Module iii complications of dm

SDM: Applications to Complications

Priorities of Care for Adults with Diabetes

CVD Risk

ASA, tobacco, ACEI/ARB, statin

CVD Risk

Diagnosis–PreventionDx Fasting Glucose > 126 Casual > 200 + Symptoms

Prevent Pre-diabetes (IFG-IGT) & Metabolic Syndrome

Self-Management Knowledge and SkillMonitoring Medication Problem solving Food plan & nutritionRisk reduction Living & coping Physical activity

Hemoglobin A1C Target < 7.0%

SMBGPre 70-120 mg/dL

2 hr. post < 160 mg/dL(~ 50% of readings)

Blood Pressure (every visit)

Dx and Rx < 130/80

Annual Lipid ProfileLDL < 100HDL > 40

Trigs < 150

DM + CVD LDL < 70

Annual ScreeningNephropathy

Microalbumin screeningCalculated GFR

RetinopathyDilated retinal exam

NeuropathyNeuro and foot exam

Sexual health

Hospital careFoot care

Dental careImmunizations

GlucoseGlucose Hypertension HypertensionLipidsLipids MicrovascularcomplicationsMicrovascularcomplications

Other essentialsof care

Pre DiabetesPre DiabetesMetabolic SyndromeMetabolic Syndrome

Insulin Level

YearsYears

-10-10 -5-5 00 55 1010 1515 2020 2525 3030

100100

150150

200200

250250

300300

350350

Insulin ResistanceInsulin Resistance

Fasting GlucoseFasting Glucose

Postmeal GlucosePostmeal Glucose

OnsetDiabetes

100100

150150

200200

250250

-15-15

Natural History of Type 2 Diabetes

--cell Fncell Fn

Impaired Incretin ActionImpaired Incretin Action

Chronic Complications of Diabetes

BrainBrainCerebrovascular diseaseCerebrovascular disease

• Transient ischemic attackTransient ischemic attack• Cerebrovascular accidentCerebrovascular accident

HeartHeartCoronary artery diseaseCoronary artery disease

• Myocardial infarctionMyocardial infarction• Congestive heart failureCongestive heart failure

ExtremitieExtremitiessPeripheral vascular diseasePeripheral vascular disease

• UlcerationUlceration• GangreneGangrene• AmputationAmputation

Macrovascular

Microvascular

EyeRetinopathyCataractsGlaucoma

KidneyNephropathy

• Microalbuminuria• Gross albuminuria• Kidney failure

NervesNeuropathy

• Peripheral• Autonomic

Benefit of Glucose Control in Reducing Microvascular Complications

Type 1 Diabetes

– Diabetes Control and Complications Trial (DCCT)

– Epidemiology of Diabetes in Complications (EDIC)

Diabetes Control and Complications Trial (DCCT) Type 1 Diabetes

- Retinopathy

- Neuropathy

- Nephropathy

- Microalbuminuria

DCCT Study Group. N Engl J Med 329:977, 1993

24-76% reduction in microvascular complications

EDIC Study ResultsIntensive Glucose Control in Type 1 Diabetes

EDIC Research Group. N Engl J Med 2000;342:381-9

Sustained Benefit of Intensive Control EDIC Study 4 Years Post DCCT

EDIC Research Group. N Engl J Med 2000;342:381-9

MetabolicMemory

Benefit of Glucose Control in Reducing Microvascular Complications

Type 1 Diabetes

– Diabetes Control and Complications Trial (DCCT)

Type 2 Diabetes

– United Kingdom Prospective Diabetes Trial (UKPDS)

– UKPDS 10 Year Follow-up

UKPDSReduction in Microvascular Disease

p = 0.015 p = 0.00054p = 0.0099

UKPDS: Lancet 352:837-853. 1998 BMJ 321:405-412, 2000

Retinopathy Microalbuminuria Any MicrovascularEndpoint

UKPDS: Long-term follow-up

Holman et al. NEJM 359(15):1577-1589, 2008

Metabolic Memory in Type 2 Diabetes

Holman et al. NEJM 359(15):1577-1589, 2008

Adapted from: Skyler JS. Endocrinol Metab Clin North Am. 1996 Jun;25(2):243-54. DCCT Study Group. N Engl J Med 329:977, 1993UKPDS 35. Stratton IM. BMJ 321:405-412, 2000.

66 77 88 99 1010 1111 1212Hemoglobin A1c

Lowering blood glucose significantly reduces the risk of microvascular complications

In both Type 1 and Type 2 diabetes

MicrovascularMicrovascular

EyeEyeRetinopathyRetinopathyCataractsCataractsGlaucomaGlaucoma

KidneyKidneyNephropathyNephropathy

• MicroalbuminuriaMicroalbuminuria• Gross albuminuriaGross albuminuria• Kidney failureKidney failure

NervesNervesNeuropathyNeuropathy

• PeripheralPeripheral• AutonomicAutonomic

Diabetic Retinopathy It is estimated that more than 2.5 million people worldwide are affected by diabetic retinopathy.

Diabetic retinopathy is the leading cause of vision loss in adults of working age (20 to 65 years) in industrialized countries.

