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Diabetes Mellitus Fifth Stage-Medicine. Dr. Sarbast Fakhradin MBChB, MSc Diabetes Care & Management. Chronic complications of DM. 1. Macrovascular: A. Coronary heart disease B. Peripheral arterial disease C. Cerebrovascular disease 2. Microvascular:

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diabetes mellitus fifth stage medicine

Diabetes MellitusFifth Stage-Medicine

Dr. Sarbast Fakhradin

MBChB, MSc Diabetes Care & Management

chronic complications of dm
Chronic complications of DM
  • 1. Macrovascular:
  • A. Coronary heart disease
  • B. Peripheral arterial disease
  • C. Cerebrovascular disease
  • 2. Microvascular:
  • A. Eye disease: Retinopathy, Maculopathy.
  • B. Neuropathy, sensory, motor, autonomic
  • C. Nephropathy.
  • 3. Other:
  • A. GIT (Gastroparesis)
  • B. Genitourinary (Uropathy, Sexual dysfunction)
  • C. Dermatologic
  • D. Infection
  • E. Cataract & Glaucoma
  • F. Periodontal disease
  • G. Hearing loss
slide3

Pathophysiology

  • Macrovascular: Atherosclerosis occur earlier in life, more extensive & more sever.
  • Microvascular: thickening of the capillary basement membrane, increased vascular permeability.
slide4

Factors associated with increased mortality and morbidity in people with diabetes

  • 1. Duration of diabetes
  • 2. Early age at onset of disease
  • 3. High glycated haemoglobin (HbA1c)
  • 4. Raised blood pressure
  • 5. Proteinuria; microalbuminuria
  • 6. Dyslipidaemia
  • 7. Obesity
preventing diabetes complications
Preventing diabetes complications
  • 1. Education
  • 2.Glycemic control
  • 3. Hypertension (ACEI, AII receptor antagonist)
  • 4. Dyslipidemia
  • 5. Smoking
  • 6. Alcohol

→Silent myocardial infarction (neuropathy)

diabetic retinopathy
Diabetic retinopathy
  • Clinical features :
  • 1. Microaneurysms
  • 2. Retinal haemorrhages (dot and blot)
  • 3. Exudates
  • 4. Cotton wool spots
  • 5. Venous changes
  • 6. Neovascularisation (retina and iris)
  • 7. Pre-retinal/subhyaloidhaemorrhage
  • 8. Vitreous haemorrhage
  • 9. Fibrosis/gliosis

Types of retinopathy:

  • Non-proliferative 'background' retinopathy without maculopathy
  • Pre-proliferative retinopathy
  • Proliferative retinopathy
  • Maculopathy
diabetic retinopathy1
Diabetic retinopathy
  • Management:
  • Glycaemic control
  • Blood pressure control
  • Lipid profile control
  • laser photocoagulation
  • Vitrectomy
diabetic nephropathy
Diabetic nephropathy

Stages of diabetic nephropathy:

Random urine sample can estimate urinary Albumin:Creatinine Ratio; normal range (mg/mmol) differs in males (< 2.5) and females (< 3.5)

slide10

Abnormal results

  • Exclude recent (24 hrs) vigorous exercise, fever, heart failure, urine infection, prostatitis, menstruation
  • Confirm observation twice within 3-6 months
  • Look for blood pressure above target levels.
  • Management
  • 1. Improved control of blood glucose
  • 2. Aggressive reduction of blood pressure
  • 3. Aggressive cardiovascular risk factor reduction (ACE inhibitors, ARB, statins and aspirin)
  • 4. Medications: Metformin dose, Insulin, etc
  • 5. Renal replacement therapy & transplantation
slide11

