SDM: Applications toComplications
Priorities of Care for Adults with Diabetes                                                      Diagnosis–Prevention     ...
Natural History of Type 2 Diabetes                    350                                                                 ...
Chronic Complications of Diabetes         Macrovascular                   Brain      Cerebrovascular disease         • Tra...
Chronic Complications of Diabetes               Microvascular                       Eye                Retinopathy        ...
Benefit of Glucose Control inReducing Microvascular Complications       Type 1 Diabetes        – Diabetes Control and Com...
Diabetes Control and Complications Trial (DCCT)Type 1 Diabetes  24-76% reduction in microvascular complications           ...
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 ...
Sustained Benefit of Intensive ControlEDIC Study 4 Years Post DCCT                                                        ...
Benefit of Glucose Control inReducing Microvascular Complications      Type 1 Diabetes       – Diabetes Control and Compl...
UKPDSReduction in Microvascular Disease                       10                         5  Risk Reduction (%)            ...
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...
Chronic Complications of Diabetes               Microvascular                       Eye                Retinopathy        ...
Diabetic Retinopathy It is estimated that more than 2.5 million  people worldwide are affected by diabetic  retinopathy....
Optic Nerve                                            Hard exudates                        Macula                        ...
Prevention of DiabeticRetinopathy Annual dilated eye examination  – Retinal lesions occur in up to 90% of     individuals...
Treatment of Diabetic Retinopathy – Glucose control – Blood pressure   control – Photocoagulation
Chronic Complications of Diabetes               Microvascular                       Eye                Retinopathy        ...
Diabetes-related Kidney Disease Diabetes is the largest  cause of kidney failure in  developed countries and is  responsi...
Diabetic Glomerulosclerosis                       Normal Glomerulus                                           Diminished &...
Screening Recommendations    Annual microalbuminuria screen      –   Albumin/creatinine (A/C) ratio preferred      – Seru...
Screening for Kidney Disease  Obtain random albumin-to-  creatinine ratio (A/C ratio);    first am urine preferred        ...
Screening for Kidney DiseaseContinued         2 of 3 A/C                        NO              Repeat screen         rati...
Treatment of Early Kidney Disease  Glucose control (A1C <7%)  Blood pressure control (<130/80 mmHg; consider target   <1...
Benefit of ACE Inhibitor TherapyType 2 Diabetes    Proteinuria (mg/24 hr)                             400                 ...
Chronic Complications of Diabetes               Microvascular                       Eye                Retinopathy        ...
Neuropathy in Diabetes Peripheral Neuropathy             Autonomic Neuropathy  Pain                             Orthosta...
Managing Peripheral NeuropathyPrevention                     Symptom Management Glucose control               Analgesia ...
SDM: Applications toComplications
Priorities of Care for Adults with Diabetes                                                      Diagnosis–Prevention     ...
Chronic Complications of Diabetes            Macrovascular                    Brain       Cerebrovascular disease         ...
Cardiovascular Disease (CVD) inDiabetes* Heart disease and stroke account for about 65% of deaths in  people with diabete...
Diabetes is a Cardiovascular                   Risk Equivalent !                             Incidence of Heart Attack or ...
Benefit of Glucose Control inReducing Macrovascular Complications     Type 1 Diabetes      – Epidemiology of Diabetes in ...
Benefit of Glucose Control inReducing Macrovascular Complications     Type 1 Diabetes      – Epidemiology of Diabetes in ...
Additional Therapies to ReduceCardiovascular Disease Encourage active lifestyle & healthy diet Lower LDL cholesterol lev...
Diabetes and Hypertension   75% of individuals with diabetes have    hypertension         International Diabetes Federati...
Type 2 Diabetes:Blood Pressure Control and Complication Risk (UKPDS)                                                      ...
Hypertension Treatment in Type 2 DiabetesStaged Diabetes Management Quick Guide,International Diabetes Center, 2009
Aspirin Recommendations inDiabetes        Primary Prevention?        Secondary Prevention?
ADA Primary Prevention Recommendations 2009 vs 2010                    2009                                               ...
Priorities of Care for Adults with Diabetes                                                      Diagnosis–Prevention     ...
Comprehensive FootExaminationPatient Education
The Foot Examination   Standards of Care at Diagnosis & Annually         Careful inspection                Skin, shoes, s...
Inspection Skin Nails Shoes/socks Presence of  deformities
Vibration Sensation• Vibration Detection/Perception Threshold has been  shown to predict the development of foot ulcers1• ...
Neurological Exam     Vibratory SensationSource: Staged Diabetes Management, 5th edition, Quick Guide, pages 7-27.
Vibratory Sensation Testing Help patient differentiate vibration vs. pressure Fork on unsupported DIP joint of 1st toe ...
Monofilament testingStaged Diabetes Management 4th Edition Quick Guide – Page 7-28
Monofilament Examination  Locations on the foot  8-10 = Normal protective         sensation  1-7 = Abnormal  0            ...
