DIABETES MILLITUS
AND COMPLICATION
พ.ญ. วิภาจรี เสน่หล์ กั ษณา
Classification of DM
Diagnosis
Risk factors
Complication
Management
DIABETES MILLITUS
 Common metabolic disorder
 Hyperglycemia
 Pathophysiologic changes in multiple
organ system
Classification of DM
 1. Type 1 diabetes ; betacell destruction
absolute insulin deficiency
 2. Type 2 diabetes ; insulin resistance
impaired insulin secretion
 3. Other specific types of diabetes
 4. Gestational DM
Diagnosis of DM
 Symptoms plus random blood glucose >
or = 200 mg/dl
 Fasting plasma glucose > or = 126 mg/dl
 A1C > 6.5 %
 2-hr plasma glucose > or = 200 mg/dl
( OGTT)
Risk factors
 Family history of diabetes
 Obesity ( BMI > 25 kg/m2 )
 Physical inactivity
 Race
 Previous IFG
 History of GDM or delivery of baby > 4 kg
 Hypertension
 HDL < 35 mg/dl and/or TG >250 mg/dl
 History of CVD
COMPLICATION
 Acute complication
- relative insulin deficiency and volume
depletion
1. Diabetic ketoacidosis
2. Hyperglycemic hyperosmolar state
 Chronic complication
CHRONIC COMPLICATION
 Vascular
Microvascular - retinopathy
- neuropathy
- nephropathy
Macrovascular - coronary heart disease
- peripheral arterial disease
- cerebrovascular disease
 Nonvascular
MECHANISMS OF COMPLICATION
 Unknown
 Chronic hyperglycemia = etiologic factor
 Hypothesis
hyperglycemia activate substance
atherosclerosis
endothelial dysfunction
glomerular dysfunction
GLYCEMIC CONTROL AND
COMPLICATIONS
 UKPDS - reduction in A1C associated with reduction
in microvascular complication
- strictly BP control reduce both macro and
microvascular complication
 DCCT - improved glycemic control associated with
reduce TG and increase HDL
EYE DISEASE COMPLICATION
 Diabetic retinopathy
retinal vascular microaneurysm
change in venous vessel caliber
vasc
permeability
hemorrhage
alter retinal
blood flow
retinal ischemia
appearance of neovascularization
rupture easily
vitreous hemorrhage , fibrosis
and retinal detachment
TREATMENT
 Prevention
most effective therapy
 Intensive glycemic and BP control
 Eye examination by ophthalmologist
 Laser photocoagulation
RENAL COMPLICATION
 Albuminuria associated risk of CVD
 Commonly have diabetic retinopathy
 Smoking accelerates the decline in renal
function
 Chronic hyperglycemia
alter renal microcirculation
 Type 1 DM
- 5-10 yrs ; 40 percent
microalbuminuria
- next 10 yrs ; 50 percent macroalbuminuria
- macroalbuminuria
reach ESRD in 7-10 yrs
 Type 2 DM
- albuminuria may be from other factors such as
HT , CHF , prostate disease or infection
- less predictive of DN and progression to
macroalbuminuria
TREATMENT
 Glycemic control
 Strictly BP control < 130/80 mmHg
 Treatment dyslipidemia
 ACE I OR ARBs
 Annual microalbuminuria ,serum Cr test
 Nephrology consultation ; GFR < 60 ml/min
NEUROPATHY
 50 percent of patient with long standing DM
 Correlate with glycemic control
 Additional risk factors are BMI ,smoking ,HT
hypertriglyceride
 Polyneuropathy
 Polyradiculopathy
 Mononeuropathy
 Autonomic neuropathy
POLYNEUROPATHY





Most common is distal symmetric polyneuropathy
Numbness , tingling , sharpness or burning
Lower extremities
Worsen at night
Progression ; the pain subsides sensory deficit
DIABETIC POLYRADICULOPATHY




Pain in one or more nerve root
Thoracic pain , abdominal pain , thigh pain
Associated with muscle weakness
Self-limited and resolve 6-12 months
MONONEUROPATHY
 Cranial and peripheral nerve
 Cranial nerve 3
diplopia
AUTONOMIC NEUROPATHY




Resting tachycardia , orthostatic hypotension
Hyperhidrosis of upper extremities
Anhidrosis of lower extremities
Hypoglycemia unawareness
TREATMENT






Glycemic control
improve autonomic neuropathy
Avoidance alcohol and smoking
Vitamin B 12 and folate supplement
Symptomatic treatment
Antidepressants , anticonvulsants
Foot wear
MACROVASCULAR COMPLICATIONS
 Cardiovascular disease
Cerebrovascular disease
 Peripheral artery disease
 DM
marked increase in CHF , CHD , MI ,
sudden death , PAD
 CHD risk equivalent
 Additional risk factors
DLP , HT , obesity
smoking ,reduced physical
activity

insulin resistance

activated PAI -1 and fibrinogen

coagulation process and impairs fibrinolysis

thrombosis
TREATMENT




Revascularization procedures
Beta blocker ,ACE I or ARB in CHD
Anti platelet therapy
Control other risk factor - DLP
- HT
- life style modification
- stop smoking
LOWER EXTREMITIES
COMPLICATION
 DM
the leading cause of non traumatic lower
extremity amputation
 Pathologic factors ; neuropathy
abnormal foot biomechanics
PAD
poor wound healing
TREATMENT
 Careful selection of footwear
 Daily feet inspection
 Keep feet clean and moist
 Avoid walking barefoot







Off – loading
Debridement
Wound dressing
ATB
Revascularization
Limited amputation
Hyperbaric oxygen
TAKE HOME MESSAGE






Glycemic control
BP and DLP control
Life style modification
Weight control
Exercise
Stop smoking
diet control
THANK YOU