Systemic Complications of Diabetes Mellitus Robert F. Nash D.O. 2006.

Systemic Complications of Diabetes Mellitus

Robert F. Nash D.O.Robert F. Nash D.O.

20062006

Diabetes “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 USTotal population in US 20.8 million people (7%)20.8 million people (7%)

Diagnosed 14.6 millionDiagnosed 14.6 millionUndiagnosed 6.2 millionUndiagnosed 6.2 million

Age 60 and overAge 60 and over 10.3 million people10.3 million people 20.9%20.9%

Cost

Health Care CostHealth Care Cost Other costsOther costs

DisabilityDisability Work LossWork Loss Premature Premature

MortalityMortality Total CostTotal Cost

$92 BILLION$92 BILLION $40 BILLION$40 BILLION

$132 BILLION$132 BILLION

Mrs. Adams

Age 51Age 51 New PatientNew Patient Not under any Not under any

Physicians carePhysicians care

CC: Check-upCC: Check-up HPI: “ I am just not feeling HPI: “ I am just not feeling

well.” Tired, polyuria, well.” Tired, polyuria, polyphagia, polydypsea, some polyphagia, polydypsea, some weight loss, abdominal pain, weight loss, abdominal pain, diarrhea, leg pain, sores on feet, diarrhea, leg pain, sores on feet, dyspepsia, occasional episodes dyspepsia, occasional episodes of chest pain, difficulty seeing, of chest pain, difficulty seeing, ankle edema, and rash. ankle edema, and rash.

Diabetes Mellitus

Type IType I Type IIType II GestationalGestational Other causesOther causes

Type I Diabetes Mellitus

““Juvenille Diabetes”- MisnomerJuvenille Diabetes”- Misnomer Autoimmune processAutoimmune process Requires Insulin secondary to beta-cell Requires Insulin secondary to beta-cell

destructiondestruction Look for other autoimmune conditionsLook for other autoimmune conditions

Gestational Diabetes Mellitus

Unknown etiology- May be secondary to Unknown etiology- May be secondary to maternal hormonesmaternal hormones

Resolves with delivery/termination of Resolves with delivery/termination of pregnancypregnancy

Watch for Hypoglycemia of neonateWatch for Hypoglycemia of neonate Insulin for managementInsulin for management

Type II Diabetes Mellitus

Decreased insulin sensitivityDecreased insulin sensitivity Initial hyperinsulinemiaInitial hyperinsulinemia ““Burn-out of Beta cells”Burn-out of Beta cells” Oral and /or Insulin therapyOral and /or Insulin therapy

Other causes

Chronic pancreatitisChronic pancreatitis Endocrine disordersEndocrine disorders Medication induced Diabetes MellitusMedication induced Diabetes Mellitus Genetic SyndromesGenetic Syndromes Genetic DefectsGenetic Defects

Diabetic Emergencies

Diabetic KetoacidosisDiabetic Ketoacidosis Non-ketotic hyperglycemic-hyperosmolar Non-ketotic hyperglycemic-hyperosmolar

ComaComa

Systemic Complications of Diabetes Mellitus CardiovascularCardiovascular NeurologicNeurologic GastrointestinalGastrointestinal EyesEyes Oral CavityOral Cavity SkinSkin GenitourinaryGenitourinary RenalRenal

Pathogenesis

Increased glucose levelsIncreased glucose levels Insulin sensitive cellsInsulin sensitive cells

MuscleMuscle Cells not requiring insulinCells not requiring insulin

Cardiovascular

Heart disease and stroke incidenceHeart disease and stroke incidence 2-4 times higher than rest of population2-4 times higher than rest of population

Accelerated atherosclerosisAccelerated atherosclerosis Increased cholesterol levelsIncreased cholesterol levels Hypertension 73%Hypertension 73%

Myocardial infarction

Neurologic

60%-70% with mild to severe neurologic 60%-70% with mild to severe neurologic diseasedisease

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

Diabetic NeuropathyDiabetic 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 nontraumaticlower-limb amputations in the United States occur among people with diabetes.

Diabetic neuropathy

Amputations

Major contributing cause of lower extremity Major contributing cause of lower extremity amputationsamputations

82,000 yearly (2000-2001)82,000 yearly (2000-2001) Loss of sensationLoss of sensation

Gastrointestinal

Polyphagia and PolydyspeaPolyphagia and Polydyspea Autonomic NeuropathyAutonomic Neuropathy

Decreased peristalsisDecreased peristalsisGastroparesisGastroparesisEsophagealEsophageal

Diarrhea and ConstipationDiarrhea and Constipation Decreased exocrine pancreatic secretionsDecreased exocrine pancreatic secretions

