DIABETES DAN KOMPLIKASI

Dr. Zaharita bt Bujang

Klinik Kesihatan Pekan Nenas
Pontian
SUDAH BERSEDIA NAK
DENGAR CERAMAH ?
Sunday Star-26 March
th

2006
 DIABETES MELITUS

Penyakit yang tinggi morbiditi dan mortaliti

Komplikasi diabetes
* Retinopathy : 14.6% NIDDM > 40 thn
* Nephropathy : 10% selepas 25 thn DM
* Neurologi : 50% selepas 50 thn
Risiko co-morbiditi
CVS 2-4

Stroke 5X

Amputasi 27.7X

Impotence 1/3 lelaki

diabetes
PATHOGENESIS
Impaired insulin secretion

Hyperglycaemia

Increased hepatic
glucose production Decreased
muscle glucose
uptake
DIAGNOSIS

• Pemeriksaan darah
- FBS , RBS , MGTT
• Gejala – gejala diabetes
DIAGNOSTIC CRITERIA FOR
DIABETES (75 G ORAL GLUCOSE
TOLERANCE TEST)
Fasting Plasma < 6.1 Normal
Glucose (mmol/l)
> 6.1 - < 7.0 Impaired Fasting
Glucose
> 7.0 Diabetes

2 hour Plasma < 7.8 Normal

Glucose (mmol/l)
> 7.8 - < 11.1 Impaired Glucose
Tolerance

> 11.1 Diabetes

 JENIS-JENIS
PENYAKIT DIABETES
 JENIS-JENIS PENYAKIT DIABETES

PRIMARY SECONDARY

Type 1 Type 2
(IDDM) (NIDDM)
TYPE 1 VS TYPE 2
• Younger: Age< 30 yrs • Older onset
• Lean • Overweight
• HLA DR3 or DR4 • No HLA links
• Autoimune disease. • No immune
• Present of Islet cell disturbance
antibodies. • Insulin resistance.
• Insulin deficiency. • Partial insulin def.
• May devel. • May devel.
Ketoacidosis. Hyperosmolar state.
• Always need insulin. • 50% need insulin after
• Dissapearance of C- many years.
peptide. • C- peptide persist.
 COULD DIABETES
PREVENTED ?????

• Lifestyle modification;
– Weight loss >5%.
– Reduce fat and increase dietary fibre .
– Exercise > 30 min daily.

• ?? Lifestyle modification could prevent

diabetes almost 100%.
• Prof J. Toumiletho Univ. Helsinki
EDUCATION ON
DIABETES
• A common chronic disorder
• Chronic hyperglycaemia
• Currently no known cure BUT can be
controlled for a healthy & productive
life
• Symptoms: Polyuria, polydipsia,
tiredness, lethargy, wt loss
• 50% not aware they are diabetic
• Majority are asymptomatic
Causes of Death Among
People With Diabetes
CAUSES % of Deaths

Ischemic heart disease 40

Other heart disease 15
Diabetes (acute complications) 13
Cancer 13
Cerebrovascular disease 10
Pneumonia/influenza 4
All other causes 5

Geiss LS et al. In: Diabetes in America. 2nd ed. 1995:233-257.

KOMPLIKASI
DIABETES
 Hypertension
Dyslipide
mia Smoking
Genetics

microvascul macrovascular
ar

CAD, PVD
CVA
KOMPLIKASI DIABETES

AKUT KRONIK
 KOMPLIKASI
AKUT

Hiperglisemia Koma Hipoglisemia Koma

(Gula terlalu tinggi) (Gula terlalu rendah)

Tanda amaran Tanda amaran

Terlalu dahaga Rasa lapar
Kencing banyak Sakit kepala
Letih Ketar tangan
Lemah Berdebar
Rasa mengantuk Berpeluh
Tingkahlaku agresif
 KOMPLIKASI
KRONIK

Rosak Rosak
Salurdarah kecil Salurdarah besar

Mata Jantung
Buah pinggang Salur darah anggota
Saraf
Kaki diabetes
DIABETIC COMPLICATIONS

RETINOPATHY
NEPHROPATHY
NEUROPATHY
DIABETIC FOOT
CARDIOVASCULAR DISEASE
 MATA

Mudah dapat katarak ( selaput mata )

Glaukoma
Retinopathy
Cataracts of the crystalline lens with opacification, as shown here, are more frequent in persons
with diabetes mellitus.
Glaucoma with marked cupping of the optic disk is seen on funduscopic examination. The
incidence of glaucoma is higher in the diabetic population.
Diabetic retinopathy is shown here on funduscopic examination.
Proliferative diabetic retinopathy on funduscopic examination is shown here. This is a
particularly serious complication in diabetics that can lead to blindness.
DIABETIC COMPLICATIONS

