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Lecture:
Screening, Treatment and Evaluation of
Complications
Husaini Umar
Slide 2
Microvascular Macrovascular
Stroke
Diabetic
retinopathy 1.2- to 1.8-fold
increase in stroke3
Leading cause
of blindness
in working-age
adults1 Cardiovascular
disease
75% diabetic patients
Diabetic die from CV events4
nephropathy
Diabetic
Leading cause of neuropathy
end-stage renal disease2 Leading cause of
non-traumatic lower
Erectile Dysfunction extremity amputations5
The most secretive
Complication of DM
Diabetic Foot
1Fong DS, et al. Diabetes Care 2003;e 26 (Suppl.1):S99–S102. 2Molitch ME, et al. Diabetes Care 2003; 26 (Suppl.1):S94–S98. 3Kannel WB, et al. Am
Heart J 1990; 120:672–676. 4Gray RP & Yudkin JS. Textbook of Diabetes 1997. 5Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl.1):S78–S79.
Slide 4
80
Incidence per 1.000
60
patient-years
Microvascular disease
40 Myocardial infarction
20
0
5 6 7 8 9 10 11
Updated Mean HbA1c (%)
Cost increases with a factor of 22.5 if patients develop complications (ASKES Data)
US$
900
900
800
700
600
500 22.5X
400
300
200
100 40
0
Without Complications With Complications
• Microvascular complications
• Kidney – nephropathy » kidney failure
• Eyes – retinopathy » blindness
• Nerves – neuropathy » disability
• Peripheral Arterial Diseases » disability
• Erectile Dysfunction
• Macrovascular complications
• Heart – myocardial infarction
• Brain – stroke
• Atherosclerosis – myocardial infarction
Slide 8
Nephropathy
Erectile Dysfunction
Neuropathy
Diabetes Nephropathy
Characteristics
• Persistent albuminuria
• Diabetic retinopathy
• Hypertension
• Decline in kidney function (about 12 ml/min/year)
Slide 10
Diabetes Nephropathy
Prevention and Treatment
• Multifactorial disease
0.8
management:
• antihypertensive agents
microalbuminuria
0.6
• good blood glucose control
Probability of
Micro / Macro-albuminuria
In 2 of 3 measurements
Micro Macro
24h: 30 - 299 mg/24h >300 mg/24h
1 2 3 4 5
5000
150
(mL/min)
100 1000
200
50
20
0
5 10 15 20 25
Years
GFR Microalbuminuria, Proteinuria, nephrotic
Functional
(90-95%) hypertension syndrome, GFR ¯
Vora JP, et al. In: Johnson RJ, Feehally J, eds. Comprehensive Clinical Nephrology. New York: Mosby; 2000
Slide 13
Treating Albuminuria
Diabetes Retinopathy
Non-
Diabetic
Retina
Diabetic Proliferative
Maculopathy Diabetic
Retinopathy
Slide 15
Diabetes Retinopathy
Risk Factors and Classification
30
blood pressure control
increase the risk of
25
retinopathy
20
• Five categories:
15 • Mild Nonproliferative
10 • Moderate
Nonproliferative
5
• Severe
0
Nonproliferative
4 5 6 7 8 9 10
London HbA1c (%) • proliferative
5.7 6.7 7.7 8.8 9.8 10.8 11.9 • advanced diabetic
DCCT HbA1c (%) eye disease
• maculopathy
Diabetes Retinopathy
Prevention and Treatment
Diabetes Neuropathy
Risk Factors and Common Types
Symmetrical
diffuse
Femoral
neuropathy
Other acute
Pressure palsies • Hyperglycaemia
sensorimotor mononeuropathies
neuropathy
(amyotrophy)
is the leading
III VI
cause of diabetic
Truncal neuropathy
Ulnar
• Alcohol makes
neuropathy worse
Median
Lateral • A number of
popliteal
clinical
Sensory loss 0 → +++ Sensory loss 0 → + Sensory loss 0 → + Sensory loss + → +++
syndromes are
Pain + → +++
Tendon reflexes N → ↓
Pain + → +++
Tendon reflexes ↓ → 0
Pain + → +++
Tendon reflexes N
Pain + → ++
Tendon reflexes N
recognisable
Motor deficit 0 → + Motor deficit + → +++ Motor deficit + → +++ Motor deficit + → +++
Watkins et al. In: Diabetes and Its Management 2003. Pickup & Williams. In: Slide Atlas of
Diabetes 2004
Slide 18
Diabetes Neuropathy
The Most Frequent Diabetes related Complication in
Indonesia (and in the World…)
Diabetes Neuropathy
Prevention and Treatment
Conventional therapy
12
neuropathy
p<0.001 • Exclude or treat
contributory factors:
8 • alcohol excess
• vitamin B12
4
deficiency
Intensified therapy • uraemia
• Offer pain relief based
0 on the dominant
0 1 2 3 4 5 symptoms
Time (years)
Erectile Dysfunction
Definition
Erectile Dysfunction
Background
Erectile Dysfunction
Risk Factors
Risk Factors
Neuropathy
Erectile Dysfunction
Screening
Rosen RC, Cappelleri JC, Smith MD, et al. Development and evaluation of an abridged, 5-item version of the
International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999
Dec;11(6):319-26
Slide 25
Erectile Dysfunction
Treatment Options
• Surgery
• Sex therapy
Slide 26
MACRO VASCULAR
COMPLICATION
Slide 27
Stroke
Cardiovascular/heart disease
Cardiovascular Diseases
Patients with Type 2 Diabetes at a increased risk of CVD
Cardiovascular Diseases
Risk for Myocardial infaction and stroke increases with
progression to Type 2 Diabetes
140 Non-diabetic
• Reduce risk factors for
Number of deaths per 10,000 patient-years
subjects
CHD screening and treatment ACE-I and aspirin and statin (if not contraindicated)
STENO-2 STUDY
Slide 38
• 160 patients
• Type 2 diabetes and
microalbuminuria
• Mean age 55 yrs, BMI 30 kg/m2;
HbA1c 8.4 %
New Engl J Med 2003; 383-93
• Randomized to
• conventional therapy assigned to
their GPs
• or intensive care at Steno
Diabetes Center
Conventional treatment
80
Micro-vascular Macro-vascular
4 years 8 years
80
Intensive treatment
Slide 40
• Food Advice
• Cut down on animal fat
• Have some kind of seafood every day
• 5-6 vegetables and fruits every day
• Exercise Advice
• Enjoy physical performance
> 150 min/week
• Smoking cessation
• Intensification of OHA and insulin
• Treatment with ACE/ARB, Statin and
baby aspirin
Slide 41
Intervention Standard
n=55 n=38
F-s-LDL-cholesterol (mg/dl) 71 77
* median
Slide 42
100
90
80
70
60
50
40
30
20
10
0