The Diabetologist and the Rheumatologist:

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The Diabetologist and the Rheumatologist What
They Share In Patient Care
Dr Hatem H Eleishi, MD Consultant
Rheumatologist Dr Soliman Fakeeh Hospital
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In this lecture,
Patients with Diabetes Who Might Need To See a
Rheumatologist
Patients with Rheumatic Diseases Who might Need
To See a Diabetologist
Patients with Other Diseases Who Might Need To
See Both a Rheumatologist and a Diabetologist
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Patients with Diabetes Who Might Need To See a
Rheumatologist
Rheumatologic disorders that can affect patients
with diabetes
Anti-diabetic drugs that might result in
rheumatologic complications
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Rheumatologic disorders that can affect patients
with diabetes
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Rheumatologic disorders that can affect patients
with diabetes
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Important Facts and Statistics
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The musculoskeletal complications of diabetes
appear particularly when the disease is poorly
controlled.
Recent data show that more then 30 of patients
with type 1 or type 2 diabetes have some
rheumatic manifestation.
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Thus, although the cardiovascular, renal and
ocular complications of diabetes are the most
severe, we should not also forget rheumatic
syndromes and complications
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The relationship between diabetes and the
musculoskeletal disorders associated with it is
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Humeral periarthropathy
Hand Abnormalities Stiff hand syndrome Flexor
tendon synovitis Dupuytren's contracture Carpal
tunnel syndrome.
Hyperostosis
Merlagia Paresthetica
Diabetic amyotrophy Muscle infarction
Diabetic neuroarthropathy
Hyperuricemia and gout
Infectious arthritis
Scleredema
Osteonecrosis
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Hand abnormalities
The prevalence of hand abnormalities in diabetic
patients is high and increases with the duration
of diabetes
Stiff hand syndrome Flexor tendon
synovitis Dupuytren's contracture Carpal tunnel
syndrome
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Stiff hand syndrome Limited joint mobility in
diabetes
Occur exclusively in diabetics
In type I and type II
Clinically Limited movement Thick waxy skin
Bothersome But Not Disabling
Caused by excessive glycosylation of collagen
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Important
Increases in association with duration of disease
(30 of patients with long-standing diabetes)
Predictive of renal retinal complicatio
ns
Test for by
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Limitation of joint movement that is most marked
in the small joints of the hands. Thickening and
waxiness of the skin are also common,
particularly on the dorsal surface of the
fingers, but these skin changes may occur in the
absence of limited joint mobility.
Caused by excessive glycosylation of collagen in
the skin, blood vessels and peri-articular
structures and to decreased collagen degeneration
and removal resulting in thick, inelastic
tissues. In its advanced stages the fingers
remain permanently contracted at the MCPs and
PIPs and the thick shiny skin may resemble that
of scleroderma.
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The "prayer sign"
tests the ability to flatten the hands together
as in prayer
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The "table top test"
tests the ability to flatten the palm against the
surface of a table
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Caused by excessive glycosylation of collagen in
the skin, blood vessels and peri-articular
structures and to decreased collagen degeneration
and removal resulting in thick, inelastic
tissues. In its advanced stages the fingers
remain permanently contracted at the MCPs and
PIPs and the thick shiny skin may resemble that
of scleroderma.