RETINOPATHY
NEPHROPATHY
NEUROPATHY
DIABETIC FOOT
CARDIOVASCULAR DISEASE
Diabetic Nephropathy-
Natural History
Screening for Diabetic
Nephropathy
DARAH TINGGI
DIABETIC COMPLICATIONS

TREATMENT

RETINOPATHY
NEPHROPATHY
NEUROPATHY
DIABETIC FOOT
CARDIOVASCULAR DISEASE
 SARAF

Kehilangan rasa pada anggota kaki

Saraf Autonomik-
Tekanan darah rendah bila bangun - pening
Kembung perut
Impotence
Mononeuropati
Diabetic neuropathy
Pemeriksaan neurologi
Diagnosis
Ada gejala

Touch and pin prick

Vibration sense
Position sense
Autonomic neuropathy
Ankle jerk
Muscle wasting

Diabetic control
Treat pain/parassthesia
footcare
TYPES OF NEUROPATHY

• PERIPHERAL NEUROPATHY
- Distal Symmetrical
Polyneuropathy
- Mononeuritis ( Amyotrophy )
- Painful Neuropathy ( Acute )
• AUTONOMIC NEUROPATHY
- Gastroperesis, ED, Diabetic
Diarrhoea
Neuropathic Bladder, etc
NEUROPATHY
TREATMENT
PERIPHERAL NEUROPATHY
SYMPTOMATICS
ANTIEPILEPTICS :
Clonoazepam, Gabapentin,
Carbamazipine
TRICYCLICS :
Amitriptyline, Imipramine

OTHERS :
Pentoxifylline, TENS, Acupuncture
TREATMENT

AUTONOMIC DYSFUNCTION

SEXUAL DYSFUNCTION

GASTROPERESIS
SEXUAL DYSFUNCTION

SEXUAL DYSFUCTION

VASCULAR HORMONAL
NEUROLOGIC ASSESSMENT
ASSESSMENT
ASSESSMENT

TREATMENT

I/CAVERNOSAL
HORMONAL INJ PENILE
PI PROTHESIS
NON HORMONAL VACUUM
DIABETIC COMPLICATIONS

RETINOPATHY
NEPHROPATHY
NEUROPATHY
DIABETIC FOOT
CARDIOVASCULAR DISEASE
 DIABETIC FOOT

DM NEUROPATHY
PVD PERIPHERAL
ULCER AUTONOMIC
TREATMENT INFECTION
W OUND DEBRID GANGRANE
ANTIBIOTICS PREVENTION
AVOID WT BEARING
REVASCULAR SURGERY OPTIMAL GLYCEMIA
ANTIPLATELET GOOD FOOT CARE
PENTOXYFYLINE FOOT EVALUATION
AMPUTATION PODIATRIC VISIT
DIABETIC FOOT
Screening

Pemeriksaan kaki
6 -12 M

DM control
Specific intensive care

Emphasize self care

Foot Ulcers and Amputations
& DM
– >50% of lower limb amputations in the
US
– Foot ulcers occur in 15% of diabetes
patients over a lifetime
– Cost of diabetes-related amputation:
$27,000

National Diabetes Fact Sheet. November 1, 1997:1-8.

Reiber GE et al. In: Diabetes in America. 2nd ed. 1995:409-428.
DIABETIC FOOT

• Foot problem ( esp. infection )

• Major reason for hospitalization
• Leading cause of nontraumatic foot
amputation.
• Disorder of foot in Diabetic patient;
• a) peripheral neuropathy
• b) Ischemia
DIABETIC FOOT

• Common presentation:
• a) Infection
• b) Gangrene
• c) Skin ulcers
• d) Neuropathic joint disorder
( Charcot fracture).
PATHOPHYSIOLOGY

• MULTIFACTORIAL:
• a) Diabetic neuropathy
• b) Vascular disease
• c) Susceptibility to infection
• d) Trauma
• All these predispose the diabetic foot
to ulcerations.
WHY ALL THE FUSS ABOUT
FOOT IN DIABETES
MELLITUS?
• Although the various system failures
associated with DM are more life
threatening, it is noted that diabetic
foot ulcer is more emotional and
more disabling
Risiko amputasi 15X lebih
tinggi untuk pesakit
diabetes berbanding
dengan orang lain.
EVALUATION OF ULCERS

• Evidence of infection in adjacent

soft tissue.
• Probe – involvement of deeper
structures, tendons, bone and
joint.
WAGNER CLASSIFICATION

• Stage 0 - Pressure area on the foot aggravated

by footwear
• Stage 1 - Superficial ulcer
• Stage 2 - Full-thickness ulcer.
• Stage 3 - Full-thickness ulcer with abscess or
osteomyelitis
Stage 4 - Infected area with local gangrene
( forefoot )
Stage 5 - Extensive gangrene, foot and leg
RISK STATUS
CLASSIFICATION
1) Normal sensation with no
deformity.
2) Normal sensation with deformity.
3) Insensitivity without deformity.
4) Ischemia without deformity.
5) Complicated:
combination insensitivity/ ischemia/
deformity; Charcot joint, previous
ulceration, ulceration.
TREATMENT

GRADE 0 – skin intact, bony

deformity, foot at risk.