Neurological Exam   Protective Sensation  10g monofilament  10 locations on foot  Apply at 90 degrees with   enough pre...
Prevention is Essential!!    Provide ongoing patient education        •Maintain good diabetes control        •Practice goo...
Good Foot Care Habits Keep feet clean and dry If skin is dry, use a lotion daily Protect feet from hot and cold Trim t...
Nail Care• Trim after washing adrying feet•Use a nail clipper (ornipper) and trim straightacross•Do not cut too short orcu...
Good Foot Care Habits Keep feet clean and dry If skin is dry, use a lotion daily Protect feet from hot and cold Trim t...
Appropriate Footwear Wear shoes that fit  well Avoid open toed  sandals, high heels  and pointed toe shoes Do not go ba...
Foot Self Inspection Inspect feet daily Check top and bottom of  each foot, toes and nails  and inside shoes Use a mirr...
Essentials of Foot Care Comprehensive Foot Examination by HCP  Annually  – Patients with neuropathy - visual inspection o...
Module iii complications of dm
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  • Proper foot care consists of regular foot examinations by a physician to detect early neuropathy and treat existing lesions, as well as daily foot examinations by the patient. Patients should check for dry, cracking skin, calluses, and signs of infection between the toes and around the toenail. The American Diabetes Association Clinical Practice Guidelines recommend that all individuals with diabetes receive an annual foot exam to identify high-risk foot conditions. This exam should include assessment of sensation, foot structure, vascular status, and skin integrity. Patients with neuropathy should have a visual inspection of their feet at every health care visit.
  • Module iii complications of dm

    1. 1. SDM: Applications toComplications
    2. 2. Priorities of Care for Adults with Diabetes Diagnosis–Prevention Dx Fasting Glucose > 126 Casual > 200 + Symptoms Prevent Pre-diabetes (IFG-IGT) & Metabolic Syndrome Self-Management Knowledge and Skill Monitoring Medication Problem solving Food plan & nutrition Risk reduction Living & coping Physical activity Microvascular Other essentials Glucose Lipids Hypertension complications of care CVD Risk ASA, tobacco, ACEI/ARB, statinHemoglobin A1C Annual Lipid Profile Blood Pressure Annual Screening Target < 7.0% LDL < 100 (every visit) Nephropathy HDL > 40 Dx and Rx < 130/80 Microalbumin screening Hospital care SMBG Calculated GFR Pre 70-120 mg/dL Trigs < 150 Foot care Retinopathy2 hr. post < 160 mg/dL Dilated retinal exam Dental care (~ 50% of readings) DM + CVD Neuropathy Immunizations Neuro and foot exam LDL < 70 Sexual health© 2008 International Diabetes Center.
    3. 3. Natural History of Type 2 Diabetes 350 Postmeal Glucose (mg/dL) 300 Pre Diabetes 250 Metabolic Syndrome Fasting GlucoseGlucose 200 150 100 50Relative function 250 200 Insulin Resistance 150 Impaired Incretin Action 100 Insulin Level 50 β-cell Fn 0 -15 -10 -5 0 5 10 15 20 25 30 Onset Diabetes Years © 2007 International Diabetes Center, Minneapolis, MN All rights reserved.
    4. 4. Chronic Complications of Diabetes Macrovascular Brain Cerebrovascular disease • Transient ischemic attack • Cerebrovascular accident Heart Coronary artery disease • Myocardial infarction • Congestive heart failure Extremities Peripheral vascular disease • Ulceration • Gangrene • Amputation
    5. 5. Chronic Complications of Diabetes Microvascular Eye Retinopathy Cataracts Glaucoma Kidney Nephropathy • Microalbuminuria • Gross albuminuria • Kidney failure Nerves Neuropathy • Peripheral • Autonomic
    6. 6. Benefit of Glucose Control inReducing Microvascular Complications  Type 1 Diabetes – Diabetes Control and Complications Trial (DCCT) – Epidemiology of Diabetes in Complications (EDIC)
    7. 7. 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
    8. 8. 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
    9. 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
    10. 10. 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
    11. 11. 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
    12. 12. UKPDS: Long-term follow-up Holman et al. NEJM 359(15):1577-1589, 2008
    13. 13. Metabolic Memory in Type 2 Diabetes Holman et al. NEJM 359(15):1577-1589, 2008
    14. 14. 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.
