Modul 2: Diabetes Mellitus complications & prevention

Dr. Salinah Mohd. MudriKlinik Kesihatan Sultan Ismail, JB31st May 2021

Overview lectures

1. Acute complications

Ø HypoglycemiaØ Diabetic ketoacidosis (DKA)Ø Euglycemia ketoacidosisØ Hyperglycemia hyperosmolar state

(HHS)

2. Chronic complications1. MICROVASCULAR´ Diabetes Retinopathy´ Nephropathy´ Diabetes Foot Ulcers2. MACROVASCULAR´ Heart disease´ Erectile / sexual Dysfunction´ Diabetes Foot Ulcers´ Stroke´ Peripheral Vascular Disease3. NEUROPATHY´ Diabetes Foot Ulcers´ Peripheral Neuropathy´ Autonomic Neuropathy4. MENTAL HEALTH ISSUES IN T2DM5. PERIODONTAL ISSUES IN T2DM

RISK FACTORS FOR COMPLICATIONS:

´ Uncontrolled BP´ Overweight / Obese´ LDL high, TG high, HDL low´ Positive Microalbuminuria´ Poor blood glucose control´ Unhealthy life style´ Poor self care management

PATHOPHYSIOLOGY OF COMPLICATIONS:

´ Atherosclerosis´ Arteriosclerosis´ Nerve dysfunction´ Renal parenchymal disease´ Vessel wall dysfunction due to inflammation secondary

to high glucose level´ Uncoordinated immune respond secondary to high

glucose level

Acute DM Complications & management:

´ Hypoglycemia´ Diabetic ketoacidosis (DKA)´ Euglycemia ketoacidosis´ Hyperglycemia hyperosmolar

state (HHS)

1. Hypoglycemia:

1. Low plasma glucose level ( < 3.9mmol/L)

2. Presence of autonomic / neuroglycopenic symptoms ( table 4-1)

3. Reversed by CHO intake

Classification of hypoglycemia:

Risk factors for hypoglycemia:

Management of hypoglycemia:

2. Diabetic ketoacidosis:

Diabetic ketoacidosis:

Diabetic ketoacidosis

3. Euglycemic ketoacidosis:

Euglycemic ketoacidosis:

Euglycemic ketoacidosis:

Hyperglycemic hyperosmolar state (HHS)

Hyperglycemic hyperosmolar state (HHS)

Management of chronic complications:1. MICROVASCULAR´ Diabetes Retinopathy´ Nephropathy´ Diabetes Foot Ulcers2. MACROVASCULAR´ Heart disease´ Erectile / sexual Dysfunction´ Diabetes Foot Ulcers´ Stroke´ Peripheral Vascular Disease3. NEUROPATHY´ Diabetes Foot Ulcers´ Peripheral Neuropathy´ Autonomic Neuropathy4. MENTAL HEALTH ISSUES IN T2DM5. PERIODONTAL ISSUES IN T2DM

Retinopathy

Retinopathy

Screening Eye examination

When to refer?

Retinopathy follow up & referral:

Diabetic kidney disease ( DKD)

Diabetic kidney disease ( DKD)1. DKD on albuminuria 2. DKD based on eGFR

DKD : nephrologist referral

Diabetic peripheral Neuropathy (DPN):

Diabetic peripheral Neuropathy (DPN):

Screening for Coronary Heart Disease

´ Diabetic patient are at increased risk of CHD. They may manifest as angina, myocardial infarction (MI), congestive cardiac failure (CCF) or sudden death.

´ Most frequent cause of death in T2DM.

´ Characterised by its early onset, extensive disease at the time of diagnosis, and higher morbidity and mortality after MI .

CVD Screening

´ Typical symptoms: referral to cardiologist.

´ May have atypical/vague symptoms especially trigger byexertion.

´ Asymptomatic: routine screening not recommended.

´ On first and subsequent visit, CVD risk calculator such asFramingham Risk Score (FRS) or SCORE should beapplied.

´ Patient with other macrovascular complications should bescreen for CHD.

