

20%

,
, (-lacunar). 20%

5%
15% .

,
.


( 4% 2% ), 50 .
89

 4% 5%

,
, .

30%
20% 10%




,
(lacunar) .

: , , ,
, ,

, , , ,

,
,

90

, (penumbra)
.

CT-Scan

,
140-150 mg%.
.

220 mm Hg 130 mm Hg

,
70% . ,
3%,
. stent .

91

 92

21.

()
.

,
,

( nckeberg)

70% ,
,
, , ,
, , ,
2-4
40-50
20% 50 30%
27%
4%
.

,
IFG IGT

, .
93

,
2
,
.

,
, , ,
, , , , .

,
, .
.
30% ,
20% .


(Ankle-Brachial Index-ABI).

, , 95% 99% ,
. ( 21.1),
.

21.1. *
>0.90
0.90 - 0.71
0.70 - 0.41
0.40
>1.30

( )
nckeberg

Doppler (5-10 MHz)

,

94

 .
.
.
(
)
( ).

0.90
1.30 ( nckeberg)
,
nckeberg, ,
>1.30,

, , :

50 ( 5/)

,
10 ,
, .

(US
Triplex) o
nckeberg,
,
(Toe Systolic Pressure Index-TSPI)

(TcpO2)
(DSA), , , DSA, .
95

, .
ABI
. 20 mm Hg
ABI .

. ,
, ( 12%, 4
/)



, ,


, ,

, (by-pass)

, ,
,
, ,
.

96

22.

() /

, , 12 (
, ,
), 10%.

.
20-50% .

-

:

()
()
.

,



97

, .

,
,
. ,

, , - ,

.

. O

.
.
:

.

.

( )
( 10 )
98

 ( )
(
128 Hz)

-
( )

,
.

,


()
() .

.
29%
:

(>100 )

, , , ,
,

, ,
.

. , ,
, , , ,
,
,

99

 /
(, )

, ,
, , -

, -

, , , , ,

,

.

()

(
)



.
1
. 20 mm Hg.

100

<10 ( >15) R-R / <1.17.

.
R-R
30 15 (30:15
index). <1.04.

Valsalva (Valsalva index) .

R-R
R-R . / R-R
<1.2.

.

,
. .

.
( ,
, ) ( , , )

101

,
.
3 . ,
.

, ,
,
(.. )



. 6-12 .

, ,
2, 60

. 6-12 .

, , ,

. ,
30
1 2
50
. 6-12 .

102

,
,




. 6-12 .

.

.

.

.
.

(Duloxetin) (Pregabalin, Gabapentin) ,

Duloxetine: 60 mg, ,
. 120mg
. 1
Gabapentin: 300 mg/, 2-3
, 3600 mg/ .

103

5
Pregabalin: 150 mg/ 2-3
. 2-4 300mg.
1

0.025-0.075% -

,
,
,


5 (, ). , ,
.

104

23.

(
) , ,
/ .

,
,
,


,
,
, ,
.

().
1.0% 15.0%


:

105

, , , , , ,
, , 1 , .

,
:

( )

( ), 

).

106

(, , , )
(, )
,
,
().

:

.
, .

.
.
:

: , , 

.
, ( ), ,


.

. , , , , , , ,
107

, ,
,

() 

, , Gram
(+) , 

, . . ,
,



.

108

24. Charcot

H Charcot ( -, Charcot,
, ) , ,
,
,


, , ..
0.1-0.4% . 1
, , , , ,
. .


.
, ,

,
,
.

, :

,
,

109

,
,

(, ..)

110

25.
1 2
.

().

HbA1c <6.5%,
.
HbA1c <6.5% 70-100 mg/
dl, 90-140 mg/dl

. , 1
.
:

(GFR <40 ml/min)

.

, ,
.

60-100 mg/dl
111

1 100-130 mg/dl

HbA1c % <6.0%. .

: 35-45% ( ),
20-25%, 30-40%


(25 kcal/kg ), 1800 ,,
25.1.

25.1.

(kg)

2 3
(kg/)

< 18.5

12.5-18.0

0.5 (0.5-0.6)

18.5-24.9

11.5-16.0

0.5 (0.4-0.5)

25.0-29.9

7.0-11.5

0.3 (0.25-0.3)

30.0

5.0-9.0

0.25 (0.2-0.3)

Lispro Aspart
detemir
, glargine
:
112

 :
1-3 , ,
3
( )

. 6-7 ( ),
, 2-4 ..


(CGMS)

.

80-110 mg/dl. :

1-2

, ,
.

()

>92 mg/dl,

2 ( >126 mg/dl), OGTT 24-28
18%
:
113

 (
)

(, , , ..)

( 2)


2 .

HbA1c.

, > 126 mg/dl,

92 mg/dl, <126 mg/dl,

<92 mg/dl,

24 28

75g
60 120

60
120

92 mg/dl
180 mg/dl
153 mg/dl

, 8

3
( >150 g/) .

114

70-95 mg/dl
1 90-130 mg/dl
2 80-120 mg/dl.

: 35-45% ( ),
20-25%, 30-40%

(25 kcal/kg ), 1800 25.1

, (.. 10 ) .

b1c

2 .

6 ( ) 4 (
).

, . ,


,
.
115

25.2

25.2.

1-3

2-3

OGTT

OGTT

OGTT

OGTT

OGTT =

116


HELLENIC DIABETES ASSOCIATION

26.

, ,
.

, ,

, ,

1 1-3 2 3-6 , .

117

 ,






: , -

, .

, , , ,
, .

, (,
, , , , , , ,
, ) .
:
, , BMI

( , -

, )

( , , : )
118

, ,
,
: , , , , , , , , , , )

( , , , , ).

, 2
,
3-6 HbA1c
( :
,
: , , HDL, LDL
, , ,
(GFR) Cockroft-Gault
(AST, ALT), , GT, CPK
(TSH)
( )

.

2
1 10 ,

2-3
2-3

.
119

()
.

120

27.

(Diabetes Self-management
Education)
, . ,

.


, , , ,


. .
. .

, , ,

.


. ,


121

.
( )

,

1, .

. ,

, .


.

,
, ,

:

122