module iii complications of dm
TRANSCRIPT
SDM: Applications to Complications
Priorities of Care for Adults with Diabetes
CVD Risk
ASA, tobacco, ACEI/ARB, statin
CVD Risk
ASA, tobacco, ACEI/ARB, statin
© 2008 International Diabetes Center.
Diagnosis–PreventionDx Fasting Glucose > 126 Casual > 200 + Symptoms
Prevent Pre-diabetes (IFG-IGT) & Metabolic Syndrome
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
Other essentialsof care
Pre DiabetesPre DiabetesMetabolic SyndromeMetabolic Syndrome
Insulin Level
©© 2007 International Diabetes Center, Minneapolis, MN All rights reserved. 2007 International Diabetes Center, Minneapolis, MN All rights reserved.
YearsYears
Glu
cose
G
luco
se (
mg
/dL
)(m
g/d
L)
Rel
ativ
e fu
nct
ion
Rel
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-10-10 -5-5 00 55 1010 1515 2020 2525 3030
5050
100100
150150
200200
250250
300300
350350
Insulin ResistanceInsulin Resistance
Fasting GlucoseFasting Glucose
Postmeal GlucosePostmeal Glucose
OnsetDiabetes
OnsetDiabetes
00
5050
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
Chronic Complications of Diabetes
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)
– Epidemiology of Diabetes in Complications (EDIC)
Type 2 Diabetes
– United Kingdom Prospective Diabetes Trial (UKPDS)
– UKPDS 10 Year Follow-up
UKPDSReduction in Microvascular Disease
-21
-34
-25
-40
-35
-30
-25
-20
-15
-10
-5
0
5
10
Ris
k R
edu
ctio
n (
%)
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.
00
22
44
66
88
66 77 88 99 1010 1111 1212Hemoglobin A1c
Rel
ativ
e R
isk
of
Co
mp
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tio
ns
Lowering blood glucose significantly reduces the risk of microvascular complications
In both Type 1 and Type 2 diabetes
Chronic Complications of 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
Chronic Complications of Diabetes
MicrovascularMicrovascular
EyeEyeRetinopathyRetinopathyCataractsCataractsGlaucomaGlaucoma
KidneyKidneyNephropathyNephropathy
• MicroalbuminuriaMicroalbuminuria• Gross albuminuriaGross albuminuria• Kidney failureKidney failure
NervesNervesNeuropathyNeuropathy
• PeripheralPeripheral• AutonomicAutonomic
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.
International Diabetes Federation, 2008
Diabetic GlomerulosclerosisNormal Glomerulus
Longstanding Diabetes
Messangial Proliferation and Sclerosis
Thickening Basement Membrane
Diminished & Leaking
Filtering Space
Proteinuria
CrCl
HTN
ESRD
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
NO
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
mg/g?
Diagnosis of macroalbuminuria
Repeat screenannually
NO
YES
A/C ratio >300 mg/g?
NO
YES
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
100
200
300
400
0 1 2 3 4 5
Placebo
Enalapril
Ravid M. Ravid M. Ann Intern MedAnn Intern Med 118:577, 1993 118:577, 1993
Pro
tein
uri
a (m
g/2
4 h
r)P
rote
inu
ria
(mg
/24
hr)
Years follow-up
Chronic Complications of Diabetes
MicrovascularMicrovascular
EyeEyeRetinopathyRetinopathyCataractsCataractsGlaucomaGlaucoma
KidneyKidneyNephropathyNephropathy
• MicroalbuminuriaMicroalbuminuria• Gross albuminuriaGross albuminuria• Kidney failureKidney failure
NervesNervesNeuropathyNeuropathy
• PeripheralPeripheral• AutonomicAutonomic
Neuropathy in Diabetes
Peripheral Neuropathy
Pain
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
Priorities of Care for Adults with Diabetes
CVD Risk
ASA, tobacco, ACEI/ARB, statin
CVD Risk
ASA, tobacco, ACEI/ARB, statin
© 2008 International Diabetes Center.
Diagnosis–PreventionDx Fasting Glucose > 126 Casual > 200 + Symptoms
Prevent Pre-diabetes (IFG-IGT) & Metabolic Syndrome
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
Other essentialsof care
Chronic Complications of Diabetes
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 !
0
1
2
3
4
5
6
7
8
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
Ev
ents
/ 1
00 p
erso
n-y
r
Benefit of Glucose Control in Reducing Macrovascular Complications
Type 1 Diabetes
– Epidemiology of Diabetes in Complications (EDIC)
Benefit of Glucose Control in Reducing Macrovascular Complications
Type 1 Diabetes
– Epidemiology of Diabetes in Complications (EDIC)
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
International Diabetes Federation, 2008
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
0
10
20
30
40
110 130 150 170
Co
mp
licat
ion
Rat
e
Co
mp
licat
ion
Rat
e
per
10
00 p
erso
n-y
ears
per
10
00 p
erso
n-y
ears
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
2010
ADA Clinical Practice Recommendations 2009. Diab Care 32:Suppl. 1; ADA Clinical Practice Recommendations 2010. Diab Care 33:Suppl. 1.
Priorities of Care for Adults with Diabetes
CVD Risk
ASA, tobacco, ACEI/ARB, statin
CVD Risk
ASA, tobacco, ACEI/ARB, statin
© 2008 International Diabetes Center.
Diagnosis–PreventionDx Fasting Glucose > 126 Casual > 200 + Symptoms
Prevent Pre-diabetes (IFG-IGT) & Metabolic Syndrome
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
Other essentialsof care
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
Skin
Nails
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.
Source: Staged Diabetes Management, 5th edition, Quick Guide, pages 7-27.
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
Source: Staged Diabetes Management, 5th edition, Quick Guide, pages 7-28.
Source: Staged Diabetes Management, 5th edition, Quick Guide, pages 7-28.
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