DIABETES DAN KOMPLIKASI

Dr. Zaharita bt Bujang Klinik Kesihatan Pekan Nenas Pontian

SUDAH BERSEDIA NAK DENGAR CERAMAH ?

Sunday Star-26th March 2006

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
Stroke Amputasi

2-4
5X 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) < 6.1 > 6.1 - < 7.0 Normal Impaired Fasting Glucose

> 7.0
2 hour Plasma Glucose (mmol/l) < 7.8

Diabetes
Normal

> 7.8 - < 11.1

Impaired Glucose Tolerance

> 11.1

Diabetes

JENIS-JENIS PENYAKIT DIABETES

JENIS-JENIS PENYAKIT DIABETES

PRIMARY

SECONDARY

Type 1 (IDDM)

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
Ischemic heart disease
Other heart disease Diabetes (acute complications) % of Deaths 40

15
13 13

Cancer
Cerebrovascular disease Pneumonia/influenza All other causes

10
4 5

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

KOMPLIKASI DIABETES

Dyslipidemi a Genetics

Hypertension

Smoking

microvascular

macrovascular

CAD, PVD CVA

KOMPLIKASI DIABETES

AKUT

KRONIK

KOMPLIKASI AKUT

Hiperglisemia Koma (Gula terlalu tinggi)

Tanda amaran Terlalu dahaga Kencing banyak Letih Lemah Rasa mengantuk

Hipoglisemia Koma (Gula terlalu rendah)

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

KOMPLIKASI KRONIK

Rosak Salurdarah kecil

Mata Buah pinggang Saraf

Rosak Salurdarah besar

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

Autonomic neuropathy

Diabetic control Treat pain/parassthesia footcare

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 TREATMENT

HORMONAL ASSESSMENT

HORMONAL NON HORMONAL

I/CAVERNOSAL INJ VACUUM

PI

PENILE PROTHESIS

DIABETIC COMPLICATIONS

RETINOPATHY NEPHROPATHY NEUROPATHY DIABETIC FOOT CARDIOVASCULAR DISEASE

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

DM
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

SILENT ISCHAEMIA HT INSULIN RESISTANCE HYPER GLYCAEMIA CLOTTING ABN SMOKING OBESE DYSLIPIDAEMIA

CARDIO MYOPATHY
AMI ANGINA

VASCULAR DYSFUNCTION

CV COMPLICATIONS
CORONARY ARTERY DISEASE
-ASYMPTOMATIC SUDDEN DEATH

PERIPHERAL ARTERY DISEASE CEREBROVASCULAR DISEASE

CHD mortality according to degree of glucose tolerance

4
Annual CHD mortality per 1000 persons 3.2 3 2.7

2 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: 416.

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.