Diabetul zaharat*

Plan curs 1. Definiie. Generaliti. Clasificare2. Etiopatogenie3. Fiziopatologie4. Tablou clinic5. Investigaii paraclinice6. Diagnostic7. Tratament8. Complicaii

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*DefiniieDiabetul zaharat este o stare patologic, caracterizat prin hiperglicemie cronic determinat de 2 factori: scderea secreiei de insulin i insulinorezisten (reducerea sensibilitii la insulin).

Consecutiv hiperglicemiei apar perturbri ale metabolismului protidic, lipidic i hidroelectrolitic.

Diabeiu = a se scurge ca printr-un sifonIstoricPaulescu 1921

Epidemiologie:Romnia: 6-8% din populaia adult750000 pacieni nregistraitot atia necunoscuiLume: frecven n cretere366 milioane n 2011183 milioane (50%) nediagnosticatiEstimat 552 milioane in 2030

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Prevalena diabetului - 2007246 Millioane

Prevalence of Diabetes - 2025380 Million

* Importana diabetului zaharatDiabetul zaharatOrbire *Insuficien renal * Amputaii*Speran de via cu 5 - 10 aniBolile cardiovasculare de 2-4 X*Diabetul zaharat este prima cauz de insuficien renal, cazuri noi de orbire i amputaii netraumaticeAfectarea SN n 60% la 70% dintre pacieniA 4-a cauz de deces (dup infecii, BCV, cancere)Diabetes Statistics. October 1995 (updated 1997). NIDDK publication NIH 96-3926.Harris MI. In: Diabetes in America. 2nd ed. 1995:1-13. SCUMP !!!

Mortalitate (4,6 mil decese in 2011)*

Hiperglicemia cronic a diabeticilor este asociat cu disfuncia i insuficiena diferitelor organe in special a:ochilor,rinichilornervilorinimiivaselor sanguineDiabet zaharat. Complicatii

* Clasificarea DZ (OMS 1999)1. Diabet zaharat tip 1 (5-10%) -distrucie de celule beta- deficit absolut de insulin

2. Diabet zaharat tip 2 (90-95%)- insulinorezisten + deficit relativ de insulin

3. Alte tipuri specifice de diabet zaharat

4. Diabet gestaional- hiperglicemie cu debut n timpul sarcinii

*DZ tip 1 autoimun

1. Predispoziia genetic

2. Factorii de mediu

3. Autoimunitatea

Distrucia celulelor Etiopatogenia DZ tip 1

Patogenia DZ tip 1*Proces autoimunIdiopatic Distrucia de celule Glicemiei Factori de mediuPredispoziia genetic secreiei de insulin

Evoluia natural a DZ1

*Factori de riscNemodificabili

Predispoziia genetic

Vrsta

EtniaModificabili

Greutatea

SedentarismulEtiopatogenia DZ tip 2

Patogenia DZ tip 2* GlicemieiInsulinorezistena secreiei de insulin Defecte la nivelul receptorului de insulin i postreceptor cu prelurii glucozeiMuchiesut adipos produciei de glucozFicat Pancreas

Tablou clinic50% asimptomatici50% simptomaticiPoliurie (diurez > 2000ml/24h)Polidipsie (senzaie de sete imperioas)scdere ponderalastenie, scderea forei fizice i intelectualePolifagie (exagerarea apetitului)semnele complicaiilor infecioase i degenerative*

*Circumstane de diagnosticSemne clinice sugestive de DZ

Categorii de persoane la riscPersoane obeze, mai ales cele cu obezitate abdominalPersoane cu antecedente heredocolaterale de diabet zaharatVrsta > 45 aniPersoane cu afectare coronarian preexistent, afectare cerebrovascular, boala arterial periferic sau HTAPersoane cu dislipidemieFemei cu istoric de diabet gestaional sau macrosomieFemei obeze cu boala ovarelor polichisticePersoane cunoscute anterior cu scderea toleranei la glucoz sau alterarea glicemiei bazale. IDF 2005

Diagnostic pozitivglicemia plasmatic a jeun 126 mg%

glicemia plasmatic recoltat ntmpltor 200mg%

TTGO (200 mg% la 2 h)

HbA1c 6,5%

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*Diferenierea dintre DZ tip 1i 2 Asociere cu boliautoimunedanu

Tratamentul: obiective generaleobinerea unui control glicemic foarte bun, n tot cursul zilei i pentru toat viaasuprimarea simptomelorprevenirea complicaiilorabsena hipoglicemiilornormalizarea profilului lipidicmonitorizarea TA

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Mijloace de tratament*1. Modificarea stilului de via:-diet-exerciiu fizic2. Medicaia antidiabetic:-insulin-medicaia antidiabetic non-insulinic

3. Educaia i autocontrolul glicemic

* Dieta n DZ: - adecvat caloric - coninut adecvat n principii alimentare- orarul meselor

Categorii de alimentealimente ce pot fi consumate fr restricie: legume

Exerciiul fizicScderea sau meninerea greutiiAmeliorarea:insulinosensibilitiiTAlipidogrameicontrolului glicemic