JPAD = Japanese Primary Prevention of Atherosclerosis with Aspirin for DiabetesPOPADAD = Prevention of Progression of Arterial Disease and DiabetesPPP = Primary Prevention ProjectETDRS = Early Treatment Diabetic Retinopathy StudyPHS = Physiciansʼ Health StudyWHS = Womenʼs Health Study

De Beradis G, et al. BMJ 2009; 339:b4531.

ASA for 1⁰Prevention in DiabetesMeta analysis of 6 studies(n = 10,117)

No overall benefit for: • Major CV events • MI• Stroke• CV mortality• All-cause mortality

0.03 0.125 0.5 12

8Favors ASA Favors control/placebo

JPADPOPADADWHSPPPETDRSTotal

68/1262105/63858/51420/519

350/1856601/4789

86/1277108/63862/51322/512

379/1855657/4795

0.80 (0.59-1.09)0.97 (0.76-1.24)0.90 (0.63-1.29)0.90 (0.50-1.62)0.90 (0.78-1.04)0.90 (0.81-1.00)

Major CV events

No. of events/No. in group

ASA Control/placebo RR (95% CI) RR (95% CI)

JPADPOPADADWHSPPPETDRSPHSTotal

28/126290/63836/5145/519

241/185611/275

395/5064

14/127782/63824/51310/512

283/185526/258

439/5053

0.87 (0.40-1.87)1.10 (0.83-1.45)1.48 (0.88-2.49)0.49 (0.17-1.43)0.82 (0.69-0.98)0.40 (0.20-0.79)0.86 (0.61-1.21)

Myocardial infarction

JPADPOPADADWHSPPPETDRSTotal

12/126237/63815/5149/519

92/1856181/4789

32/127750/63831/51310/51278/1855201/4795

0.89 (0.54-1.46)0.74 (0.49-1.12)0.46 (0.25-0.85)0.89 (0.36-2.17)1.17 (0.87-1.58)0.83 (0.60-1.14)

Stroke

JPADPOPADADPPPETDRSTotal

1/126243/63810/519

244/1856298/4275

10/127735/6388/512

275/1855328/4282

0.10 (0.01-0.79)1.23 (0.80-1.89)1.23 (0.49-3.10)0.87 (0.73-1.04)0.94 (0.72-1.23)

Death from CV causes

JPADPOPADADPPPETDRSTotal

34/126294/63825/519

340/1856493/4275

38/1277101/63820/512

366/1855525/4282

0.90 (0.57-1.14)0.93 (0.72-1.21)1.23 (0.69-2.19)0.91 (0.78-1.06)0.93 (0.82-1.05)

All-cause mortality

CVD Screening :

Cerebrovascular Disease (stroke)

´ Risk are increase twice of ischaemic stroke compared to those without diabetes.

´ The risk of stroke is higher in women than in men.

´ Dyslipidaemia, endothelial dysfunction and platelet or coagulation abnormalities are among the risk factors that promote the development of carotid atherosclerosis in diabetics.

Diabetic Foot ´ Ulcerations and amputations are major causes of morbidity and

mortality.

´ Prevalence of lower limb amputation was 4.3%.

´ Risk factors for foot ulcers:´ Previous amputation´ Past foot ulcer history´ Peripheral neuropathy´ Foot deformity´ Peripheral vascular disease´ Visual impairment´ Diabetic nephropathy (especially patients on dialysis)´ Poor glycaemic control´ Cigarette smoking

Prevention of Foot Ulcers (DFU)

´ Starts with examination of the feet (shoes and socks removed) and identifying those at high risk of ulceration. Assess the peripheral neuropathy and peripheral pulses.

´ At-risk patients are then given relevant education to reduce the likelihood of future ulcers.

´ The feet should be examined at least once annually or more often in the presence of risk factors.

Treatment DFU

´ An ulcer in a patient with any of the above risk factors will warrant an early referral to a specialist for shared care.

´ Cellulitis will require antibiotics.

´ A multidisciplinary approach is recommended for patients with foot ulcer and high-risk feet (e.g. dialysis patients, those with charcot’s foot, prior ulcers or amputation).

Erectile Dysfunction (ED)´ Definition: Inability to achieve, maintain or sustain an

erection firm enough for sexual intercourse.

´ Prevalence of ED among diabetic men varies from 35%to 90%.

