Best Dx/Best Rx: Complications of Diabetes = Mellitus

From: Subject: Best Dx/Best Rx: Complications of Diabetes Mellitus Date: Wed, 3 Jun 2009 21:12:36 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_013B_01C9E490.04F81300" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_013B_01C9E490.04F81300 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.acpmedicine.com/acp/newrxdx/rxdx/dxrx0903.htm Best Dx/Best Rx: Complications of Diabetes = Mellitus

Complications of=20 Diabetes Mellitus

Mark E. Molitch, M.D.
Feinberg = School of=20 Medicine, Northwestern University

Saul Genuth, M.D.
Case Western = Reserve=20 University School of Medicine

Re= tinopathy
Ne= phropathy
Ne= uropathy

Retinopathy=20

Defin= ition/Key=20 Clinical Features
Best = Tests
Best = Therapy
Best = References

Definition/Key=20 Clinical Features

Nonproliferative (background) = retinopathy=20
- Most common form=20
- Microaneurysms=20
- Dot hemorrhages=20
- Hard lipid exudates=20
- Macular edema
Preproliferative retinopathy=20
- Blot hemorrhages=20
- Soft exudates=20
- Intraretinal microvascular = abnormalities=20
- Venous beading=20
- Macular edema
Proliferative retinopathy=20
- Preretinal hemorrhages=20
- Vitreous hemorrhage=20
- Retinal detachment=20
- Macular edema

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Best=20 Tests

Dilated and comprehensive eye exam by=20 ophthalmologist=20
- Annually in most diabetic patients=20
- More often during pregnancy=20
- Every 2 yr in patients achieving glycemic = goals and=20 without cardiovascular disease

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Best=20 Therapy

Maintain glucose levels near normal = (Hemoglobin=20 A_1c [HbA_1c] < 7%)=20
Proliferative retinopathy: panretinal scatter=20 photocoagulation=20
Macular edema: laser treatment=20
Vitreous hemorrhage that does not clear or = with=20 scarring and debris: vitrectomy

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Best = References

Diabetes Control and Complications = Trial/Epidemiology of=20 Diabetes Interventions and Complications Research Group. JAMA 287:2563, = 2002=20 [PMID 12020338]

Ferris FL 3rd, et al: N Engl J Med 341:667, 1999 = [PMID=20 10460819]

Fong DS, et al: Diabetes Care 26:226, 2003 [PMID=20 12502685]

Willams GA: Adv Stud Ophthalmol 3:13, = 2006

Williams R, et al: Eye 18:963, 2004 [PMID=20 15232600]

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Nephropathy=20

Defin= ition/Key=20 Clinical Features
Best = Tests
Best = Therapy
Best = References

Definition/Key=20 Clinical Features

Thickening of capillary basement = membrane=20
Causes microalbuminuria (30=96299 = mg/day)=20
Macroalbuminuria (=3D 300 mg/day)=20
Falling glomerular filtration rate = (GFR)=20
Hypertension=20
Affects 35%=9645% of patients with type 1 = diabetes=20
Affects 10%=9620% of patients with type 2 = diabetes=20
Incidence peaks at 15=9617 yrs of diabetes, = then=20 declines

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Best=20 Tests

Urinary albumin measurement, annually=20
Serum creatinine measurement, annually, with = calculated=20 GFR

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Best=20 Therapy

Maintain near-normal glycemic levels (Hb = A_1c=20 < 7%)=20
Maintain good blood pressure control = (<130/80 mm=20 Hg)=20
- Restrict dietary sodium=20
- Antihypertensive agents: three or more drugs = usually=20 needed=20
  - ACE inhibitor or ARB for first drug =
  - Diuretic for second drug=20
  - ACE inhibitor or ARB for third drug, if = not chosen=20 for first=20
  - Calcium channel blocker: alternative = choice=20
  - Beta blockers can mask hypoglycemia during = insulin=20 therapy
Protein restriction if GFR continues to = fall=20
Renal transplantation: better outcomes than=20 dialysis

