Benefit of Glucose Control inReducing Microvascular Complications Type 1 Diabetes – Diabetes Control and Complications Trial (DCCT) – Epidemiology of Diabetes in Complications (EDIC)
Diabetes Control and Complications Trial (DCCT)Type 1 Diabetes 24-76% reduction in microvascular complications - Retinopathy - Neuropathy - Nephropathy - Microalbuminuria DCCT Study Group. N Engl J Med 329:977, 1993
EDIC Study ResultsIntensive Glucose Control in Type 1 Diabetes E D I C R e s e a r c h G r o u p . N E n g l J M e d 2 0 0 0 ; 3 4 2 : 3 8 1- 9
Sustained Benefit of Intensive ControlEDIC Study 4 Years Post DCCT Metabolic Memory E D I C R e s e a r c h G r o u p . N E n g l J M e d 2 0 0 0 ; 3 4 2 : 3 8 1- 9
Benefit of Glucose Control inReducing Microvascular Complications Type 1 Diabetes – Diabetes Control and Complications Trial (DCCT) – Epidemiology of Diabetes in Complications (EDIC) Type 2 Diabetes – United Kingdom Prospective Diabetes Trial (UKPDS) – UKPDS 10 Year Follow-up
UKPDSReduction in Microvascular Disease 10 5 Risk Reduction (%) 0 -5 -10 -15 -20 -25 -21 -25 -30 -35 -34 -40 Retinopathy Microalbuminuria Any Microvascular p = 0.015 p = 0.00054 Endpoint p = 0.0099 UKPDS: Lancet 352:837-853. 1998 BMJ 321:405-412, 2000
UKPDS: Long-term follow-up Holman et al. NEJM 359(15):1577-1589, 2008
Metabolic Memory in Type 2 Diabetes Holman et al. NEJM 359(15):1577-1589, 2008
Lowering blood glucose significantly reduces the risk of microvascular complications In both Type 1 and Type 2 diabetes 8 of Complications Relative Risk 6 4 2 0Hemoglobin A1c 6 7 8 9 10 11 12Adapted from: Skyler JS. Endocrinol Metab Clin North Am. 1996 Jun;25(2):243-54.DCCT Study Group. N Engl J Med 329:977, 1993UKPDS 35. Stratton IM. BMJ 321:405-412, 2000.
Diabetic Retinopathy It is estimated that more than 2.5 million people worldwide are affected by diabetic retinopathy. Diabetic retinopathy is the leading cause of vision loss in adults of working age (20 to 65 years) in industrialized countries. Largely preventable International Diabetes Federation, 2008
Optic Nerve Hard exudates Macula Early Nonproliferative Normal Retina RetinopathyHemorrhage Neovascularization Proliferative Retinopathy
Prevention of DiabeticRetinopathy Annual dilated eye examination – Retinal lesions occur in up to 90% of individuals at 20 years Glycemic control Limits risk of retinal disease, slows rate of progression Benefits observed in both Type 1 and Type 2 diabetes Blood pressure control
Treatment of Diabetic Retinopathy – Glucose control – Blood pressure control – Photocoagulation
Diabetes-related Kidney Disease Diabetes is the largest cause of kidney failure in developed countries and is responsible for huge dialysis costs. Type 2 diabetes has become the most frequent condition in people with kidney failure in countries of the Western world. International Diabetes Federation, 2008
Screening Recommendations Annual microalbuminuria screen – Albumin/creatinine (A/C) ratio preferred – Serum creatinine/ estimated GFR Type 1 Diabetes – After 5 years duration Type 2 Diabetes – At diagnosis – During pregnancy American Diabetes Association Standards of Medical Care Position Statement Diabetes Care 2006; 29:S21-S23.Kate ref for 2008
Screening for Kidney Disease Obtain random albumin-to- creatinine ratio (A/C ratio); first am urine preferred A/C ratio NO Repeat screen >30 mg/g? annually YES Staged Diabetes Management Quick Guide, Repeat screen twice within International Diabetes Center, 2009 60 days, R/O UTI
Screening for Kidney DiseaseContinued 2 of 3 A/C NO Repeat screen ratios >30 mg/g? annually YES A/C ratio NO Diagnosis of >300 mg/g? microalbuminuria YES Staged Diabetes Management Quick Guide, International Diabetes Center, 2009 Diagnosis of macroalbuminuria
Treatment of Early Kidney Disease Glucose control (A1C <7%) Blood pressure control (<130/80 mmHg; consider target <120/75 mmHg) Smoking cessation Start ACE Inhibitor or ARB – Baseline serum creatinine and potassium – Monitor for side effects, may experience cough with ACE inhibitor – Monitor response in 3-6 months – Adjust dose as necessary
Benefit of ACE Inhibitor TherapyType 2 Diabetes Proteinuria (mg/24 hr) 400 Placebo Enalapril 300 200 100 0 0 1 2 3 4 5 Years follow-up Ravid M. Ann Intern Med 118:577, 1993
Neuropathy in Diabetes Peripheral Neuropathy Autonomic Neuropathy Pain Orthostatic hypotension Loss of sensation Gastroparesis Loss of position sense Diarrhea / constipation (proprioception) Cardiac – tachycardia Impaired protective sensation Erectile dysfunction Risk for foot ulcer, loss of Gustatory sweating limb
Cardiovascular Disease (CVD) inDiabetes* Heart disease and stroke account for about 65% of deaths in people with diabetes. Adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes. The risk for stroke is 2 to 4 times higher and the risk of death from stroke is 2.8 times higher among people with diabetes Diabetes is a CVD (risk) equivalent – Risk of MI comparable to those with known CVD *US Data American Diabetes Association, 2008
