Dm Dan Komplikasi-tg

DIABETES DAN KOMPLIKASI Dr. Zaharita bt Bujang Klinik Kesihatan Pekan Nenas Pontian

SUDAH BERSEDIA NAK DENGAR CERAMAH ?

Sunday Star-26 March 2006 th

DIABETES MELITUS Penyakit yang tinggi morbiditi dan mortaliti Komplikasi diabetes * Retinopathy : 14.6% NIDDM > 40 thn * Nephropathy : 10% selepas 25 thn DM * Neurologi : 50% selepas 50 thn

Risiko co-morbiditi CVS

2-4

Stroke

5X

Amputasi

27.7X

Impotence

1/3 lelaki diabetes

PATHOGENESIS Impaired insulin secretion

Hyperglycaemia Increased hepatic glucose production

Decreased muscle glucose uptake

DIAGNOSIS • Pemeriksaan darah - FBS , RBS , MGTT • Gejala – gejala diabetes

DIAGNOSTIC CRITERIA FOR DIABETES (75 G ORAL GLUCOSE TOLERANCE TEST) Fasting Plasma Glucose (mmol/l)

2 hour Plasma Glucose (mmol/l)

< 6.1

Normal

> 6.1 - < 7.0

Impaired Fasting Glucose

> 7.0

Diabetes

< 7.8

Normal

> 7.8 - < 11.1

Impaired Glucose Tolerance

> 11.1

Diabetes

JENIS-JENIS PENYAKIT DIABETES

JENIS-JENIS PENYAKIT DIABETES

PRIMARY Type 1 (IDDM)

SECONDARY Type 2 (NIDDM)

TYPE 1 VS TYPE 2 • • • • • • • • •

Younger: Age< 30 yrs Lean HLA DR3 or DR4 Autoimune disease. Present of Islet cell antibodies. Insulin deficiency. May devel. Ketoacidosis. Always need insulin. Dissapearance of Cpeptide.

• • • • • • • • •

Older onset Overweight No HLA links No immune disturbance Insulin resistance. Partial insulin def. May devel. Hyperosmolar state. 50% need insulin after many years. C- peptide persist.

COULD DIABETES PREVENTED ????? • Lifestyle modification; – Weight loss >5%. – Reduce fat and increase dietary fibre . – Exercise > 30 min daily.

• ?? Lifestyle modification could prevent diabetes almost 100%.

• Prof J. Toumiletho Univ. Helsinki

EDUCATION ON DIABETES • A common chronic disorder • Chronic hyperglycaemia • Currently no known cure BUT can be

controlled for a healthy & productive life • Symptoms: Polyuria, polydipsia, tiredness, lethargy, wt loss • 50% not aware they are diabetic • Majority are asymptomatic

Causes of Death Among People With Diabetes CAUSES

% of Deaths

Ischemic heart disease

40

Other heart disease

15

Diabetes (acute complications)

13

Cancer

13

Cerebrovascular disease

10

Pneumonia/influenza

4

All other causes

5

Geiss LS et al. In: Diabetes in America. 2nd ed. 1995:233-257.

KOMPLIKASI DIABETES

Dyslipide mia Genetics

microvascul ar

Hypertension Smoking

macrovascular

CAD, PVD CVA

KOMPLIKASI DIABETES

AKUT

KRONIK

KOMPLIKASI AKUT

Hiperglisemia Koma

Hipoglisemia Koma

(Gula terlalu tinggi)

(Gula terlalu rendah)

Tanda amaran Terlalu dahaga Kencing banyak Letih Lemah Rasa mengantuk

Tanda amaran Rasa lapar Sakit kepala Ketar tangan Berdebar Berpeluh Tingkahlaku agresif

KOMPLIKASI KRONIK

Rosak

Rosak

Salurdarah kecil

Salurdarah besar

Mata Buah pinggang Saraf

Jantung Salur darah anggota

Kaki diabetes

DIABETIC COMPLICATIONS RETINOPATHY NEPHROPATHY NEUROPATHY DIABETIC FOOT CARDIOVASCULAR DISEASE

MATA Mudah dapat katarak ( selaput mata ) Glaukoma Retinopathy

Cataracts of the crystalline lens with opacification, as shown here, are more frequent in persons with diabetes mellitus.

Glaucoma with marked cupping of the optic disk is seen on funduscopic examination. The incidence of glaucoma is higher in the diabetic population.

Diabetic retinopathy is shown here on funduscopic examination.

