به نام خداوند جان و خرد

دکتر نادر طاهری متخصص داخلی فوق تخصص غدد Refrence:ADA(2012) and William textbook of endocrinology

Global Prevalence of Diabetes

An epidemic of T2DM is under way in both developed and developing countries. An epidemic of T2DM is under way in both developed and developing countries. The number of people with diabetes will rise The number of people with diabetes will rise from 171 million in 2000 to 366 million in from 171 million in 2000 to 366 million in 2030.

Classification of diabetes

The classification of diabetes includes four clinical classes: The classification of diabetes includes four clinical classes: Type 1 diabetes: results from beta -cell destruction, usually leading to absolute insulin deficiency Type 1 diabetes: results from beta -cell destruction, usually leading to absolute insulin deficiency Type 2 diabetes (90% of diabetic cases globally): results from a progressive insulin secretory defect on the background of insulin resistance. Type 2 diabetes (90% of diabetic cases globally): results from a progressive insulin secretory defect on the background of insulin resistance.

genetic defects in beta-cell function, or in insulin action, genetic defects in beta-cell function, or in insulin action, diseases of the exocrine pancreas (such as cystic fibrosis), diseases of the exocrine pancreas (such as cystic fibrosis), and drug- induced (such as in the treatment of HIV/AIDS or after organ transplantation and drug- induced (such as in the treatment of HIV/AIDS or after organ transplantation Gestational diabetes mellitus (GDM: diabetes diagnosed during pregnancy) Gestational diabetes mellitus (GDM: diabetes diagnosed during pregnancy)

Diagnosis of diabetes For decades, the diagnosis of diabetes was based on For decades, the diagnosis of diabetes was based on the fasting plasma glucose (FPG) the fasting plasma glucose (FPG) or the 2-h value in the 75-g oral glucose tolerance test (OGTT). or the 2-h value in the 75-g oral glucose tolerance test (OGTT).

Diagnosis of diabetes In 2009, an International Committee that included representatives of In 2009, an International Committee that included representatives of the ADA, the ADA, the International Diabetes Federation (IDF), the International Diabetes Federation (IDF), and the European Association for the Study of Diabetes (EASD) and the European Association for the Study of Diabetes (EASD) recommended the use of the A1C test to diagnose diabetes. recommended the use of the A1C test to diagnose diabetes.

Diagnosis of diabetes The A1C has several advantages to the FPG and OGTT, including The A1C has several advantages to the FPG and OGTT, including greater convenience, greater convenience, and less day-to-day perturbations and less day-to-day perturbations But, these advantages must be balanced by But, these advantages must be balanced by greater cost, greater cost, and the limited availability of A1C testing in certain regions of the developing world, and the limited availability of A1C testing in certain regions of the developing world,

Diagnosis of diabetes The diagnosis of diabetes must employ glucose criteria exclusively, The diagnosis of diabetes must employ glucose criteria exclusively, in conditions with abnormal red cell turnover, such as pregnancy, recent blood loss or transfusion, or some anemias. in conditions with abnormal red cell turnover, such as pregnancy, recent blood loss or transfusion, or some anemias.

Criteria for the diagnosis of Diabetes FPG > or = 126 mg/dl, FPG > or = 126 mg/dl, or 2-h plasma glucose > or = 200 mg/dl, during an the 75-g OGTT. or 2-h plasma glucose > or = 200 mg/dl, during an the 75-g OGTT. or In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, A random plasma glucose > or = 200 mg/dl. or In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, A random plasma glucose > or = 200 mg/dl. Or A1C > or = 6.5%. Or A1C > or = 6.5%.

Criteria for the diagnosis of Prediabetes Prediabetes definded as Prediabetes definded as FPG > or = 100–125 mg/dl (IFG) FPG > or = 100–125 mg/dl (IFG) Or 2-h plasma glucose in the 75-g OGTT > or = 140–199 mg/dl (IGT) Or 2-h plasma glucose in the 75-g OGTT > or = 140–199 mg/dl (IGT) Or A1C > or = 5.7–6.4%. Or A1C > or = 5.7–6.4%.

Prediabetes Individuals with IFG and/or IGT have the relatively high risk for Individuals with IFG and/or IGT have the relatively high risk for the future development of diabetes the future development of diabetes and cardiovascular disease (CVD). and cardiovascular disease (CVD).

Prediabetes IFG and IGT are associated IFG and IGT are associated with obesity (especially abdominal or visceral obesity) with obesity (especially abdominal or visceral obesity) high triglycerides and/or low HDL cholesterol, high triglycerides and/or low HDL cholesterol, and hypertension. and hypertension.

