1. Systemic Complications of Diabetes Mellitus Robert F. Nash D.O. 2006

2. Diabetes “The term diabetes was coined by Aretaeus (81–133 CE) of Cappadocia. The Greek word diabaínein literally means "passing through," or "siphon," a reference to one of diabetes' major symptoms—excessive urine production. The word became "diabetes" from the English adoption of the medieval Latin diabetes. In 1675 Thomas Willis added mellitus from the Latin word for honey (mel in the sense of "honey sweet") when he noted that the blood and urine of a diabetic has a sweet taste. This had been noticed long before in ancient times by the Greeks, Chinese, Egyptians, and Indians. In 1776 it was confirmed the sweet taste was because of an excess of a kind of sugar in the urine and blood of people with diabetes.”

3. Prevalence (2005) Total population in US Total population in US  20.8 million people (7%)  Diagnosed 14.6 million  Undiagnosed 6.2 million Age 60 and over Age 60 and over  10.3 million people  20.9%

5. Cost Health Care Cost Health Care Cost Other costs Other costs  Disability  Work Loss  Premature Mortality Total Cost Total Cost $92 BILLION $40 BILLION $132 BILLION

6. Mrs. Adams Age 51 Age 51 New Patient New Patient Not under any Physicians care Not under any Physicians care CC: Check-up HPI: “ I am just not feeling well.” Tired, polyuria, polyphagia, polydypsea, some weight loss, abdominal pain, diarrhea, leg pain, sores on feet, dyspepsia, occasional episodes of chest pain, difficulty seeing, ankle edema, and rash.

7. Diabetes Mellitus Type I Type I Type II Type II Gestational Gestational Other causes Other causes

8. Type I Diabetes Mellitus “Juvenille Diabetes”- Misnomer “Juvenille Diabetes”- Misnomer Autoimmune process Autoimmune process Requires Insulin secondary to beta-cell destruction Requires Insulin secondary to beta-cell destruction Look for other autoimmune conditions Look for other autoimmune conditions

9. Gestational Diabetes Mellitus Unknown etiology- May be secondary to maternal hormones Unknown etiology- May be secondary to maternal hormones Resolves with delivery/termination of pregnancy Resolves with delivery/termination of pregnancy Watch for Hypoglycemia of neonate Watch for Hypoglycemia of neonate Insulin for management Insulin for management

10. Type II Diabetes Mellitus Decreased insulin sensitivity Decreased insulin sensitivity Initial hyperinsulinemia Initial hyperinsulinemia “Burn-out of Beta cells” “Burn-out of Beta cells” Oral and /or Insulin therapy Oral and /or Insulin therapy

11. Other causes Chronic pancreatitis Chronic pancreatitis Endocrine disorders Endocrine disorders Medication induced Diabetes Mellitus Medication induced Diabetes Mellitus Genetic Syndromes Genetic Syndromes Genetic Defects Genetic Defects

12. Diabetic Emergencies Diabetic Ketoacidosis Diabetic Ketoacidosis Non-ketotic hyperglycemic-hyperosmolar Coma Non-ketotic hyperglycemic-hyperosmolar Coma

13. Systemic Complications of Diabetes Mellitus Cardiovascular Cardiovascular Neurologic Neurologic Gastrointestinal Gastrointestinal Eyes Eyes Oral Cavity Oral Cavity Skin Skin Genitourinary Genitourinary Renal Renal

14. Pathogenesis Increased glucose levels Increased glucose levels Insulin sensitive cells Insulin sensitive cells  Muscle Cells not requiring insulin Cells not requiring insulin

15. Cardiovascular Heart disease and stroke incidence Heart disease and stroke incidence  2-4 times higher than rest of population Accelerated atherosclerosis Accelerated atherosclerosis Increased cholesterol levels Increased cholesterol levels Hypertension 73% Hypertension 73%

16. Myocardial infarction

17. Neurologic 60%-70% with mild to severe neurologic disease 60%-70% with mild to severe neurologic disease Carpal Tunnel Syndrome Carpal Tunnel Syndrome

19. Diabetic neuropathy

20. Amputations Major contributing cause of lower extremity amputations Major contributing cause of lower extremity amputations 82,000 yearly (2000-2001) 82,000 yearly (2000-2001) Loss of sensation Loss of sensation

21. Gastrointestinal Polyphagia and Polydyspea Polyphagia and Polydyspea Autonomic Neuropathy Autonomic Neuropathy  Decreased peristalsis  Gastroparesis  Esophageal  Diarrhea and Constipation  Decreased exocrine pancreatic secretions Lumbar and Thoracic Polyradiculopathy Lumbar and Thoracic Polyradiculopathy

22. Skin Common complication Common complication

23. Acanthosis Nigricans

24. Bullosis diabeticorum

25. Skin Tags

26. Diabetic dermopathy

27. Necrobiosis lipoidica diabeticorum

28. Granuloma annulare

29. Eyes Blindness ages 20-74 Blindness ages 20-74 12,000 to 24,000 new cases of blindness yearly 12,000 to 24,000 new cases of blindness yearly Retinopathy-late first decade to early second Retinopathy-late first decade to early second Macular Edema Macular Edema Cataracts Cataracts Blurry vision Blurry vision