Lumbar and Thoracic PolyradiculopathyLumbar and Thoracic Polyradiculopathy

Skin

Common complicationCommon complication

Acanthosis Nigricans

Bullosis diabeticorum

Skin Tags

Diabetic dermopathy

Necrobiosis lipoidica diabeticorum

Granuloma annulare

Eyes

Blindness ages 20-74Blindness ages 20-74 12,000 to 24,000 new cases of blindness 12,000 to 24,000 new cases of blindness

yearlyyearly Retinopathy-late first decade to early Retinopathy-late first decade to early

secondsecond Macular EdemaMacular Edema CataractsCataracts Blurry visionBlurry vision

Retinopathy

Cataract

Oral Cavity

Periodontal Disease- 1/3 of all diabeticsPeriodontal Disease- 1/3 of all diabetics ThrushThrush

Periodontal Disease

Thrush

Genitourinary

PolyuriaPolyuria Female ReproductionFemale Reproduction

Poorly controlled diabeticsPoorly controlled diabeticsPrior to conception to end of first 1/3Prior to conception to end of first 1/3

• 5-10% birth defects5-10% birth defects

• 15-20% abort15-20% abort2/3 to birth causes high birth weight2/3 to birth causes high birth weight

Genitourinary

Female GenitourinaryFemale Genitourinary Vaginal CandidisisVaginal Candidisis DyspareuniaDyspareunia UTI’sUTI’s Bladder dysfunctionBladder dysfunction

Male Genitialia

Erectile dysfunctionErectile dysfunction Decreased libidoDecreased libido UTI’sUTI’s

Renal

44 % of all End Stage Renal Disease44 % of all End Stage Renal Disease Glomerular lesionsGlomerular lesions ArteriolosclerosisArteriolosclerosis PyelonephritisPyelonephritis

NephropathyFive Stages of Kidney DiseaseFive Stages of Kidney DiseaseStage 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 urea-nitrogen rise. Blood pressure may rise during this stage.

Five Stages of Kidney Disease (con’t.)

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 IIDiabetes Type II Weight loss and dietary changeWeight loss and dietary change Adjust medications to keep Fasting Adjust medications to keep Fasting

Glucose between 90 and 130Glucose between 90 and 130 HGBHGBa1c a1c Below 7.0

Pain managementPain management

Treatment of Diabetic Nephropathy

Hypertension Control - Goal: lower blood pressure to <130/80 Hypertension Control - Goal: lower blood pressure to <130/80 mmHg mmHg Antihypertensive agentsAntihypertensive agents

Angiotensin-converting enzyme (ACE) inhibitorsAngiotensin-converting enzyme (ACE) inhibitors

• captopril, enalapril, lisinopril, benazepril, captopril, enalapril, lisinopril, benazepril, fosinopril, ramipril, quinapril, perindopril, fosinopril, ramipril, quinapril, perindopril, trandolapril, moexipriltrandolapril, moexipril

Angiotensin receptor blocker (ARB) therapy Angiotensin receptor blocker (ARB) therapy • candesartan cilexetil, irbesartan, losartan candesartan cilexetil, irbesartan, losartan

potassium, telmisartan, valsartan, esprosartan potassium, telmisartan, valsartan, esprosartan

Beta-blockersBeta-blockers

Prevention of Diabetic Retinopathy Associated Vision Loss

Intensive glycemic controlIntensive glycemic control Tight blood pressure control Tight blood pressure control

(<130/80 mmHg)(<130/80 mmHg) Comprehensive eye examinations Comprehensive eye examinations

Treatment GIGI

Metoclopramide or erythromycinMetoclopramide or erythromycin Loperamide or stool softnersLoperamide or stool softners

PolyneuropathyPolyneuropathy AntidepressantAntidepressant AnticonvulsantsAnticonvulsants Regular foot examsRegular foot exams

Erectile DysfunctionErectile Dysfunction DyspareuniaDyspareunia

LubricantsLubricants Estrogen CreamEstrogen Cream

References

American Diabetes Association:American Diabetes Association: Preventive Foot Care in DiabetesPreventive Foot Care in Diabetes(Position Statement).(Position Statement). Diabetes Care Diabetes Care 27 (Suppl.1): S63-S64, 2004 27 (Suppl.1): S63-S64, 2004

Feldman, EL: Classification of diabetic neuropathy. In Feldman, EL: Classification of diabetic neuropathy. In UpToDate.UpToDate.Wellesley, MA, UpToDate, 2003Wellesley, MA, UpToDate, 2003

National Diabetes Information Clearinghouse. National Diabetes Information Clearinghouse. Diabetic Neuropathies:Diabetic Neuropathies:The Nerve Damage of Diabetes. The Nerve Damage of Diabetes. Bethesda, MD: National Institute ofBethesda, MD: National Institute ofDiabetes and Digestive and Kidney Diseases, National Institutes ofDiabetes and Digestive and Kidney Diseases, National Institutes ofHealth (NIH), DHHS; 2002Health (NIH), DHHS; 2002

National Diabetes Information Clearinghouse. National Diabetes Information Clearinghouse. Prevent DiabetesPrevent DiabetesProblems: Keep Your Feet and Skin Healthy. Problems: Keep Your Feet and Skin Healthy. Bethesda, MD: NationalBethesda, MD: NationalInstitute of Diabetes and Digestive and Kidney Diseases, NationalInstitute of Diabetes and Digestive and Kidney Diseases, NationalInstitutes of Health (NIH), DHHS; 2003Institutes of Health (NIH), DHHS; 2003

References, cont.