Proliferative diabetic retinopathy on funduscopic examination is shown here. This is a particularly serious complication in diabetics that can lead to blindness.

DIABETIC COMPLICATIONS

RETINOPATHY NEPHROPATHY NEUROPATHY DIABETIC FOOT CARDIOVASCULAR DISEASE

Diabetic NephropathyNatural History

Screening for Diabetic Nephropathy

DARAH TINGGI

DIABETIC COMPLICATIONS TREATMENT RETINOPATHY NEPHROPATHY NEUROPATHY DIABETIC FOOT CARDIOVASCULAR DISEASE

SARAF Kehilangan rasa pada anggota kaki Saraf AutonomikTekanan darah rendah bila bangun - pening Kembung perut Impotence Mononeuropati

Diabetic neuropathy Pemeriksaan neurologi Diagnosis Ada gejala Touch and pin prick Vibration sense Position sense Ankle jerk Muscle wasting

Diabetic control Treat pain/parassthesia footcare

Autonomic neuropathy

TYPES OF NEUROPATHY • PERIPHERAL NEUROPATHY - Distal Symmetrical Polyneuropathy - Mononeuritis ( Amyotrophy ) - Painful Neuropathy ( Acute ) • AUTONOMIC NEUROPATHY - Gastroperesis, ED, Diabetic Diarrhoea Neuropathic Bladder, etc

NEUROPATHY TREATMENT PERIPHERAL NEUROPATHY SYMPTOMATICS ANTIEPILEPTICS : Clonoazepam, Gabapentin,

Carbamazipine TRICYCLICS :

Amitriptyline, Imipramine

OTHERS : Pentoxifylline, TENS, Acupuncture

TREATMENT AUTONOMIC DYSFUNCTION SEXUAL DYSFUNCTION GASTROPERESIS

SEXUAL DYSFUNCTION SEXUAL DYSFUCTION VASCULAR ASSESSMENT

NEUROLOGIC ASSESSMENT

HORMONAL ASSESSMENT

TREATMENT I/CAVERNOSAL HORMONAL INJ NON HORMONAL VACUUM

PI

PENILE PROTHESIS

DIABETIC COMPLICATIONS

RETINOPATHY NEPHROPATHY NEUROPATHY DIABETIC FOOT CARDIOVASCULAR DISEASE

DIABETIC FOOT DM PVD TREATMENT W OUND DEBRID ANTIBIOTICS AVOID WT BEARING REVASCULAR SURGERY ANTIPLATELET PENTOXYFYLINE AMPUTATION

ULCER INFECTION GANGRANE

NEUROPATHY PERIPHERAL AUTONOMIC

PREVENTION OPTIMAL GLYCEMIA GOOD FOOT CARE FOOT EVALUATION PODIATRIC VISIT

DIABETIC FOOT Screening Pemeriksaan kaki 6 -12 M DM control Specific intensive care Emphasize self care

Foot Ulcers and Amputations & DM – >50% of lower limb amputations in the US – Foot ulcers occur in 15% of diabetes patients over a lifetime – Cost of diabetes-related amputation: $27,000 National Diabetes Fact Sheet. November 1, 1997:1-8. Reiber GE et al. In: Diabetes in America. 2nd ed. 1995:409-428.

DIABETIC FOOT

• Foot problem ( esp. infection ) • Major reason for hospitalization • Leading cause of nontraumatic foot amputation. • Disorder of foot in Diabetic patient; • a) peripheral neuropathy • b) Ischemia

DIABETIC FOOT

• Common presentation: • a) Infection • b) Gangrene • c) Skin ulcers • d) Neuropathic joint disorder ( Charcot fracture).

PATHOPHYSIOLOGY • MULTIFACTORIAL: • a) Diabetic neuropathy • b) Vascular disease • c) Susceptibility to infection • d) Trauma • All these predispose the diabetic foot to ulcerations.

WHY ALL THE FUSS ABOUT FOOT IN DIABETES MELLITUS? • Although the various system failures associated with DM are more life threatening, it is noted that diabetic foot ulcer is more emotional and more disabling

Risiko amputasi 15X lebih tinggi untuk pesakit diabetes berbanding dengan orang lain.

EVALUATION OF ULCERS • Evidence of infection in adjacent soft tissue. • Probe – involvement of deeper structures, tendons, bone and joint.