Largely preventable

International Diabetes Federation, 2008

Normal RetinaEarly Nonproliferative

Retinopathy

Proliferative Retinopathy

Optic Nerve

Macula

Hard exudates

Hemorrhage

Neovascularization

Prevention of Diabetic Retinopathy

Annual dilated eye examination

– Retinal lesions occur in up to 90% of individuals at 20 years

Glycemic control Limits risk of retinal disease, slows rate of

progression

Benefits observed in both Type 1 and Type 2 diabetes

Blood pressure control

Treatment of Diabetic Retinopathy

– Glucose control

– Blood pressure control

– Photocoagulation

Diabetes-related Kidney Disease

Diabetes is the largest cause of kidney failure in developed countries and is responsible for huge dialysis costs.

Type 2 diabetes has become the most frequent condition in people with kidney failure in countries of the Western world.

Diabetic GlomerulosclerosisNormal Glomerulus

Longstanding Diabetes

Messangial Proliferation and Sclerosis

Thickening Basement Membrane

Diminished & Leaking

Filtering Space

Proteinuria

Dialysis

Screening Recommendations

Annual microalbuminuria screen

– Albumin/creatinine (A/C) ratio preferred

– Serum creatinine/ estimated GFR Type 1 Diabetes

– After 5 years duration

Type 2 Diabetes

– At diagnosis

– During pregnancy

American Diabetes Association Standards of Medical Care Position Statement Diabetes Care 2006; 29:S21-S23.

Kate ref for 2008

Screening for Kidney Disease

Obtain random albumin-to-creatinine ratio (A/C ratio);

first am urine preferred

Repeat screen twice within 60 days, R/O UTI

A/C ratio >30 mg/g?

Repeat screen annually

YESStaged Diabetes Management Quick Guide, International Diabetes Center, 2009

Staged Diabetes Management Quick Guide, International Diabetes Center, 2009

Screening for Kidney Disease Continued

2 of 3 A/C ratios >30

Diagnosis of macroalbuminuria

Repeat screenannually

A/C ratio >300 mg/g?

Diagnosis of microalbuminuria

Treatment of Early Kidney Disease

Glucose control (A1C <7%)

Blood pressure control (<130/80 mmHg; consider target <120/75 mmHg)

Smoking cessation

Start ACE Inhibitor or ARB

– Baseline serum creatinine and potassium

– Monitor for side effects, may experience cough with ACE inhibitor

– Monitor response in 3-6 months

– Adjust dose as necessary

Benefit of ACE Inhibitor Therapy Type 2 Diabetes

0 1 2 3 4 5

Placebo

Enalapril

Ravid M. Ravid M. Ann Intern MedAnn Intern Med 118:577, 1993 118:577, 1993

Years follow-up

Neuropathy in Diabetes

Peripheral Neuropathy

Loss of sensation

Loss of position sense (proprioception)

Impaired protective sensation

Risk for foot ulcer, loss of limb

Autonomic Neuropathy

Orthostatic hypotension

Gastroparesis

Diarrhea / constipation

Cardiac – tachycardia

Erectile dysfunction

Gustatory sweating

Managing Peripheral Neuropathy

Prevention Glucose control

Annual comprehensive foot examination

? ά-Lipoic acid

Daily self foot inspection

Foot care

Wear appropriate shoes

Vascular lesions

Symptom Management Analgesia (aspirin, NSAIDs)

Anti-depressant Rx (amitriptylline, venlafaxine, duloxetine, others)

Anti-seizure meds (gabapentin)

SDM: Applications to Complications

CVD Risk

Dx and Rx < 130/80

Trigs < 150

DM + CVD LDL < 70

Sexual health

BrainCerebrovascular disease

• Transient ischemic attack• Cerebrovascular accident

HeartCoronary artery disease

• Myocardial infarction• Congestive heart failure

ExtremitiesPeripheral vascular disease

• Ulceration• Gangrene• Amputation

Macrovascular

Cardiovascular Disease (CVD) in Diabetes*

Heart disease and stroke account for about 65% of deaths in people with diabetes.

Adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes.

The risk for stroke is 2 to 4 times higher and the risk of death from stroke is 2.8 times higher among people with diabetes

Diabetes is a CVD (risk) equivalentDiabetes is a CVD (risk) equivalent

– Risk of MI comparable to those with known CVDRisk of MI comparable to those with known CVD

American Diabetes Association, 2008

*US Data

Diabetes is a Cardiovascular Risk Equivalent !