´ Factors associated:´Advancing age, duration of diabetes, poor glycaemic

control, presence of other diabetic complications,hypertension, hyperlipidaemia, sedentary lifestyle andsmoking

ED Screening and Diagnosis

´ All adult diabetic males should be asked about ED.

´ Screened for any symptoms or signs of hypogonadism.

´ Screening can be done using the 5-item version of theInternational Index of Erectile Function (IIEF) questionnaire.

Female Sexual Dysfunction (FSD)

´ Occur in 24–75% in diabetic women.

´ Age, duration of diabetes, poor glycaemic control,menopause, microvascular complications, and psychologicalfactors are associated with FSD.

Screening and Diagnosis

´ Diagnosis of FSD can be established by using the FSFIquestionnaire that consists of 19 questions covering all domainsof sexual dysfunction available at www.fsfiquestionnaire.com.The validated Malay version is also available.

FSD Treatment´ Emphasis should be made to treat psychosocial disorders

and relationship disharmony.

´ Avoid drugs that may affect sexual function:´Beta-blockers, alpha-blockers, diuretics´Tricyclic antidepressants, SSRIs, lithium, neuroleptics´Anticonvulsants´Oral contraceptive pills

´ In postmenopausal women, tibolone has been associatedwith significant increases in sexual desire and arousal.

Mental Health Issues in Diabetes

´Symptoms to look for may include the prolonged period of moodiness with any or all of the following:´Appetite changes´Loss of interest in daily activities´Feeling of despair´Inappropriate sense of guilt´Sleep disturbance´Weight loss´Suicidal thoughts

Indications for referral to a mental health specialist may include:

´Depression with the possibility of self-harm´Debilitating anxiety (alone or with depression)´Indications of an eating disorder ´Cognitive functioning that significantly impairs

judgment

Periodontal disease in T2DM

Screening for DM complications:

Screening for DM complications:

´ Mental health: DASS score´ Infectious disease: TB screening´ Cancer screening : iFoBt, pap smear, mammogram,

breast examination.

HbA1c Targets:

Individualised A1c Targets and Patients’ Profile

Tight (6.0 – 6.5%) 6.6 – 7.0% Less tight (7.1 – 8.0%)

• Newly diagnosed• Younger age• Healthier •(long life expectancy, no CVD complications)

• Low risk of hypoglycaemia

• All others • Co-morbidities (coronary artery disease, heart failure, renal failure, liver dysfunction)

• Short life expectancy• Prone to hypoglycaemia

Treatment Strategies: Glucose Triad

´ Treatment strategy should target all 3 components

Ceriello A, Colagiuri S. Diabet Med. 2008;25(10):1151-1156.

HbA1c

PPGFPG

Strategy Complication Reduction of Complication

Blood glucose control ▪ Heart attack ¯ 37%1

Blood pressure control

▪ Cardiovascular disease▪ Heart failure▪ Stroke▪ Diabetes-related deaths

¯ 51%2

¯ 56%3

¯ 44%3

¯ 32%3

Lipid control

▪ Coronary heart disease mortality▪ Major coronary heart disease event▪ Any atherosclerotic event▪ Cerebrovascular disease event

¯35%4

¯55%5

¯37%5

¯53%4

Treating to targets Reduces Diabetic Complications

1 UKPDS Study Group (UKPDS 33). Lancet. 1998;352:837-853.2 Hansson L, et al. Lancet. 1998;351:1755-1762.3 UKPDS Study Group (UKPDS 38). BMJ. 1998;317:703-713.4 Grover SA, et al. Circulation. 2000;102:722-727.5 Pyŏrälä K, et al. Diabetes Care. 1997;20:614-620.

Targets for BP Control

Targets for lipids control

Targets for ControlParameters Levels

Glycaemic control* Pasting or pre-prandial 4.4 – 7.0 mmol/L

Post-prandial** 4.4 – 8.5 mmol/L

A1c++ Target groups

Lipids Triglycerides ≤1.7 mmol/L

HDL-cholesterol >1.0 mmol/L (male)

>1.2 mmol/L (female)

LDL-cholesterol ≤2.6 mmol/L#

Blood pressure ≤130/80 mmHg$

Exercise 150 minutes/week

Body weight If overweight or obese, aim for 5-10%weight loss in 6 months