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Type 2 Diabetes

Florence.travert@bch.aphp.fr

Basic knowledge about type 2 diabetes
Diabetes complications
Lessons from large scale trials
Training

Basic knowledge
Type 2 diabetes
1.The disease
2.The treatment
3.The prognosis

THE DISEASE .

Is type 2 diabetes another world ? .

sudden death Chronic complications Macrovascular .What for a diabetologist « Death prevention! » Ketoacidosis Chronic complications Microvascular MI.

Type 2 diabetes is our today's’ challenge And it is complex to treat … ‘westernisation’ is leading to the rapid spread of type 2 diabetes. especially in developing countries Increasing prevalence of type 2 diabetes population (million) • Increasing 155 Prevalence of diabetes worldwide 150 145 140 135 130 125 0 1995 2000 year .

8M  91% 1.4M  88% Zimmet et al.2M  97% 81.Diabetes: 2003 prevalence and  projected increase by 2025 38.6M  98% 18.0M  59% 10.20:693–702 13.1M World prevalence  59% 2003: 189 million 2025: 324 million 72% increase 8 .2M  16% 25. Diab Med  2003.

THE PROGNOSIS .

PROGNOSIS Genetics Hypertension Smoking Diabetes .

What for a diabetologist ? .

.Complications of type 2 diabetes   The story of  a vascular disease ….

Complications of type 2 diabetes What they suffer from? Incidence /prevalence Check up and detection Impact on morbi-mortality     .

Complications of type 2 diabetes What they suffer from? Incidence /prevalence Check up and detection Impact on morbi-mortality     .

Suffering or not? • Patients do not suffer directly from  their hyperglycemia (high blood  glucose level) • But they suffer from some of the  chronic or acute complications     .

  it’s the apanage of type 1 dabetes. asthenia…)     .Suffering or not? Acute hyperglycemia • Ketoacidosis is due to a lack of insulin. weight loss.  • In type 2 polyuropolydipsy (cardinal  syndrom) can be seen • Glycosuria.

Suffering or not? Acute hypoglycemia never occurs in a normal subject occurs only if the patient receives certain  drug targeting the stimulation of insulin  secretion     .

 hearing. concentration and  progressive loss of consciousness and  finally coma     .Suffering or not? Acute hypoglycemia the first signs are an adrenergic reaction including:  sweating. reading or  writing troubles.  Neurological signs occur then as visual. fatigue. paleness tremor dizziness. elocution disorders.

Complications • Patients do not suffer directly from  their hyperglycemia (high blood  glucose level) • But they suffer from some of the  chronic or acute complications     .

glaucoma.Where are located these complications eyes Rétinopathy. foot Erectile dysfonction Various consequences     . cataract Blindness Heart & Vessels CHD Vascular cerebral attack Periph arteriopathy Hypertension Cardiomyopathy Cardiac failure Death MI Hemiplegia Amputation Kidney Renal failure Dialysis transplantation Nerves peripheral neuropathy autonomic neuropathie pain Various consequences others Infection. tees.

today Mainly a vascular disease Macroangiopathy Coronary arteries Carotid arteries Periperal arteries Low limbs Cerebral arteries Microangiopathy eyes kidney   nerves   skin .DIABETES …….

• Lesions similar to non diabetics • earlier. more serious. fibrosis & calcium Mediacalcosis : calcification of the média and of the external limit of the vessels . complex CHD. blood components. more scattered Atherosclerosis : Remodelling of the intima of big and medium size arteries (accumulation of lipids.Macro angiopathy artery diameter > 200 µm.

Atherosclérosis : Intima Media Adventice Erythrocytes platelets Monocyte Lipoprotéins 1) 2) 3) 4) accumulation of LDL in intima inc ome of monocytes and fibroblasts prolifération of mucular cells     Intensified by tissular and circulating (oxidative stress) Endothélium Mucle cells .

Consequences • Coronary Heart disease • Hypertension • Cardiac failure • Diabetic myocardiopathy • Peripheral arteriopathy • Cerebrovascular attack .

MI .Coronary Heart Disease • 30% of ischemia are painless (silent) • Non typical symptoms • When present (jaw. stomach) • Possible onset : • Sudden death.

The Alfred . Cardiology.“classical” acute proximal lesion Coronary artery atherosclerosis Diffuse distal disease of diabetes To detect silent myocardial infarction  Perform systematic annual ECG     Coronary angiograms Dr Archer Broughton.

Transluminal Angioplasty     .

  coronarography before / after stenting      .

Coronary Bypass Venous bridges Obstructed Coronary arteries     .

Blood Hypertension • Associated pathology or consequence • Vascular stiffness is characteristic from diabetes • more often and more serious .

Tight blood pressure control and risk   of macrovascular and microvascular complications in  type 2 diabetes : UKPDS 38.Blood pressure Objective Average 10 mmHg of SBP  risk decrease Myocardial infarction – 21 % Stroke – 44 % Microangiopathy UKPDS – 37 % UK Prospective Diabetes Study Group. 317: 70313. . BMJ 1998.

Systolic Blood Pressure and CV death 250 225 Goal : 130/80 mmHg 200 175 Cardiovascular 150 deaths rate/10 000 125 sub/year 100 Non diabetics Diabetics 75 50 25 0 < 120 120–139 140–159 160–179 180–199 Systolic Blood pressure (mmHg)   Care. 1993. Diabetes    200 .16:434-444. Stamler J et al.

