Diabetes Basics

1
Diabetes Basics

• Dr John Doig
• Consultant Diabetologist
• DRS Clinical Lead Forth Valley

2
Diabetes Its Relevance to Retinopathy Screening

• What is diabetes
• Diagnosis
• Types of Diabetes
• Treatment
• Complications
• Acute metabolic
• Macrovascular
• Microvascular
• Managing Risk Factors

3
What is Diabetes Mellitus

• Diabetes excessive production of urine
• mellitus honeyed
• Life-long illness associated with various
  complications
• Blindness
• Heart disease
• Kidney disease
• Damage to the feeling in the limbs (peripheral
  neuropathy).

4
Diabetes Mellitus

• characterised by high blood sugar levels,
  disturbances of carbohydrate, fat and protein
  metabolism
• absolute lack or a relative deficiency in insulin
  action and/or insulin secretion
• Prevalence increasing
• Scottish Survey 2001 2.1
• Forth Valley 2007 4.4
• Some practices 5.0

5
Management of Diabetic Patient

• Main Issues
• Diagnosis
• Glycaemic Control
• Screening
• Microvascular Complications
• Macrovascular Complications
• Diabetes related issues / Education
• Driving, Work, Pregnancy
• Injection sites, Diet, Monitoring

6
Diagnosis

• Symptoms
• Osmotic Symptoms Fatigue
• Weight loss / gain
• Infection
• Neuropathic Symptoms
• Visual Upset
• Cardiovascular symptoms

7
Diagnosis Diagnostic Criteria

• Fasting Plasma Glucose gt7.0 (on 2 occasions)
• Random Plasma Glucose gt11.1 (on 2 occasions)
• (1 occasion if symptomatic)
• Fasting Plasma Glucose 6.1 - 6.9 IFG
• 2 hr post 75g glucose 7.8 - 11.1 IGT
• 2 hr post 75g glucose gt 11.1 DM

8
Type of Diabetes

• Type I
• Young lt 35
• Thin weight loss
• Rapid onset
• Ketonuria
• Autoimmune
• B Cell failure
• Insulin Dependent

• Type 2
• Older gt 35
• Overweight
• Onset months
• Strong FH
• Complications
• Insulin resistance
• Late B Cell failure
• Hyperinsulinaemia
• Metabolic syndrome
• Cardiovascular Disease

9
Other types of Diabetes

• Gestational
• Drug induced
• Steroids, Atypical Neuroleptics
• Metabolic
• Haemachromatosis, Cushings, Acromegaly
• Pancreatic disease
• MODY (Genetic)
• Stress hyperglycaemia

10
Treatment

• Diet
• Oral Hypoglycaemic Agents
• Sulphonylureas
• Biguanides
• Alpha 1 glucosidase inhibitors
• Thiazolidinediones(Glitazones or Insulin
  sensitisers)
• Exenatide GLP-1 agonists
• DPP4 Inhibitors Gliptins
• Insulin
• Soluble, Biphasic, Intermediate / Long acting

11
Acute Metabolic Complications

• Diabetic Ketoacidosis
• Hyper Osmolor Nonketotic Coma
• Lactic Acidosis
• Hypoglycaemia

12
Hypoglycaemia

• Common side effect of Insulin or Sulphonylureas
• Does not occur with Metformin, Acarbose or TZDs
• Minor hypos often go unreported (Self treated)
• Severe hypos occurs in 25-30 of patients each
  year
• Coma occurs in 10 of patients each year

13
(No Transcript)
14
Causes of hypoglycaemia
15
Risk factors for severe hypoglycaemia

• Insulin treatment regimen Intensified High
  insulin doses
• Impaired awareness of hypoglycaemia Acute
  (Preceding hypoglycaemic episodes) Chronic
  (Central autonomic failure)
• Long duration of diabetes
• Increasing age of patient
• Sleep, Excessive alcohol consumption

16
Morbidity of hypoglycaemia

• CNS Coma and Convulsions Transient motor
  deficits Permanent brain damage Cerebral
  Oedema
• CVS Arrhythmia Myocardial ischaemia Stroke
• Fractures, Vitreous haemorrhage

17
Treatment of hypoglycaemia

• Treated immediately by oral glucose 10-20 g
• If unable to swallow then
• Intravenous glucose 50ml 20
• Intravenous glucose 25ml 50
• Subcutaneous glucagon 1 mg
• Patients should recover within minutes
• Failure to do so may be due to cerebral oedema
• On recovery encourage consumption of complex
  carbohydrate
• Identify cause take appropriate action /
  patient to contact diabetes care team.