30. Retinopathy

31. Cataract

32. Oral Cavity Periodontal Disease- 1/3 of all diabetics Periodontal Disease- 1/3 of all diabetics Thrush Thrush

33. Periodontal Disease

34. Thrush

35. Genitourinary Polyuria Polyuria Female Reproduction Female Reproduction  Poorly controlled diabetics  Prior to conception to end of first 1/3 5-10% birth defects5-10% birth defects 15-20% abort15-20% abort  2/3 to birth causes high birth weight

36. Genitourinary Female Genitourinary Female Genitourinary  Vaginal Candidisis  Dyspareunia  UTI’s  Bladder dysfunction

37. Male Genitialia Erectile dysfunction Erectile dysfunction Decreased libido Decreased libido UTI’s UTI’s

38. Renal 44 % of all End Stage Renal Disease 44 % of all End Stage Renal Disease Glomerular lesions Glomerular lesions Arteriolosclerosis Arteriolosclerosis Pyelonephritis Pyelonephritis

39. Nephropathy

41. Treatment Diabetes Type II Diabetes Type II  Weight loss and dietary change  Adjust medications to keep Fasting Glucose between 90 and 130  HGB a1c  HGB a1c Below 7.0 Pain management Pain management

42. Treatment of Diabetic Nephropathy Hypertension Control - Goal: lower blood pressure to <130/80 mmHg Hypertension Control - Goal: lower blood pressure to <130/80 mmHg  Antihypertensive agents  Angiotensin-converting enzyme (ACE) inhibitors captopril, enalapril, lisinopril, benazepril, fosinopril, ramipril, quinapril, perindopril, trandolapril, moexiprilcaptopril, enalapril, lisinopril, benazepril, fosinopril, ramipril, quinapril, perindopril, trandolapril, moexipril  Angiotensin receptor blocker (ARB) therapy candesartan cilexetil, irbesartan, losartan potassium, telmisartan, valsartan, esprosartancandesartan cilexetil, irbesartan, losartan potassium, telmisartan, valsartan, esprosartan  Beta-blockers

43. Prevention of Diabetic Retinopathy Associated Vision Loss Intensive glycemic control Intensive glycemic control Tight blood pressure control (<130/80 mmHg) Tight blood pressure control (<130/80 mmHg) Comprehensive eye examinations Comprehensive eye examinations

44. Treatment GI GI  Metoclopramide or erythromycin  Loperamide or stool softners Polyneuropathy Polyneuropathy  Antidepressant  Anticonvulsants  Regular foot exams Erectile Dysfunction Erectile Dysfunction Dyspareunia Dyspareunia  Lubricants  Estrogen Cream

45. References American Diabetes Association: Preventive Foot Care in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S63-S64, 2004 Feldman, EL: Classification of diabetic neuropathy. In UpToDate. Wellesley, MA, UpToDate, 2003 National Diabetes Information Clearinghouse. Diabetic Neuropathies: The Nerve Damage of Diabetes. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH), DHHS; 2002 National Diabetes Information Clearinghouse. Prevent Diabetes Problems: Keep Your Feet and Skin Healthy. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH), DHHS; 2003

46. References, cont. Feldman, EL: Pathogenesis and prevention of diabetic polyneuropathy. In UpToDate. Wellesley, MA, UpToDate, 2003. Feldman, EL, McCulloch, DK: Treatment of diabetic neuropathy. In UpToDate. Wellesley, MA, UpToDate, 2003. Stevens, MJ: Diabetic autonomic neuropathy. In UpToDate. Wellesley, MA, UpToDate, 2003. Feldman, EL: Clinical manifestations and diagnosis of diabetic polyneuropathy. In UpToDate. Wellesley, MA, UpToDate, 2003.

47. References American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S79-S83, 2004 National Kidney and Urologic Diseases Information Clearinghouse. Kidney Disease of Diabetes. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH), DHHS; 2003. United States Renal Data System. USRDS 2003 Annual Data Report. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH), DHHS; 2003. DeFronzo RA: Diabetic nephropathy: etiologic and therapeutic considerations. Diabetes Reviews 3:510-547, 1995 National Kidney and Urologic Diseases Information Clearinghouse. Kidney Failure: Choosing a Treatment That’s Right For You. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH), DHHS; 2003.

48. References American Diabetes Association: Retinopathy in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S84-S87, 2004 Diabetic Retinopathy: What you should know. Bethesda, MD: National Eye Institute, National Institutes of Health (NIH), DHHS; 2004. Aiello LP, Gardner TW, King GL, Blankenship G, Cavallerano JD, Ferris FL 3rd, Klein R: Diabetic Retinopathy. Diabetes Care 21 (1): 143-156,1998.

49. Mrs. Adams

50. Hypertension 73% 73%