    15. 15. Chronic Complications of Diabetes Microvascular Eye Retinopathy Cataracts Glaucoma Kidney Nephropathy • Microalbuminuria • Gross albuminuria • Kidney failure Nerves Neuropathy • Peripheral • Autonomic
    16. 16. 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
    17. 17. Optic Nerve Hard exudates Macula Early Nonproliferative Normal Retina RetinopathyHemorrhage Neovascularization Proliferative Retinopathy
    18. 18. 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
    19. 19. Treatment of Diabetic Retinopathy – Glucose control – Blood pressure control – Photocoagulation
    20. 20. Chronic Complications of Diabetes Microvascular Eye Retinopathy Cataracts Glaucoma Kidney Nephropathy • Microalbuminuria • Gross albuminuria • Kidney failure Nerves Neuropathy • Peripheral • Autonomic
    21. 21. 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
    22. 22. Diabetic Glomerulosclerosis Normal Glomerulus Diminished & Leaking Filtering SpaceMessangialProliferation Proteinuriaand Sclerosis ↓ CrCl HTN Thickening Basement Membrane ESRD Longstanding Diabetes Dialysis
    23. 23. 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
    24. 24. 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
    25. 25. 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
    26. 26. 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
    27. 27. 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
    28. 28. Chronic Complications of Diabetes Microvascular Eye Retinopathy Cataracts Glaucoma Kidney Nephropathy • Microalbuminuria • Gross albuminuria • Kidney failure Nerves Neuropathy • Peripheral • Autonomic
    29. 29. 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
    30. 30. Managing Peripheral NeuropathyPrevention Symptom Management Glucose control  Analgesia (aspirin, NSAIDs) Annual comprehensive foot  Anti-depressant Rx examination (amitriptylline, venlafaxine, ? ά-Lipoic acid duloxetine, others) Daily self foot inspection  Anti-seizure meds (gabapentin) Foot care Wear appropriate shoes Vascular lesions
    31. 31. SDM: Applications toComplications
    32. 32. Priorities of Care for Adults with Diabetes Diagnosis–Prevention Dx Fasting Glucose > 126 Casual > 200 + Symptoms Prevent Pre-diabetes (IFG-IGT) & Metabolic Syndrome Self-Management Knowledge and Skill Monitoring Medication Problem solving Food plan & nutrition Risk reduction Living & coping Physical activity Microvascular Other essentials Glucose Lipids Hypertension complications of care CVD Risk ASA, tobacco, ACEI/ARB, statinHemoglobin A1C Annual Lipid Profile Blood Pressure Annual Screening Target < 7.0% LDL < 100 (every visit) Nephropathy HDL > 40 Dx and Rx < 130/80 Microalbumin screening Hospital care SMBG Calculated GFR Pre 70-120 mg/dL Trigs < 150 Foot care Retinopathy2 hr. post < 160 mg/dL Dilated retinal exam Dental care (~ 50% of readings) DM + CVD Neuropathy Immunizations Neuro and foot exam LDL < 70 Sexual health© 2008 International Diabetes Center.
    33. 33. Chronic Complications of Diabetes Macrovascular Brain Cerebrovascular disease • Transient ischemic attack • Cerebrovascular accident Heart Coronary artery disease • Myocardial infarction • Congestive heart failure Extremities Peripheral vascular disease • Ulceration • Gangrene • Amputation
    34. 34. 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
    35. 35. 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
    36. 36. Benefit of Glucose Control inReducing Macrovascular Complications  Type 1 Diabetes – Epidemiology of Diabetes in Complications (EDIC)
    37. 37. 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
    38. 38. 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
    39. 39. Diabetes and Hypertension 75% of individuals with diabetes have hypertension International Diabetes Federation, 2008
    40. 40. 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
    41. 41. Hypertension Treatment in Type 2 DiabetesStaged Diabetes Management Quick Guide,International Diabetes Center, 2009
    42. 42. Aspirin Recommendations inDiabetes Primary Prevention? Secondary Prevention?
    43. 43. 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.
    44. 44. Priorities of Care for Adults with Diabetes Diagnosis–Prevention Dx Fasting Glucose > 126 Casual > 200 + Symptoms Prevent Pre-diabetes (IFG-IGT) & Metabolic Syndrome Self-Management Knowledge and Skill Monitoring Medication Problem solving Food plan & nutrition Risk reduction Living & coping Physical activity Microvascular Other essentials Glucose Lipids Hypertension complications of care CVD Risk ASA, tobacco, ACEI/ARB, statinHemoglobin A1C Annual Lipid Profile Blood Pressure Annual Screening Target < 7.0% LDL < 100 (every visit) Nephropathy HDL > 40 Dx and Rx < 130/80 Microalbumin screening Hospital care SMBG Calculated GFR Pre 70-120 mg/dL Trigs < 150 Foot care Retinopathy2 hr. post < 160 mg/dL Dilated retinal exam Dental care (~ 50% of readings) DM + CVD Neuropathy Immunizations Neuro and foot exam LDL < 70 Sexual health© 2008 International Diabetes Center.
    45. 45. Comprehensive FootExaminationPatient Education
    46. 46. 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.
    47. 47. Inspection Skin Nails Shoes/socks Presence of deformities
    48. 48. 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.
    49. 49. Neurological Exam Vibratory SensationSource: Staged Diabetes Management, 5th edition, Quick Guide, pages 7-27.
    50. 50. 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
    51. 51. Monofilament testingStaged Diabetes Management 4th Edition Quick Guide – Page 7-28
    52. 52. 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.
    53. 53. 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.
    54. 54. 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
    55. 55. 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
    56. 56. 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
    57. 57. 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
    58. 58. 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
    59. 59. 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
    60. 60. 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
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