18
Macrovascular Complications

• Coronary Artery Disease
• Peryipheral Vascular Disease
• Cerebro Vascular Disease
• Hyperlipidaemia
• Hypertension
• Obesity

19
Cumulative Hazard for Any CVD Endpoint CARDS
Relative Risk -32 (95 CI -45, -15) p0.001
Placebo 189 events
Atorvastatin 134 events
Cumulative Hazard ()
Years
621
992
1275
1334
Placebo
1410
287
663
1040
1337
1372
Atorva
1428
306
20
All Cause Mortality
21
HOT Events in relation to target blood pressure.
Diabetic patients
22
All Cause Mortality
23
Cardiovascular Disease Prevention

• Improved cardiovascular risk with
• Improved glycaemic control (Metformin)
• Improved BP control (Target lt 140/80)
• Addition of long acting ACEI if high risk
• Lipid reduction
• All secondary preventative measures
• Aspirin, B Blocker

24
Microvascular Complications

• Diabetic Retinopathy
• Diabetic Nephropathy
• Microalbuminuria
• Macroalbuminuria
• Renal impairment
• End Stage Renal Disease
• Diabetic Neuropathy
• Sensory - Ulceration, Neuroarthropathy
• Motor Foot deformity
• Autonomic GI upset, Hypotension, ED

25
Prevalence of Retinopathy

• In young persons with duration less than 5
  yrs rare
• In patients gt 30 yrs with duration 5 yrs 20
• Duration 10 yrs 40-50
• Duration 20 yrs 90
• Approx 30 of diabetic population have DR
• Prevalence of visual impairment in UK ? 2-5 ?

26
Diabetic Retinopathy

• Approx 10-15 of patients progress to sight
  threatening retinopathy
• Pre proliferative retinopathy
• Proliferative retinopathy
• Vitreous haemorrhage
• Maculopathy
• Other sight threatening disease more common in
  diabetes
• Cataract
• Macular Degeneration
• Glaucoma

27
Risk Factors for Diabetic Retinopathy

• Duration of diabetes (age of onset)
• Poor glycaemic control
• Raised blood pressure
• Microalbuminuria and proteinuria (nephropathy)
• Raised triglycerides and lowered haematocrit
• Pregnancy
• Genetic
• Smoking

28
Modifiable Risk Factors for Prevention of
Diabetic Retinopathy

• Glycaemic Control
• Blood Pressure Control
• Smoking?

29
Evidence For Good Control

• 1993 DCCT Type 1 HbA1c 8.9 vs. 7.2
• Reduced risk of developing
• Retinopathy 76
• Microalbuminuria 39
• Clinical neuropathy 60
• 1998 UKPDS Type 2 HbA1c 7.9 vs. 7.0
• Reduced risk of
• Retinopathy 21
• Microalbuminuria 33
• Myocardial Infarction 16

30
Reduction in Risk for Microvascular Complications
Complication DCCT EDIC 1982-1993 1994
-2006 HbA1c 7.2 v 9.1 7.9 v
8.1 Retinopathy 3-step change 63
72 Proliferative 47 76 Macular oedema
26 77 Laser therapy 51
77 Nephropathy Microalbuminuria (gt
28mg/min) 39 53 Clinical albuminuria (gt
208mg/min) 54 82
31
Microvascular Endpoints
32
UKPDS Blood Pressure Control Study

• 1148 Type 2 diabetic patients
• tight blood pressure 144 / 82 mmHg v standard
  154/87
• gave reduced risk for
• any diabetes-related endpoint 24 p0.0046
• diabetes-related deaths 32 p0.019
• stroke 44 p0.013
• heart failure 56 p0.0043
• microvascular disease 37 p0.0092
• retinopathy progression 34 p0.0038
• deterioration of vision 47 p0.0036

33
Patients with retinopathy

• Aim for
• Good glycaemic control HbA1c lt 7.0
• Good BP control lt130/70
• Lipid control / Statin Cholesterol lt4.0
• Stop smoking
• Correct anaemia