Treatment aldose reductase inhibitors
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Dupuytren's Contracture
30 of adults with diabetes
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May or may not be seen in patients with diabetic
stiff hand syndrome
Like stiff hand syndrome,
Also caused by excessive glycosylation of
collagen
Unlike stiff-hand syndrome,
May be seen relatively early in the course of
the disease Not exclusive to diabetics
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Flexor Tenosynovitis (or trigger fingers)
Same pathogenesis as stiff hand syndrome
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Carpal Tunnel Syndrome
25 of patients with diabetics
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It can be quite subtle
especially in patients with
peripheral neuropathy who, too, will have
noturnal paresthesias
Problem
Be Aware
Solution
of the possibility of CTS so that you can
intervene early before muscle wasting develops
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Humeral periarthropathy
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Can be associated with reflex sympathetic
dystrophy
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Diffuse Idiopathic Skeletal Hyperostosis DISH
Proliferative new bone formation at joint margins
particularly in axial skeleton
Clinically limited joint mobility similar to
that seen in AS
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Strongly associated with diabetes especially
in obese patients with type II diabetes
Cause not known ?hyperlipidemia
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In DISH undulating ossification of the anterior
longitudinal ligament (more in the mid-thoracic
region), intervertebral disc and paravertebral
connective tissue resulting in a flowing pattern
of ossification that is thicker than that seen in
AS. They are best seen on the lateral radiographs
of the spine. Ossification in DISH also
involves Syndesmophytes ossification of the
outer fibers of the annulus fibrosus. Thin
vertical and symmetrical. Seen in lower thoracic,
upper lumbar and cervical spine. Symmetrical.
With time, progress to result in bamboo spine
(characteristic of AS and of arthritis associated
with IBD). They are best seen in the frontal
radiographs of the spine. When the disease starts
early in life, syndesmophytes do not develop
before age 20.
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Diabetic Neuroarthropathy (Or Charcot Joint)
Long-standing diabetes
Its a must to have sensory neuropathy
Tarsometatarsal Metatarsophalangeal joints
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Superimposed infection
Micro-fragmentation from trauma
Ischemia from small blood vessel disease
What looks like a
very
very
very
advanced and destructive osteoarthritis disease
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In advanced disease, the longitudinal arch of the
foot collapses leading to,
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An unstable gait Ulcerations and plantar
callosities occur over hypoesthetic pressure
points
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A combination of microfragmentation from trauma,
ischemia from small blood vessel disease, and
superimposed infection can contribute to the
clinical and radiographic changes of
neuroarthropathy. Unstable gait may be seen in
diabetic neuroarthropathy of the tarsometatarsal
and metatarsophalangeal joints. This is because,
in advanced disease, the longitudinal arch of the
foot collapses, leading to an unstable gait and a
rocker-sole appearance. Ulcerations and plantar
callosites occur over hypoesthetic pressure
points
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Onset of Charcot joint can be abrupt
Occasionally in association with minor trauma
With swelling
With radiographs showing bone fragmentation and
disorganization
This can be a problem
Be Aware
Solution
of the possibility of Charcot otherwise you will
unnecessarily spend a lot of time searching for
an infection
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Treatment
Unsatisfactory Little to offer more than
splinting and bracing
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Osteonecrosis
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Musculoskeletal Infections
Osteomyelitis in the foot in long standing
diabetes
Role for peripheral sensory neuropathy
Prevention meticulous foot care and blood sugar
control
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Infectious arthritis
Osteomyelitis in the foot is a major problem in
long standing diabetes.
Because of the peripheral sensory neuropathy,
foot injuries and pressure Ulcers tend to be
underappreciated, and patients may not realize
anything is seriously wrong until advanced
osteomyelitis has developed.
In addition, subcutaneous foreign bodies as
needles can be present for weeks Or months before
the diabetic patient is aware of them
Prevention meticulous foot care
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Hyperuricemia and gout
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Scleredema
Skin tightness of the upper back that spares
the hands
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Diabetic Amyotrophy
Rare Pain Maybe weakness EMG
neuropathy Resolves slowly
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Meralgia Paresthetica
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Rare Abrupt onset of pain and rapid atrophy in
large muscle groups, usually the thighs, the
peripinous muscles and the shoulder girdle.