Feldman, EL: Pathogenesis and prevention of diabeticFeldman, EL: Pathogenesis and prevention of diabeticpolyneuropathy. In polyneuropathy. In UpToDate.UpToDate. Wellesley, MA, UpToDate, 2003. Wellesley, MA, UpToDate, 2003.

Feldman, EL, McCulloch, DK: Treatment of diabetic neuropathy. InFeldman, EL, McCulloch, DK: Treatment of diabetic neuropathy. InUpToDate.UpToDate. Wellesley, MA, UpToDate, 2003. Wellesley, MA, UpToDate, 2003.

Stevens, MJ: Diabetic autonomic neuropathy. In Stevens, MJ: Diabetic autonomic neuropathy. In UpToDate.UpToDate.Wellesley, MA, UpToDate, 2003.Wellesley, MA, UpToDate, 2003.

Feldman, EL: Clinical manifestations and diagnosis of diabeticFeldman, EL: Clinical manifestations and diagnosis of diabeticpolyneuropathy. In polyneuropathy. In UpToDate.UpToDate. Wellesley, MA, UpToDate, 2003. Wellesley, MA, UpToDate, 2003.

ReferencesAmerican Diabetes Association:American Diabetes Association: Nephropathy in DiabetesNephropathy in Diabetes (Position(PositionStatement).Statement). Diabetes Care Diabetes Care 27 (Suppl.1): S79-S83, 2004 27 (Suppl.1): S79-S83, 2004

National Kidney and Urologic Diseases Information Clearinghouse.National Kidney and Urologic Diseases Information Clearinghouse.Kidney Disease of Diabetes. Kidney Disease of Diabetes. Bethesda, MD: National Institute ofBethesda, MD: National Institute ofDiabetes and Digestive and Kidney Diseases, National Institutes ofDiabetes and Digestive and Kidney Diseases, National Institutes ofHealth (NIH), DHHS; 2003. Health (NIH), DHHS; 2003.

United States Renal Data System. United States Renal Data System. USRDS 2003 Annual DataUSRDS 2003 Annual DataReportReport. Bethesda, MD: National Institute of Diabetes and Digestive. Bethesda, MD: National Institute of Diabetes and Digestiveand Kidney Diseases, National Institutes of Health (NIH), DHHS;and Kidney Diseases, National Institutes of Health (NIH), DHHS;2003. 2003.

DeFronzo RA: Diabetic nephropathy: etiologic and therapeuticDeFronzo RA: Diabetic nephropathy: etiologic and therapeuticconsiderations. considerations. Diabetes ReviewsDiabetes Reviews 3:510-547, 1995 3:510-547, 1995

National Kidney and Urologic Diseases Information Clearinghouse.National Kidney and Urologic Diseases Information Clearinghouse.Kidney Failure: Choosing a Treatment That’s Right For You.Kidney Failure: Choosing a Treatment That’s Right For You.Bethesda, MD: National Institute of Diabetes and Digestive andBethesda, MD: National Institute of Diabetes and Digestive andKidney Diseases, National Institutes of Health (NIH), DHHS; 2003. Kidney Diseases, National Institutes of Health (NIH), DHHS; 2003.

References

American Diabetes Association:American Diabetes Association: Retinopathy in DiabetesRetinopathy in Diabetes (Position(PositionStatement).Statement). Diabetes Care Diabetes Care 27 (Suppl.1): S84-S87, 200427 (Suppl.1): S84-S87, 2004

Diabetic Retinopathy: What you should know. Diabetic Retinopathy: What you should know. Bethesda, MD: NationalBethesda, MD: NationalEye Institute, National Institutes of Health (NIH), DHHS; 2004.Eye Institute, National Institutes of Health (NIH), DHHS; 2004.

Aiello LP, Gardner TW, King GL, Blankenship G, Cavallerano JD,Aiello LP, Gardner TW, King GL, Blankenship G, Cavallerano JD,Ferris FL 3rd, Klein R: Diabetic Retinopathy. Ferris FL 3rd, Klein R: Diabetic Retinopathy. Diabetes CareDiabetes Care 21 (1): 21 (1):143-156,1998.143-156,1998.

Mrs. Adams

Hypertension

73%73%