No CAD CAD

No DMDM

Haffner S et al. N Engl J Med 1998;339:229-234

Incidence of Heart Attack or Stroke during 7 year follow-up

Benefit of Glucose Control in Reducing Macrovascular Complications

Type 1 Diabetes

Benefit of Glucose Control in Reducing Macrovascular Complications

Type 1 Diabetes

Type 2 Diabetes

– ACCORD

– ADVANCE

– UKPDS 10 Year Follow-up

Additional Therapies to Reduce Cardiovascular Disease

Encourage active lifestyle & healthy diet

Lower LDL cholesterol levels:

– Primary Prevention (CARDS study)

– Target LDL <100 mg/dL all individuals with type 2 diabetes

– If diabetes and CVD target LDL < 70 mg/dL

Control blood pressure <130/80 mmHg

Daily aspirin therapy

Diabetes and Hypertension

75% of individuals with diabetes have hypertension

Type 2 Diabetes: Blood Pressure Control and Complication Risk (UKPDS)

Adler A. Adler A. BMJBMJ 321;412-419, 2000 321;412-419, 2000

~ 15% reduction in risk ~ 15% reduction in risk for each 10 mm Hg decrease in SBPfor each 10 mm Hg decrease in SBP

110 130 150 170

Mean systolic blood pressure (mm Hg)Mean systolic blood pressure (mm Hg)

Myocardial Infarction

Microvascular

Hypertension Treatment in Type 2 Diabetes

Staged Diabetes Management Quick Guide, International Diabetes Center, 2009

Aspirin Recommendations in Diabetes

Primary Prevention?Secondary Prevention?

ADA Primary Prevention Recommendations 2009 vs 2010

Aspirin 75-162 mg/day in type 1 and type 2 at increased CV risk

– Age >40 years

– Family history CVD

– Hypertension

– Smoking

– Dyslipidemia

– Albuminuria

2009 Aspirin 75-162 mg/day in

type 1 and type 2 if 10 yr CHD risk >10%

Men >50 yrs and

Women >60 yrs with at least one additional risk factor

Family history CVD

Hypertension

Smoking

Dyslipidemia

Albuminuria

ADA Clinical Practice Recommendations 2009. Diab Care 32:Suppl. 1; ADA Clinical Practice Recommendations 2010. Diab Care 33:Suppl. 1.

CVD Risk

Dx and Rx < 130/80

Trigs < 150

DM + CVD LDL < 70

Sexual health

Comprehensive Foot ExaminationPatient Education

The Foot Examination

Careful inspection Skin, shoes, shape of foot

Vascular integrity Pulses Capillary refill

Neurological examination and function Light touch (5.07/ 10g monofilament) Vibratory sensation (128-Hz tuning fork) Reflexes

Source: Staged Diabetes Management, 5th edition, Quick Guide, pages 7-26.

Standards of Care at Diagnosis & Annually

Inspection

Shoes/socks

Presence of deformities

Vibration Sensation

• Vibration Detection/Perception Threshold has been shown to predict the development of foot ulcers1

• The tuning fork (128 Hz) is a practical tool to screen

vibratory sensation loss

Young MJ, et at, Diabetes Care 1994; 17:557-560. Abbott CA, et al, Diabetes Care 1998; 21:1071-1075. Coppini DV, et al, J Clinical Neuroscience 2001; 8:520-524.

Neurological ExamVibratory Sensation

Vibratory Sensation Testing

Help patient differentiate vibration vs. pressure Fork on unsupported DIP joint of 1st toe When vibration sensation on toe ceases, compare to

examiners distal forefinger in seconds If this is normal, no need to do monofilament test

Normal = 0-10 seconds

Abnormal = Greater than 10 seconds

Absent = No vibration sensed

Staged Diabetes Management 4th Edition Quick Guide – Page 7-28

Monofilament testing

Monofilament Examination

Locations on the foot

8-10 = Normal protective sensation

1-7 = Abnormal

0 = Absent

Plantar Dorsal

Neurological ExamProtective Sensation

10g monofilament

10 locations on foot

Apply at 90 degrees with enough pressure to bend filament (10 grams) for 1.5 seconds

Prevention is Essential!!

•Maintain good diabetes control•Practice good foot care habits•Check feet every day•Treat problems right away•Have regular health check-ups

Provide ongoing patient education

Good Foot Care Habits

Keep feet clean and dry

If skin is dry, use a lotion daily

Protect feet from hot and cold

Trim toenails weekly

Nail Care

• Trim after washing a drying feet

•Use a nail clipper (or nipper) and trim straight across

•Do not cut too short or cut into nail corners

•Have a podiatrist or foot specialist trim nails if the patient cannot see or reach their nails OR if fungal nails present

Good Foot Care Habits

Keep feet clean and dry

If skin is dry, use a lotion daily

Protect feet from hot and cold

Trim toenails weekly

Wear shoes and socks at all times

Appropriate Footwear

Wear shoes that fit well

Avoid open toed sandals, high heels and pointed toe shoes

Do not go barefoot especially if neuropathy present

Foot Self Inspection

Inspect feet daily

Check top and bottom of each foot, toes and nails and inside shoes

Use a mirror if unable to see feet well

Have someone check for you if unable

Contact doctor if concerns

Essentials of Foot Care

Comprehensive Foot Examination by HCP Annually– Patients with neuropathy - visual inspection of feet at every visit with

a health care professional

Advise patients to:– Inspect their feet daily

– Use lotion to prevent dryness and cracking (not between toes)

– File calluses with a pumice stone (no razors!)

– Cut toenails straight across or see podiatrist

– Always wear (natural fiber) socks and well-fitting shoes

– Notify their health care provider immediately if any foot problems occur

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