Prominent fasciculations EMG neuropathy Severe
pain is the most frequent complaint although
profound weakness of the affected muscles is also
a problem Slowly resolves in the majority of cases
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Patients with Diabetes Who Might Need To See a
Rheumatologist
Rheumatologic disorders that can affect patients
with diabetes
Anti-diabetic drugs that might result in
rheumatologic complications
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At site of insulin injections Still frequent
Immune complex-mediated inflammatory lesion
Insulin-induced lipodatrophy
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At the site of insulin injections. Still
frequent complication of insulin therapy
irrespective of the insulin source and mode of
administration. Considered to be an immune
complex-mediated inflammatory lesion
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Lipoatrophy or lipohypertrophy can develop at the
site of insulin injections. It remains a frequent
complication of insulin therapy irrespective of
the insulin source and mode of administration.
Lipoatrophy at insulin injection sites is
considered to be an immune complex-mediated
inflammatory lesion however, it has become a
rare event since the advent of human insulin.
Nowadays, continuous subcutaneous insulin
infusion (CSII) using a portable pump and/or
injections of insulin analogs with an altered
amino acid sequence compared with native insulin
may cause lipodystrophy in diabetic patients.
Some case reports describe the recovery of
lipoatrophy following the use of CSII and/or
short-acting insulin analogs. Conversely,
exceptional cases of lipoatrophy have occurred in
patients receiving lispro insulin analog via
CSII. Lipodystrophy reactions remain a potential
problem when managing diabetic patients with new
insulin therapy technologies.
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Sulfonylureas
Allergic skin reactions that may rarely progress
to erythema multiforme
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Sulfonylureas
Allergic skin reactions that may rarely progress
to erythema multiforme And exfoliative dermatitis
Some sulfonylureas (chlorprpamide annd glipizide)
can cause Photosensitivity
Ploglitazone (Actos)
May cause arthralgias
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Patients with Rheumatic Diseases Who might Need
To See a Diabetologist

Rheumatic diseases that might cause diabetes or
related disorders
Rheumatic treatments that might cause diabetes
mellitus
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52-year old female Arthritis of the small joints
of the hands Morning stiffness 60 min Positive
RF ESR 67
Positive ANA Urine glycosuria
FBS and PPBS normal Palpable purpura of legs
Fanconis syndrome
Anti-Ro and anti-La ve Dry eyes and mouth
Sjogrens syndrome
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Patients with Rheumatic Diseases Who might Need
To See a Diabetologist
Rheumatic diseases that might cause diabetes or
related disorders
Rheumatic treatments that might cause diabetes
mellitus
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Glucocorticoids
If already with established glucose intolerance
or diabetes mellitus
Worsening of glycemic control
If not known to be diabetic from the start
Postprandial hyperglycemia Only mildly elevated
fasting blood sugar
The risk is further increased risk in patients
with other risk factors for diabetes
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Management
Wait
Reversible
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Patients with Diabetes Who Might Need To See a
Rheumatologist
Patients with Rheumatic Diseases Who might Need
To See a Diabetologist
Patients with Other Diseases Who Might Need To
See a Rheumatologist and a Diabetologist
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A 55-year old male with Arthralgias of the
wrists Elevated liver enzymes
Diabetes mellitus
Positive family history heart disease
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A commonly missed diagnosis
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To conclude
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Rheumatologists and Diabetologists have a lot to
share in patient care
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There are diverse musculoskeletal complications
related to diabetes
Some are related to duration of diabetes
Not much to do
Some are related to good glycemic control
Do it
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Rheumatologists and Diabetologists have a lot to
share in patient care
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Glucocorticoids, being an integral part of the
treatment of many chronic autoimmune rheumatic
diseases which are mostly genetically predisposed
to, may cause glucocorticoid-induced diabetes
mellitus or may press the diabetes mellitus
button in high risk patients
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So
If you are a diabetologist
Then
The best advice to give to your patients is
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To be very compliant with their anti-diabetic
treatment to achieve good glycemic control and to
prevent what could be prevented of
musculoskeletal diabetes complications
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And
If you are a rheumatologist, involved with
patients who have those genetically determined
autoimmune diseases that need glucocorticoid
treatment
Then
The best advice to give to your patients is
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To be very careful when they choose
their parents
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T h a n k y o u