WAGNER CLASSIFICATION • Stage 0 - Pressure area on the foot aggravated • • •

by footwear Stage 1 - Superficial ulcer Stage 2 - Full-thickness ulcer. Stage 3 - Full-thickness ulcer with abscess or osteomyelitis Stage 4 - Infected area with local gangrene ( forefoot ) Stage 5 - Extensive gangrene, foot and leg

RISK STATUS CLASSIFICATION 1) Normal sensation with no deformity. 2) Normal sensation with deformity. 3) Insensitivity without deformity. 4) Ischemia without deformity. 5) Complicated: combination insensitivity/ ischemia/ deformity; Charcot joint, previous ulceration, ulceration.

TREATMENT GRADE 0 – skin intact, bony deformity, foot at risk.

• Proper foot wear with padding. • Patient education. • Surgical correction of claw toes & prominent PIP joint.

TREATMENT GRADE 1 – superficial ulcers.

• Outpatient dressing changes. • Total contact cast. • Antibiotics.

TREATMENT GRADE 2 – Deep ulcers

• Hospitilazation. • Wound debridement/ aggressive. • Wound care and IV antibiotics. • Goal to correct to Grade 1 ulcer.

TREATMENT GRADE 3 – Abscess and osteomylitis

• Emergency drainage. • Wound left open for daily dressing till definite closure. • IV antibiotic • If failed, amputation.

TREATMENT

GRADE 4 - Gangrene of toes/ forefoot

AMPUTATION

TREATMENT GRADE 5 - whole foot gangrene

AMPUTATION

Foot ulcer

Foot ulcer

DIABETIC COMPLICATIONS RETINOPATHY NEPHROPATHY NEUROPATHY DIABETIC FOOT CARDIOVASCULAR DISEASE

PENYAKIT MACROVASCULAR • 80% KEMATIAN DIABETES ADALAH

BERKAITAN DENGAN PENYAKIT CARDIOVASKULAR • ANTARANYA* CORONARY ARTERY DISEASE *CEREBROVASCULAR – STROKE * PERIPHERAL VASCULAR DISEASE

PENGURUSAN KOMPLIKASI MACROVASCULAR SARINGAN CARDIOVASCULAR YEARLY / GEJALA

SEJARAH ANGINA , CLAUDICATION STROKE

CHECK BP CAROTID BRUIT PERPHERAL PULSE

ECG , CXR, STRESS TEST ECHO

Kardiovaskular • Untuk mengurangkan komplikasi

makrovaskular ,selain hyperglisemia semua faktor risiko harus dirawat • Merokok , dyslipidemia , kawal HPT, ubah gaya hidup

CV DISEASE & DIABETES HT

SILENT ISCHAEMIA CARDIO MYOPATHY

VASCULAR DYSFUNCTION

HYPER GLYCAEMIA

AMI ANGINA

INSULIN RESISTANCE

CLOTTING ABN SMOKING OBESE

DYSLIPIDAEMIA

CV COMPLICATIONS • CORONARY ARTERY DISEASE -ASYMPTOMATIC  SUDDEN DEATH

• PERIPHERAL ARTERY DISEASE • CEREBROVASCULAR DISEASE

CHD mortality according to degree of glucose tolerance Annual CHD mortality per 1000 persons

4

3.2 3 2

2.7

1.4

1 0 Normal glucose tolerance (n = 6055)

IGT (n = 690)

Newly diagnosed + known diabetes (n = 293)

Adapted from Eschwege E et al. Horm Metab Res Suppl 1985; 15: 41–6.

infarction (MI) in subjects with and without diabetes Diabetics must Fatal or non-fatal MI incidence during follow-up (%)

7-year follow-up

45

45

Be treated as if have Had heart attacks

40 35 30 25

18.8

20.2

20 15 10

3.5

5 0

Prior MI No MI Non DM Haffner SM et al. N Engl J Med 1998;339:229–34

Prior MI No MI DM

CORONARY ARTERY DISEASE TREATMENT MEDICAL INVASIVE/SURGICAL PREVENTION

MEDICAL TREATMENT THROMBOLYTIC THERAPY ANTIPLATELET BETA BLOCKER ACE INHIBITOR TIGHT GLYCAEMIC CONTROL CORRECT CVS RISK FACTORS

INVASIVE/SURGICAL PERCUTANEOUS CORONARY INTERVENTION ( PCI ) ANGIOPLASTY +/- STENTING SURGICAL BYPASS ( CABG ) HIGH RATE OF RESTENOSIS IN ANGIOPLASTY USE OF IIa/IIIb Platelet Inhibitor prevent restenosis post stenting ( EPISTENT Study )

• SEKIAN TERIMAKASIH ATAS PERHATIAN ANDA.