Screening for diabetic retinopathy & nephropathy

  • 1. Patients with type 1 diabetes annually from 5 yrs after diagnosis
  • 2. Patients with type 2 diabetes annually from time of diagnosis
diabetic neuropathy
Diabetic Neuropathy
  • Approximately 30% of diabetic patients.
  • Associated with the duration of diabetes and the degree of metabolic control.
  • They can occur in motor, sensory and autonomic nerves, or in combination.
classification of diabetic neuropathy
Classification of diabetic neuropathy
  • A. Somatic
  • 1. Polyneuropathy
    • Symmetrical, mainly sensory and distal
    • Asymmetrical, mainly motor and proximal (including amyotrophy)
  • 2. Mononeuropathy (including mononeuritis multiplex)
  • B. Visceral (autonomic)
  • 1. Cardiovascular
  • 2. Gastrointestinal
  • 3. Genitourinary
  • 4. Sudomotor
  • 5. Vasomotor
  • 6. Pupillary
clinical features
Clinical features
  • Symmetrical sensory polyneuropathy:
  • Asymptomatic
  • Symptomatic: The most common clinical signs are diminished perception of vibration sensation distally, 'glove-and-stocking' impairment of all other modalities of sensation, & loss of tendon reflexes in the lower limbs.
slide15

Symmetrical sensory polyneuropathy: (Cont)

  • Paraesthesiae in the feet, pain in the lower limbs (worse at night &on the anterior aspect of the legs), burning sensations in the soles of the feet, hyperaesthesia and an abnormal gait (commonly wide-based), Muscle weakness and wasting(advanced case), The toes may be clawed with wasting of the interosseous muscles, which results in increased pressure on the plantar aspects of the metatarsal heads (callus formation).
slide17

Asymmetrical motor diabetic neuropathy (diabetic amyotrophy)

  • Severe & progressive weakness & wasting of the proximal muscles of the limbs (Mainly lower)
  • Severe pain (anterior aspect of the leg), hyperaesthesia & paraesthesiae.
  • Loss of weight ('neuropathic cachexia').
  • The patient may look extremely ill & be unable to get out of bed.
  • There may be absent tendon reflexes, extensor plantar responses, & the CSF protein is often raised.
  • Some deficits become permanent.
  • Management is mainly supportive.
slide18

Mononeuropathy

  • Motor or sensory
  • Peripheral or cranial nerve
  • Unlike the gradual progression of distal symmetrical and autonomic neuropathies, mononeuropathies are severe and of rapid onset but they eventually recover.
  • Most commonly affected are the 3rd and 6th cranial nerves (diplopia), the femoral and sciatic nerves, median nerve (carpal tunnel syndrome), ulnar nerve, Lateral popliteal nerve (foot drop).
autonomic neuropathy
Autonomic neuropathy
  • Clinical features
  • 1. CVS: Postural hypotension, resting tachycardia, fixed heart rate.
  • 2. GIT:Dysphagia, abdominal fullness, nausea & vomiting, unstable glycaemia, due to delayed gastric emptying ('gastroparesis'), nocturnal diarrhoea ± faecal incontinence, & Constipation.
  • 3. Genitourinary:Difficulty in micturition, urinary incontinence, recurrent infection, erectile dysfunction & retrograde ejaculation,
  • 4. Sudomotor: Gustatory sweating, nocturnal sweats without hypoglycaemia, anhidrosis; fissures in the feet
  • 5. Vasomotor: Feet feel cold, dependent oedema, & bullous formation
  • 6. Pupillary:Decreased pupil size, delayed or absent reflexes to light.
  • →The development of autonomic neuropathy is less clearly related to poor metabolic control than somatic neuropathy, and improved control rarely results in amelioration of symptoms.
management
Management
  • Pain and paraesthesiae from peripheral somatic neuropathies
  • 1. Strict glycaemic control
  • 2. Anticonvulsants (gabapentin, pregabalin, carbamazepine, phenytoin)
  • 3. Antidepressants (amitriptyline, imipramine, duloxetine)
  • 4. Opiates (tramadol, oxycodone)
management1
Management
  • Postural hypotension: Support stockings, Fludrocortisone, α-adrenoceptor agonist, NSAIDs
  • Gastroparesis: Dopamine antagonists (metoclopramide, domperidone), Erythromycin.
  • Diarrhoea :Loperamide, Broad-spectrum antibiotics
  • Constipation: laxatives (senna)
  • Erectile dysfunction (impotence): Phosphodiesterase type 5 inhibitors (sildenafil, vardenafil, tadalafil)-oral, vacume, implantation, psychosexual therapy.