Insulina loc de administrare

Stilouri de insulin

Medtronic: MiniMedPompe de insulinDisetronic: H-Tron+

Hipoglicemia-Definiie: glicemia

Hipoglicemia: simptome i semneSeveritate:uoarmoderatseverUoar: transpiraii, tremurturi, durere epigastric, foameModerat: + cefalee, oboseal, diplopieSever: + somnolen, dezorientare, agitaie, convulsii, com, Babinski bilateralHipoglicemie sever = pacientul are nevoie de ajutor pentru a trata episodul hipoglicemic

Hipoglicemia: terapieUoar i moderat:2-3 lingurie cu zahr (10-15g)1 lingur miere1 lingur dulcea1 pahar suc dulce3 ptrele ciocolat, 1 bomboan dulceComa hipoglicemic- glucoz 33% i.v- glucagon 1 - 2 mg i.m.

Lipodistrofiile

Medicaia antidiabetic non-insulinic: indicaii DZ tip 2

Clase de medicamenteBiguanide (metformin)SulfonilureiceMeglitinideTiazolidindioneInhibitori de -glucozidazAgoniti GLP-1Inhibitori DPP-4

Medicaia antidiabetic non-insulinic

Complicaiile diabetului zaharatI. Complicaii acuteMetabolice:a) acidozele diabetice - cetoacidoza diabetic- acidoza mixt (diabetic + lactic)b) coma diabetic hiperosmolar

Infecioase:a) respiratoriib) urinarec) cutaneo-mucoase, esut celular subcutanat (orice sediu este posibil)*

Complicaiile diabetului zaharatII. Complicaii croniceInfecioase:a) respiratorii (tuberculoza pulmonar)b) urinarec) cutaneo-mucoased) ORL, stomatologice (orice sediu este posibil)

Degenerative:a) angiopatia - microangiopatia: retinopatia, nefropatia - macroangiopatiab) neuropatiac) cataractad) parodontopatia*

Cetoacidoza diabeticDefiniia : hiperglicemie + cetoz acidoz

complicaie grav: furtun metabolic

factor determinant: deficitul sever de insulin*

Factorii favorizani/precipitani ai CAD

ntreruperea tratamentului insulinic (n DZ tip 1)

infecii severe, IMA, stres chirurgical sau traumatic, pancreatit acut, etc.

CAD inaugural

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Clinic n CADpoliurie, polidipsie halen acetonemic uoar, apoi miros evident de aceton (mere putrede)deshidratare (uoar apoi sever) +/- jen epigastric (poate mima abdomenul acut chirurgical)ROT reduse/abolite, dezorientare, somnolen, pierderea contieneidispneea Kussmaul (pH sub 7,2)

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Coma hiperglicemic Coma hipoglicemic

Debut lent, progresivrapid

Tonus muscular sczutcrescut, contracturi

Hidrataredeshidratare N, +/- transpiraii

Neuropsihicaton, linititagitat, convulsii, Babinski+ bilateral

Biologichiperglicemiehipoglicemieglicozurie + glicozurie -corpi cet. ur +corpi cet. ur. -*

Complicaii cronice degenerativeDZ cu durat lung + ru controlatAngiopatia diabetic- microangiopatia - retinopatia - nefropatia- macroangiopatia - cardiopatia ischemic - boala vascular cerebral - arteriopatia mb. inferioareNeuropatia diabeticCataracta etc.*

*Structura ochiului

principala cauz de orbirespecific DZ, bilateral, de aceeai severitate la ambii ochirolul hiperglicemiei de durat

Diagnosticul RD = OFTALMOSCOPIC !!! (fund de ochi)Dg. precoce = angiografia cu fluorescein*Retinopatia diabetic

*Aspect normalAspect normal- angiografia cu fluoresceina

*Angiografie cu fluorescein microanevrismeNormal

*Retinopatie neproliferativ form uoarmicroanevrismehemoragie punctiformaNormal

*Retinopatie neproliferativ form uoar -fluorescein-microanevrismehemoragie punctiformaNormal

*Retinopatie neproliferativ-exsudate dure, hemoragii-Normal

*Retinopatie proliferativexsudate moivase de neoformatie la nivelul discului optic

*a= retinopatie proliferativb=hemoragie masivab

Tratamentul retinopatiei diabetice

asigurarea controlului metabolicfotocoagularea (laserterapia) *

Nefropatia diabetic (ND)Localizarea glomerular (renal) a microangioapatiei

Cauz de insuficien renal terminal (1/3 dintre dializai)

Este asimptomatic pn n stadii tardive!!!