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Best = References

Epidemiology of Diabetes Interventions and = Complications=20 (EDIC)/Diabetes Control and Complications Trial (DCCT) Study Group: JAMA = 290:2159, 2003 [PMID 14570951]

Bakris GL, et al: Am J Kidney Dis 36:646, 2000 = [PMID=20 10977801]

Mogensen CE, et al: Diabet Med 21:4, 2004 [PMID=20 14706048]

Gross JL, et al: Diabetes Care 28:164, 2005 [PMID = 15616252]

Karalliedde J, et al: J Hum Hypertens 20:239, = 2006 [PMID=20 16452996]

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Neuropathy=20

Defin= ition/Key=20 Clinical Features
Best= =20 Tests
Best= =20 Therapy
Best= =20 References

Definition/Key=20 Clinical Features

Peripheral Neuropathy=20
- Symmetrical=20
- Affects up to 60% of patients=20
- Numbness, tingling in toes and feet=20
- Hypoesthesia or anesthesia=20
- Foot ulcers=20
- Pain
Carpal tunnel and other entrapment = syndromes=20
Autonomic Neuropathy=20
- Male impotence=20
- Female anorgasmia=20
- Difficulty voiding and urinary = retention=20
- Impaired gastric emptying, early satiety,=20 emesis=20
- Diarrhea or constipation=20
- Orthostatic hypotension=20
- Decreased sweating and vasomotor tone in = legs=20
- Resting sinus tachycardia
Amyotrophy=20
- Occurs mostly in elderly men=20
- 1- to 2-year course=20
- Severe pain, weakness in thigh = muscles=20
- Muscle infarcts=20
- Severe depression, cachexia, weight = loss=20

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Best=20 Tests

Examination for distal polyneuropathy at = diagnosis and=20 annually=20
- Test for vibration sensation using 128 mHz = tuning=20 fork=20
- Test Achilles tendon reflexes=20
- Test sensation with 10 g monofilament =
Clinical assessment for autonomic neuropathy: = 5 yr after=20 diagnosis in type 1 diabetes, at diagnosis in type 2=20
Inspection of insensate feet at every = visit=20
Comprehensive foot exam annually =

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Best=20 Therapy

Maintain near-normal glycemic levels = (HbA_1c=20 < 7%)=20
Duloxetine, pregabalin, and tricyclic = antidepressants:=20 first-tier therapy=20
Carbamazepine, gabapentin, lamotrigine, = tramadol,=20 venlafaxine: second-tier therapy=20
Prevent foot ulcers; treat aggressively with=20 broad-spectrum antibiotics=20
Autonomic neuropathy=20
- Gastroparesis: frequent small feedings and = parenteral=20 or liquid oral metoclopramide=20
- Feeding jejunostomy=20
- Tetracycline, clonidine, somatostatin for=20 diarrhea=20
- Oral bethanechol, bladder compression, = catheterization=20 for bladder dysfunction=20
- Compression stockings, ample sodium intake,=20 fludrocortisone for orthostatic hypotension=20
- For impotence: phosphodiesterase V = inhibitors=20 (dangerous in coronary disease), alprostadil, vacuum pumps, penile=20 implants
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Best=20 References

Martin CL, et al: Diabetes Care 29:340, 2006 = [PMID=20 16443884]

Eaton S, et al: Diabetes Rev 7:312, = 1999

Vinik AI: Am J Med 107(suppl 2B):17S, 1999 = [PMID=20 10484041]

Argoff CE, et al: Mayo Clin Proc 81(suppl = 4):S3, 2006=20 [PMID 16608048]

Cavanagh PR, et al: Lancet 366:1725, 2005 [PMID = 16291067]

Mark E. Molitch, M.D., has received research = support=20 from Sanofi-Aventis, Inc., Eli Lilly & Co., Novo-Nordisk, Inc., and = Pfizer,=20 Inc. and has served as a consultant to Sanofi-Aventis, Inc., = Novo-Nordisk, Inc.,=20 and Abbott Laboratories. Saul Genuth, M.D., has no commercial = relationships with=20 manufacturers of products or providers of services discussed in this = module.=20

February=20 2007