Screening in asymptomatic patients Testing for type 2 diabetes in asymptomatic people, considered in Testing for type 2 diabetes in asymptomatic people, considered in adults of any age, who are overweight or obese adults of any age, who are overweight or obese and have one additional risk factor for diabetes. and have one additional risk factor for diabetes. In those without these risk factors, testing begin at age 45 years. In those without these risk factors, testing begin at age 45 years.

Risk factors of type 2 diabetes physical inactivity physical inactivity first-degree relative with diabetes first-degree relative with diabetes high-risk race/ethnicity high-risk race/ethnicity women who delivered a baby weighing 9 lb or past history of GDM women who delivered a baby weighing 9 lb or past history of GDM women with polycystic ovarian syndrome women with polycystic ovarian syndrome Hypertension Hypertension A1C > or = 5.7%, A1C > or = 5.7%,

Risk factors of type 2 diabetes HDL cholesterol level < 35 mg/dl HDL cholesterol level < 35 mg/dl Triglyceride level > 250mg/dl Triglyceride level > 250mg/dl clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) History of CVD History of CVD

Screening in asymptomatic patients If tests are normal, repeat testing carried out at least at 3-year intervals. If tests are normal, repeat testing carried out at least at 3-year intervals. Monitoring for the development of diabetes in those with prediabetes performed every year. Monitoring for the development of diabetes in those with prediabetes performed every year. To test for diabetes To test for diabetes A1C, A1C, FPG, FPG, or 2-h 75-g OGTT can be used. or 2-h 75-g OGTT can be used.

Diabetes Complications diabetes associated with microvascular pathology in: diabetes associated with microvascular pathology in: the retina (retinopathy) the retina (retinopathy) renal glomerulus (nephropathy), renal glomerulus (nephropathy), peripheral nerve (neuropathy). peripheral nerve (neuropathy). and accelerated atherosclerotic macrovascular disease in the heart, brain, and lower extremities. and accelerated atherosclerotic macrovascular disease in the heart, brain, and lower extremities.

Diabetic retinopathy A highly specific vascular complication of both type 1 and type 2 diabetes, A highly specific vascular complication of both type 1 and type 2 diabetes, The most frequent cause of new cases of blindness among adults, aged 20–74 years. The most frequent cause of new cases of blindness among adults, aged 20–74 years. All patients with T1DM and more than 60% of patients with T2DM develop some degree of retinopathy after 20 years. All patients with T1DM and more than 60% of patients with T2DM develop some degree of retinopathy after 20 years.

The primary end-point to evaluate the relationship between glucose levels and diabetic complications is retinopathy.

International Classification of Diabetic Retinopathy no apparent retinopathy (no abnormalities), no apparent retinopathy (no abnormalities), mild NPDR (microaneurysms only), mild NPDR (microaneurysms only), moderate NPDR (more than microaneurysms only but less than severe NPDR), moderate NPDR (more than microaneurysms only but less than severe NPDR),

International Classification of Diabetic Retinopathy severe NPDR (any of the following: severe NPDR (any of the following: more than 20 intraretinal hemorrhages in each of four quadrants, more than 20 intraretinal hemorrhages in each of four quadrants, definite venous beading in two or more quadrants, definite venous beading in two or more quadrants, prominent intraretinal microvascular abnormalities in one or more quadrants, prominent intraretinal microvascular abnormalities in one or more quadrants, and no PDR and no PDR

International Classification of Diabetic Retinopathy and PDR : and PDR : one or more of retinal neovascularization, one or more of retinal neovascularization, vitreous hemorrhage, vitreous hemorrhage, or preretinal hemorrhage or preretinal hemorrhage

Risk factor for retinopathy Duration of diabetes Duration of diabetes Quality of Glycemic control Quality of Glycemic control Hypertesion Hypertesion Renal disease Renal disease Anemia Anemia Elevated serum lipid levels Elevated serum lipid levels

Risk factor for retinopathy Duration of diabetes: Duration of diabetes: closely associated with the onset and severity of diabetic retinopathy. closely associated with the onset and severity of diabetic retinopathy. Diabetic retinopathy is rare in prepubescent patients with T1DM, Diabetic retinopathy is rare in prepubescent patients with T1DM, but all patients with T1DM and more than 60% of patients with T2DM develop some degree of retinopathy after 20 years. but all patients with T1DM and more than 60% of patients with T2DM develop some degree of retinopathy after 20 years.