• Proper foot wear with padding.

• Patient education.
• Surgical correction of claw toes &
prominent PIP joint.
TREATMENT

GRADE 1 – superficial ulcers.

• Outpatient dressing changes.

• Total contact cast.
• Antibiotics.
TREATMENT

GRADE 2 – Deep ulcers

• Hospitilazation.
• Wound debridement/ aggressive.
• Wound care and IV antibiotics.
• Goal to correct to Grade 1 ulcer.
TREATMENT

GRADE 3 – Abscess and

osteomylitis

• Emergency drainage.
• Wound left open for daily dressing till
definite closure.
• IV antibiotic
• If failed, amputation.
TREATMENT

GRADE 4 - Gangrene of toes/

forefoot

AMPUTATION
TREATMENT

GRADE 5 - whole foot gangrene

AMPUTATION
Foot ulcer
Foot ulcer
DIABETIC COMPLICATIONS

RETINOPATHY
NEPHROPATHY
NEUROPATHY
DIABETIC FOOT
CARDIOVASCULAR DISEASE
PENYAKIT MACROVASCULAR

• 80% KEMATIAN DIABETES ADALAH

BERKAITAN DENGAN PENYAKIT
CARDIOVASKULAR
• ANTARANYA-
* CORONARY ARTERY DISEASE
*CEREBROVASCULAR – STROKE
* PERIPHERAL VASCULAR DISEASE
PENGURUSAN KOMPLIKASI
MACROVASCULAR

SARINGAN CARDIOVASCULAR
YEARLY / GEJALA

SEJARAH ANGINA , CLAUDICATION

STROKE

CHECK BP
CAROTID BRUIT
PERPHERAL PULSE

ECG , CXR, STRESS TEST

ECHO
Kardiovaskular

• Untuk mengurangkan komplikasi

makrovaskular ,selain hyperglisemia
semua faktor risiko harus dirawat
• Merokok , dyslipidemia , kawal HPT,
ubah gaya hidup
CV DISEASE & DIABETES

SILENT HT
ISCHAEMIA
INSULIN
CARDIO VASCULAR
RESISTANCE
MYOPATHY DYSFUNCTION

HYPER
AMI GLYCAEMIA
CLOTTING ABN
ANGINA SMOKING DYSLIPID-
OBESE AEMIA
CV COMPLICATIONS

• CORONARY ARTERY DISEASE

-ASYMPTOMATIC  SUDDEN
DEATH

• PERIPHERAL ARTERY DISEASE

• CEREBROVASCULAR DISEASE
CHD mortality according to
degree of glucose tolerance
4
3.2
Annual CHD mortality
per 1000 persons

3 2.7

2
1.4

0
Normal glucose IGT (n = 690) Newly diagnosed
tolerance (n = 6055) + known diabetes
(n = 293)

Adapted from Eschwege E et al. Horm Metab Res Suppl 1985; 15: 41–6.
 infarction (MI) in subjects
with and without diabetes
Diabetics must
7-year follow-up
45 Be treated as if have
Fatal or non-fatal MI incidence

45
40
Had heart attacks
during follow-up (%)

35
30
25 18.8 20.2
20
15
10 3.5
5
0
Prior MI No MI Prior MI No MI
Non DM DM
Haffner SM et al. N Engl J Med 1998;339:229–34
CORONARY ARTERY
DISEASE

TREATMENT
MEDICAL
INVASIVE/SURGICAL

PREVENTION
MEDICAL TREATMENT

THROMBOLYTIC THERAPY
ANTIPLATELET
BETA BLOCKER
ACE INHIBITOR
TIGHT GLYCAEMIC CONTROL
CORRECT CVS RISK FACTORS
INVASIVE/SURGICAL
PERCUTANEOUS CORONARY
INTERVENTION ( PCI )
ANGIOPLASTY +/- STENTING
SURGICAL BYPASS ( CABG )

HIGH RATE OF RESTENOSIS IN ANGIOPLASTY

USE OF IIa/IIIb Platelet Inhibitor prevent restenosis
post stenting ( EPISTENT Study )
• SEKIAN TERIMAKASIH

ATAS PERHATIAN ANDA.