Diagnostic de laborator

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Macroangiopatia diabeticGeneraliti-Definiie: Proces de ateroscleroz, ce afecteaz arterele-Particulariti:- mai frecvent- mai precoce (cu 10 ani)- mai distal (dificil de corectat chirurgical)- mai sever- egal la cele dou sexe*

Localizare1. Cardiopatia ischemic: -angin pectoral-infarct miocardic acut - form nedureroas -moarte subit -aritmii-insuficien cardiac etc.2. Boala vascular cerebral: -AVC -lacunarism cerebral*

Localizare3. Arteriopatia membrelor inferioare: Diagnosticul pozitiv: - clinic = puls absent de la diferite niveluri - eco Doppler, arteriografieStadializare: 4 stadii- std I: asimptomatic, parestezii- std II: claudicaie intermitent- std III: durere permanent- std IV: necroze i gangrene

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Neuropatia diabetic (NED)Generaliti- Definiie: reprezint ansamblul tulburrilor neurologice, anatomice i clinice aprute n DZ i datorate acestuia.

Dup 20 de ani de boal, majoritatea diabeticilor au o manifestare a neuropatiei !

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Localizare: poriunea distal a mb. inf. (1/2 gamb, picior)

Simptome simetrice: parestezii, ascendente evolutiv (n oset), arsuri (nocturne, mai ales), nepturi, furnicturi

sensibilitii dureroase i termice

*Polineuropatia senzitiv simetric distal

Piciorul diabetic-Definiie: totalitatea modificrilor i leziunilor anatomo-clinice ce pot aprea la nivelul piciorului unui pacient cu DZ, fiind cauzate de aceast afeciune.-Principala cauz de amputaie (30-50 x mai frecvent dect la nediabetici)-Etiologia:- arteriopatia- neuropatia diabetic

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*Gangrena ischemo-neuropat

Gangrena ischemo-neuropat*

*Gangrena neuro-ischemic

*Picior Charcot

*Picior Charcot, cu ulceraie

*ngrijirea piciorului de ctre pacientul cu DZ

Decalogul prevenirii gangreneii amputaiilorNu umbla niciodat descul!Nu pune ap fierbinte sau nclzitoare pe picioare!Inspecteaz-i picioarele zilnic!Pstreaz-i picioarele curate i uscate!Folosete creme dac pielea este uscat!Folosete nclminte comod!Taie unghiile drept!Trateaz precoce orice leziune!Oprete fumatul!!!!

Alte complicaii ale DZCataracta diabetic - precoce, naintea vrstei de 40 = 50 de ani- bilateral

Parodontopatia diabetic (cderea precoce a dinilor)*

***Slide V/13Biguanides work principally at the liver, decreasing hepatic glucose output.155 Metformin, the only biguanide available, is particularly useful in obese patients as it does not produce weight gain and may facilitate weight reduction. Side effects, particularly those affecting the gastrointestinal system, are not uncommon, however, and care is necessary to avoid lactic acidosis, the most dangerous side effect. The UKPDS provides evidence of its benefit as single therapy, with equivocal results in combination with a sulfonylurea.107 Sulfonylureas reduce blood glucose concentrations by stimulating insulin secretion through their effect on ATP-sensitive potassium channels in the beta cell.155 Their use is associated with weight gain, their long-term safety as regards macrovascular disease has been in doubt since publication of the UGDP study;137 however, this was not confirmed in the UKPDS.50 Alpha-glucosidase inhibitors decrease glucose absorption by inhibiting the breakdown of disaccharides to monosaccharides. They reduce postprandial glycemia and HbA1c levels.156 Poor tolerability due to mild to moderate gastrointestinal side effects limits their use.The thiazolidinediones are a new class whose first member is troglitazone.157 These agonists for peroxisome proliferator-activated receptor (PPAR) gamma improve insulin sensitivity in muscle and adipose tissue.155 The class is effective alone and particularly in combination with sulfonylureas or metformin. Use of troglitazone requires careful monitoring because of idiosyncratic hepatic toxicity.157Type 2 diabetics often need insulin eventually,158 but it can be associated with weight gain. Combining insulin with metformin or troglitazone is useful.

*Diabetic microvascular complications are most commonly manifested in the eyes, kidneys, and nerves.Diabetic retinopathy and diabetic macular edema: Diabetes is the leading cause of new cases of blindness in adults between the ages of 20 and 74 years.1 After 15 years of diabetes, 2% of patients become blind and 10% develop severe visual disability.4Diabetic nephropathy: In end-stage renal disease, diabetes accounts for about 35% to 40% of new cases.1 People with diabetes make up the fastest-growing group of renal dialysis and transplant recipients.3Diabetic neuropathy and amputations: Diabetes is the leading cause of nontraumatic lower-extremity amputations, accounting for 50% of amputations in the United States. About 60% to 70% of people with diabetes have some degree of diabetic nerve damage.4There is also a high frequency of atherosclerosis (macrovascular disease) leading to increased risk of stroke and/or heart attack.Cardiovascular disease: People with diabetes are 2 to 4 times more likely to die from heart disease than people without diabetes. Cardiovascular disease is responsible for 50% of diabetes-related deaths.2Stroke: A person with diabetes is 2 to 4 times more likely to suffer a stroke than a person without diabetes.1

1. National Diabetes Information Clearinghouse. Diabetes StatisticsComplications of Diabetes. http://www.niddk.nih.gov/health/diabetes/pubs/dmstats/dmstats.htm#comp. Accessed May 1, 2001.

Diabetes mellitus is associated with a wide variety of microvascular and macrovascular complications.