Transcript Slide 1
Complications Complications-mortality • Life expectancy 5-10 years • Fatal coronary heart disease 2-4 fold • Fatal stroke 2-3 fold Complications-morbidity • • • • • • • • • Coronary heart disease 2-3 fold Cerebrovascular disease >2 fold Peripheral vascular disease 2-3 fold Retinopathy(over lifetime) affects 80% Nephropathy (proteinuria) affects 5-30% Neuropathy( over lifetime) affects 60% Hypertension(over lifetime) affects >60% Lower limb amputation increased several fold Depression increased 2 fold Vascular • Macrovascular, peripheral vascular disease IHD. • Microvascular. Retinopathy, nephropathy,peripheral neuropathy. Necrobiosis lipoidica Diabeticorum Diabetic Retinopathy • • • • Prevalence at diagnosis in type 2 diabetes 6.7-30.2% Modifiable risk factors glycaemic control and BP(37% reduction UKPDS) Maculopathy (all refered HES) Retinopathy – – – – • None RO, annual screen background R1 annual screen but inform diabetes carer Preproliferative R2 refer HES Proliferative R 3 urgent ref HES HES hospital eye service Risk factor control • • • • HBa1c <6.5% Bp target 130/80 less if also nephropathy Lipids TC<5,LDL <3,TG<2.3 Commence statin all patients >40 or >19 if coexisting retinopathy. Screening Diabetic retinopathy • NSF 100% screening by 2007 • Uses digital photography • All diabetics aged 12 years and over recalled annually • Pupils dilated short acting eye drop lasts 23hrs • Pregnant women screened pre-pregnant,at end of each trimester and 9-12 months post natally. Responsibilities of GP • • • • • • Refer all diabetic patients to screening programme Maintain up to date practice register Refer children when reach age 12 Inform patients importance screening Identify exclusions to screening Ensure patients who opt out have made informed choice • Act on non-responder notifications. Neuropathic ulcer ED Pathogenesis of ED in DM • • Macro-angiopathy • • Micro-angiopathy • • Polyneuropathy : somatic pudendal & dorsal penile nerve parasympathetic -> pelvic & cavernous nerves ( erection) sympathetic -> pelvic & cavernous nerves (emission & ejaculation) Ghanem H Standard Practice in Sexual Medicine 2006:51-52 • ED reduces quality of life of diabetic men – ED was associated with worse psychological adaptation to diabetes, which, affects metabolic control. ED was also associated with a dramatic increase in the prevalence of severe depressive symptoms • ED predicts silent CAD in apparently uncomplicated type 2 diabetic patients 1) De Berardis G, Franciosi, M, Belfiglio, M, et al.. Erectile Dysfunction and Quality of Life in Type 2 Diabetic Patients.Diabetes Care. 2002;25:284-291. 2) Gazzaruso et al., Relationship Between Erectile Dysfunction and Silent Myocardial Ischemia in Apparently Uncomplicated Type 2 Diabetic Patients. Circulation. 2004;110:22-26 Erectile impotence PDE5 inhibitors Name Dose duration Caution CI SE CVD Anatomical deformation penis Predisposition to priapism Not in patients on nitrates. Within 4 hours of alpha blockesr Indigestion Headache facial flushing Sildenafil Viagra 25-100mg Single dose 1 hour before intercourse Take on empty stomach Onset action 25 min delayed if taking food Duration action 4-5 hours Tadalafil Cialis 10mg-20mg at least 30min before max20mg in 24 hours Onset action 16-45 min Duration 36 hours Not in patients on nitrates. Alpha blockers Indigestion Headache Vardenafil levitra 5-20mg 25-60 min before Can eat/drink Onset action 25 min. Delayed by fatty meal. Duration 4-5 hours Not in patients on nitrates. Alpha blockers Headache facial flushing Nephropathy • Microvascular complication • Commonest cause of end stage renal failure • Major risk factors, hyperglycaemia, hypertension, genes and ethnicity. screening • • • • Annual a/c ratio on emu >2.5mg/mmol men,>3.5mg/mmol women. Annual creatinine and eGFR False positives ( 3 tests within 4/12 2 abnormals) management • Exercise/weight/dietry salt/alcohol • ACE type 1 reduce progression to macroalbuminuria and may regression • ARB type 2 reduce progression to macroalbuminuria and may regression • BP<130/80 (125/75 if proteinuria >1g/day) • ? Other cause if no other microvascular disease. Resources • • • • • • • • • • • • • • Web sites Diabetes UK www.diabetes.org.uk National diabetes audit www.ic.nhs.uk/nda National Diabetes information service www.ndis.ic.nhs.uk www.nice.org.uk/guidance/CG87 Sponsored by MSD www.diabetesneweragents.co.uk Patient support Sanofi-aventis insulin helpline 08456066887 [email protected] Orlistat www.mapassist.co.uk (need batch no.) Novonordisk emergency out of hours helpline 08456005055 Further study Bmj learning modules Diabetes and primary care journal www.diabetesandprimarycare.co.uk learning modules