Heart failure • Incidence x 2 to 6 in diabetic population • Shorten the life • May cause sudden death • Results from 2 others : • CHD • HTA .

15% (10 years) 45% ( 20 years).Peripheral arteriopathy 8% at diagnosis.3 (male) 13. • Atheroma plaques more scattered. more distal • Associated risk factors Smoking.1/3 both - . obesity.8 (female) • 1 /3 proximal (+ HTA/ dyslipidemia/ smoking) • 1/3 distal below the knee (hyperglycemia / duration of diabetes) • . renal transplantation • Risk of amputation = 10. HTA.

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Peripheral arteriopathy • Symptoms : • Intermittent limp • Calf pain when walking • Missing pulses • If < 200m  requires surgery • Pain at rest / nocturnal pain • Due to nerves ischemia • More during the night  force to let the legs hang • If permanent  requires surgery .

Cerebrovascular attack Stroke risk x 2 .

Brain scan : left infarction (sylvien territory)     .

Microangiopathy

• Diabetic retinopathy
• Diabetic nephropathy
• Diabetic neuropathy
• Diabetic foot

Diabetic retinopathy
• Background:

• Increased capillar permeability
• œdema microexsudates

• Retinal ischemia:

• micro aneurysms
• punctiformes haemorrhages

• Proliferative retinopathy:
• Neovessels

• Ruptures causing haemorrhages
• Development of glial tissu
• Retina retraction and detachment

• Macular oedema
• cataract

Diabetic nephropathy
40% of type 2 diabetics
have at least background
lesions in their course

Hollenberg NK. J Hypertens 1997,15(S7): 7-13.

Diabetic nephropathy STAGES Time of occurence 1 Hypertrophy & early hyperfiltration 2 Kidney histologic lesions 3 Microalbuminuria backround 4 nephropathy Proteinuria Néphropathy (clinical) 5 Renal failure   diagnosis 2 .15 years 10 .40 years   N .3 years 7 .30 years 20 .

or legs.Diabetic neuropathy • An estimated 50 percent of those with diabetes have some form of neuropathy. causing numbness and sometimes pain in the hands. and sex organs. feet. • The highest rates of neuropathy are among people who have had the disease for at least 25 years. • Mechanism is very complex . and problems with the digestive tract. heart. • Neuropathy can affect nerves throughout the body. but not all with neuropathy have symptoms. arms.

hands. and feet. legs. even a light touch . burning. • numbness or insensitivity to pain or temperature • a tingling. or prickling sensation • sharp pains or cramps • extreme sensitivity to touch.Peripheral Neuropathy Peripheral neuropathy affects the nerves in arms.

leading to troubles in walking . • Peripheral neuropathy may also cause muscle weakness and loss of reflexes. especially at the ankle.Peripheral Neuropathy • loss of balance and coordination • These symptoms are often worse at night.

Autonomic Neuropathy Unawareness of Hypoglycemia Heart and Circulatory System Digestive System Urinary Tract and Sex Organs Sweat Glands Eyes .

Diabetic foot macrovascular mIcrovascular infection Skin disease neuropathy .

Complications of type 2 diabetes What they suffer from? Incidence /prevalence Check up and detection Impact on morbi-mortality ADVANCE what for ?     .

Complications of type 2 diabetes What they suffer from? Incidence /prevalence Check up and detection Impact on morbi-mortality     .

exercise test.Urinary tests.eye examination . kidney function -ECG. myocardial scintigraphy -Vascular echo-doppler -Nerves lesions detection -Focus on foot     .« Detection attitude » In diabetes population = any vascular complication  look for all other types .

Complications of type 2 diabetes What they suffer from? Check up and detection Impact on morbi-mortality     .

Type 2 diabetes means  Risk for Coronary heart disease x 2-4 Not decreased during the last 30 years  Risk for Stroke x 1.4-2.30 % of hémodialysis (2500 /year)     .2   Risk for Arteriopathy x 10 1st cause of blindness < 50 years (500 – 1000 /year) 15 % of MI (30 000 / year) 50 % of amputations (8500 /year) 20 .

THE TREATMENT .

“I don’t feel sick” “I suffer from being overweight” “I prefer to live normally now. even if I have to pay it in the future” Visits at the clinics Cardiovascular risk Glucometers Diet Exercise More than 10 tablets/day Insulin injections “never forget that you have a serious disease !!!!” .

Molecules in development… Whatever you prescribe … The only points you have to consider is: 1) Compliance 2) HbA1c .Treatment (1) Suphonylurea Glinide Metformin GLP1 Acarbose Insulin Pump …..

Barriers to insulin therapy Patient Needle anxiety Hypoglycemia Weight gain Health Professional ? CV Risks Hypoglycemia Weight gain .

Date Presentation title 57 .

Hypoglycaemia What are the signs and symptoms of hypoglycaemia? What are the causes of hypoglycaemia? How is a ‘hypo’ managed? How is a ‘hypo’ prevented? What are the complications associated with prolonged hypoglycaemia? .

Oral Diabetes Medication What are the target ranges for home blood glucose monitoring? Fasting Pre-meals 2 hours after meals What factors would you need to take into consideration before starting oral diabetes medication? .

Insulin What insulins' are you aware of? How is insulin given? What is meant by ‘basal’ insulin? What is meant by ‘bolus’ insulin? Where may insulin be injected? How often should the pen needle be changed on the insulin injection pens? May insulin be injected through clothes? How should insulin be stored? What are the side effects of insulin? How often may insulin doses be titrated? .

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