Quality of diabetes control The DCCT showed: Tight glucose control The DCCT showed: Tight glucose control reduced the development of retinopathy by 27%. reduced the development of retinopathy by 27%. Also, reduced the progression of retinopathy by 76%, Also, reduced the progression of retinopathy by 76%, But not prevent retinopathy completely. But not prevent retinopathy completely.

Hypertension Patients with DM and hypertension are Patients with DM and hypertension are more likely to develop retinopathy and diffuse macular edema, more likely to develop retinopathy and diffuse macular edema, and more severe levels of retinopathy (PDR) and more severe levels of retinopathy (PDR) and more rapid progression of retinopathy and more rapid progression of retinopathy when compared with diabetic patients who do not have hypertension. when compared with diabetic patients who do not have hypertension.

Renal Disease ( proteinuria ) The presence and severity of diabetic retinopathy The presence and severity of diabetic retinopathy are indicators of the risk of gross proteinuria, are indicators of the risk of gross proteinuria, and, conversely, proteinuria predicts PDR. and, conversely, proteinuria predicts PDR.

Renal Disease ( proteinuria ) In a patient with long history of DM In a patient with long history of DM and where retinopathy has been previously stable, and where retinopathy has been previously stable, Rapidly progressive retinopathy Rapidly progressive retinopathy Suggest the need for renal evaluation. Suggest the need for renal evaluation.

conclusion To reduce the risk or slow the progression of retinopathy: To reduce the risk or slow the progression of retinopathy: optimize glycemic control. optimize glycemic control. and optimize blood pressure control. and optimize blood pressure control.

Vision loss results from: results from: persistent vitreous hemorrhage, persistent vitreous hemorrhage, traction retinal detachment, traction retinal detachment, or severe macular edema. or severe macular edema. The most common cause of vision loss from diabetes, is macular disease and macular edema. The most common cause of vision loss from diabetes, is macular disease and macular edema.

Other Ocular Manifestations of Diabetes Mononeuropathies of the third, fourth, or sixth cranial nerves can arise in association with diabetes; Mononeuropathies of the third, fourth, or sixth cranial nerves can arise in association with diabetes; Mononeuropathies may be the initial presenting sign of new-onset diabetes, Mononeuropathies may be the initial presenting sign of new-onset diabetes, even in patients not claim a history of diabetes even in patients not claim a history of diabetes

Other Ocular Manifestations of Diabetes Diabetes-induced third-, fourth-, and sixth- nerve palsies are Diabetes-induced third-, fourth-, and sixth- nerve palsies are usually self-limited usually self-limited and resolve spontaneously in 2 to 6 months. and resolve spontaneously in 2 to 6 months. Palsies can recur or subsequently develop in the contralateral eye. Palsies can recur or subsequently develop in the contralateral eye.

Other Ocular Manifestations of Diabetes Diabetic papilleddema must distinguished from other causes of disc swelling such as Diabetic papilleddema must distinguished from other causes of disc swelling such as increased intracranial pressure, increased intracranial pressure, pseudopapilledema, pseudopapilledema, toxic optic neuropathies, toxic optic neuropathies, neoplasms of the optic nerve, neoplasms of the optic nerve, and hypertension. and hypertension.

Other Ocular Manifestations of Diabetes Optic disc pallor can occur Optic disc pallor can occur following spontaneous remission of proliferative retinopathy or following spontaneous remission of proliferative retinopathy or remission of panretinal laser photocoagulation remission of panretinal laser photocoagulation Neovascularization of the iris Neovascularization of the iris neovascular glaucoma neovascular glaucoma

Other Ocular Manifestations of Diabetes The cornea of the diabetic person is The cornea of the diabetic person is more susceptible to injury more susceptible to injury slower to heal after injury slower to heal after injury and more prone to infectious corneal ulcers, and more prone to infectious corneal ulcers,

Other Ocular Manifestations of Diabetes Open-angle glaucoma is 1.4 times more common in the diabetic population Open-angle glaucoma is 1.4 times more common in the diabetic population Cataracts are 1.6 times more common in people with diabetes Cataracts are 1.6 times more common in people with diabetes Cataracts can occur earlier in life and progress more rapidly in the presence of diabetes. Cataracts can occur earlier in life and progress more rapidly in the presence of diabetes.

All patients with diabetes should have All patients with diabetes should have dilated ocular examinations by an experienced ophthalmologist dilated ocular examinations by an experienced ophthalmologist and diabetic patients should be under the direct care of an ophthalmologist and diabetic patients should be under the direct care of an ophthalmologist at least by the time severe diabetic retinopathy or diabetic macular edema is present. at least by the time severe diabetic retinopathy or diabetic macular edema is present.