Diabetes is a Cardiovascular Risk Equivalent ! Incidence of Heart Attack or Stroke during 7 year follow-up 8 7Events / 100 person-yr 6 5 No DM 4 DM 3 2 1 0 No CAD CAD Haffner S et al. N Engl J Med 1998;339:229-234
Benefit of Glucose Control inReducing Macrovascular Complications Type 1 Diabetes – Epidemiology of Diabetes in Complications (EDIC)
Benefit of Glucose Control inReducing Macrovascular Complications Type 1 Diabetes – Epidemiology of Diabetes in Complications (EDIC) Type 2 Diabetes – ACCORD – ADVANCE – UKPDS 10 Year Follow-up
Additional Therapies to ReduceCardiovascular Disease Encourage active lifestyle & healthy diet Lower LDL cholesterol levels: – Primary Prevention (CARDS study) – Target LDL <100 mg/dL all individuals with type 2 diabetes – If diabetes and CVD target LDL < 70 mg/dL Control blood pressure <130/80 mmHg Daily aspirin therapy
Diabetes and Hypertension 75% of individuals with diabetes have hypertension International Diabetes Federation, 2008
Type 2 Diabetes:Blood Pressure Control and Complication Risk (UKPDS) Microvascular 40 Myocardial Infarction Complication Rate per 1000 person-years 30 20 10 ~ 15% reduction in risk for each 10 mm Hg decrease in SBP 0 110 130 150 170 Mean systolic blood pressure (mm Hg) Adler A. BMJ 321;412-419, 2000
Hypertension Treatment in Type 2 DiabetesStaged Diabetes Management Quick Guide,International Diabetes Center, 2009
ADA Primary Prevention Recommendations 2009 vs 2010 2009 2010 Aspirin 75-162 mg/day in Aspirin 75-162 mg/day in type 1 and type 2 at type 1 and type 2 if 10 yr increased CV risk CHD risk >10% – Age >40 years Men >50 yrs and – Family history CVD Women >60 yrs with at – Hypertension least one additional risk factor – Smoking Family history CVD – Dyslipidemia Hypertension Smoking – Albuminuria Dyslipidemia AlbuminuriaADA Clinical Practice Recommendations 2009. Diab Care 32:Suppl. 1;ADA Clinical Practice Recommendations 2010. Diab Care 33:Suppl. 1.
The Foot Examination Standards of Care at Diagnosis & Annually Careful inspection Skin, shoes, shape of foot Vascular integrity Pulses Capillary refill Neurological examination and function Light touch (5.07/ 10g monofilament) Vibratory sensation (128-Hz tuning fork) ReflexesSource: Staged Diabetes Management, 5th edition, Quick Guide, pages 7-26.
Inspection Skin Nails Shoes/socks Presence of deformities
Vibration Sensation• Vibration Detection/Perception Threshold has been shown to predict the development of foot ulcers1• The tuning fork (128 Hz) is a practical tool to screen vibratory sensation loss Young MJ, et at, Diabetes Care 1994; 17:557-560. Abbott CA, et al, Diabetes Care 1998; 21:1071-1075. Coppini DV, et al, J Clinical Neuroscience 2001; 8:520-524.
Vibratory Sensation Testing Help patient differentiate vibration vs. pressure Fork on unsupported DIP joint of 1st toe When vibration sensation on toe ceases, compare to examiners distal forefinger in seconds If this is normal, no need to do monofilament test Normal = 0-10 seconds Abnormal = Greater than 10 seconds Absent = No vibration sensed
Monofilament Examination Locations on the foot 8-10 = Normal protective sensation 1-7 = Abnormal 0 = Absent Plantar DorsalSource: Staged Diabetes Management, 5th edition, Quick Guide, pages 7-28.
Neurological Exam Protective Sensation 10g monofilament 10 locations on foot Apply at 90 degrees with enough pressure to bend filament (10 grams) for 1.5 secondsSource: Staged Diabetes Management, 5th edition, Quick Guide, pages 7-28.
Prevention is Essential!! Provide ongoing patient education •Maintain good diabetes control •Practice good foot care habits •Check feet every day •Treat problems right away •Have regular health check-ups
Good Foot Care Habits Keep feet clean and dry If skin is dry, use a lotion daily Protect feet from hot and cold Trim toenails weekly
Nail Care• Trim after washing adrying feet•Use a nail clipper (ornipper) and trim straightacross•Do not cut too short orcut into nail corners•Have a podiatrist or footspecialist trim nails if thepatient cannot see orreach their nails OR iffungal nails present
Good Foot Care Habits Keep feet clean and dry If skin is dry, use a lotion daily Protect feet from hot and cold Trim toenails weekly Wear shoes and socks at all times
Appropriate Footwear Wear shoes that fit well Avoid open toed sandals, high heels and pointed toe shoes Do not go barefoot especially if neuropathy present
Foot Self Inspection Inspect feet daily Check top and bottom of each foot, toes and nails and inside shoes Use a mirror if unable to see feet well Have someone check for you if unable Contact doctor if concerns
Essentials of Foot Care Comprehensive Foot Examination by HCP Annually – Patients with neuropathy - visual inspection of feet at every visit with a health care professional Advise patients to: – Inspect their feet daily – Use lotion to prevent dryness and cracking (not between toes) – File calluses with a pumice stone (no razors!) – Cut toenails straight across or see podiatrist – Always wear (natural fiber) socks and well-fitting shoes – Notify their health care provider immediately if any foot problems occur