cours en anglais nov 2012
DESCRIPTION
Cours en AnglaisTRANSCRIPT
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Basic knowledge about type 2 diabetes
Lessons from large scale trials
Diabetes complications
Training
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1.The disease2.The treatment3.The prognosis
Basic knowledge Type 2 diabetes
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THE DISEASE
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Is type 2 diabetes another world ?
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What for a diabetologist
KetoacidosisChronic complicationsMicrovascular
MI, sudden deathChronic complications
Macrovascular
« Death prevention! »
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Increasing prevalence of type 2 diabetes
• Increasing ‘westernisation’
is leading to the rapid spread of type 2 diabetes, especially in developing countries
Prevalence of diabetesworldwide
125
130
135
140
145
150
155
1995 2000year
pop
ulat
ion
(mill
ion)
0
Type 2 diabetes is our today's’ challenge And it is complex to treat …
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8
Diabetes: 2003 prevalence and projected increase by 2025
25.0M 59%
81.8M 91%
13.6M 98%
18.2M 97%
38.2M 16%
10.4M 88% World prevalence
2003: 189 million2025: 324 million 72% increase
1.1M 59%
Zimmet et al. Diab Med 2003;20:693–702
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THE PROGNOSIS
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PROGNOSIS
GeneticsHypertensionSmokingDiabetes
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What for a diabetologist ?
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Complications of type 2 diabetes
The story of a vascular disease ….
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Complications of type 2 diabetes
What they suffer from?Incidence /prevalenceCheck up and detectionImpact on morbi-mortality
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Complications of type 2 diabetes
What they suffer from?Incidence /prevalenceCheck up and detectionImpact on morbi-mortality
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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
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Suffering or not?Acute hyperglycemia
• Ketoacidosis is due to a lack of insulin, it’s the apanage of type 1 dabetes,
• In type 2 polyuropolydipsy (cardinal syndrom) can be seen
• Glycosuria, weight loss, asthenia…)
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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
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Suffering or not?Acute hypoglycemia
the first signs are an adrenergic reaction including: sweating, paleness tremor dizziness, fatigue. Neurological signs occur then as visual, hearing, reading or
writing troubles, elocution disorders, concentration and progressive loss of consciousness and finally coma
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Complications• Patients do not suffer directly from
their hyperglycemia (high blood glucose level)
• But they suffer from some of the chronic or acute complications
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Where are located these complicationseyes Rétinopathy, glaucoma,
cataractBlindness
Heart & Vessels CHDVascular cerebral attack
Periph arteriopathy Hypertension
CardiomyopathyCardiac failure
DeathMI
HemiplegiaAmputation
Kidney Renal failure Dialysistransplantation
Nerves peripheral neuropathy autonomic neuropathie
painVarious
consequences
others Infection, tees, footErectile dysfonction
Various consequences
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Macro-angiopathy
Coronaryarteries
Carotidarteries
Cerebralarteries
Periperalarteries
Lowlimbs
Micro-angiopathy
eyes kidney nerves skin
DIABETES ……. today Mainly a vascular diseaseMainly a vascular disease
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Macro angiopathyartery diameter > 200 µm.
•Lesions similar to non diabetics•earlier, more serious, more scattered
Atherosclerosis :Remodelling of the intima of big and medium size arteries (accumulation of lipids, complex CHD, blood components, fibrosis & calcium
Mediacalcosis :calcification of the média and of the external limit of the vessels
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Atherosclérosis :
Mucle cells
Endothélium
platelets
Lipoprotéins
Monocyte
Intima Media Adventice
Erythrocytes
1) accumulation of LDL in intima 2) inc ome of monocytes and fibroblasts3) prolifération of mucular cells 4) Intensified by tissular and circulating (oxidative stress)
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Consequences
•Coronary Heart disease•Hypertension •Cardiac failure•Diabetic myocardiopathy•Peripheral arteriopathy•Cerebrovascular attack
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CoronaryHeart Disease
• 30% of ischemia are painless (silent)
• Non typical symptoms• When present (jaw,
stomach)
• Possible onset :• Sudden death, MI
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“classical” acute proximal lesion
Diffuse distal disease of diabetes
Coronary angiogramsDr Archer Broughton, Cardiology, The Alfred
Coronary artery atherosclerosis
To detect silent myocardial infarction Perform systematic annual ECG
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TransluminalAngioplasty
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coronarography before / after stenting
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CoronaryBypass
Venous bridges
ObstructedCoronaryarteries
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Blood Hypertension
• Associated pathology or consequence
• Vascular stiffness is characteristic from diabetes
• more often and more serious
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Blood pressure ObjectiveAverage 10 mmHg of SBP
risk decrease
UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes : UKPDS 38. BMJ 1998, 317: 703-13.
Myocardial infarction – 21 %
Stroke – 44 %Microangiopathy – 37 %UKPDS
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Systolic Blood Pressure and CV deathSystolic Blood Pressure and CV death
250
225
200
175
150
125
100
75
50
0
25
< 120 120–139 140–159 160–179 180–199 200Systolic Blood pressure (mmHg)
Cardiovascular deaths
rate/10 000 sub/year
Non diabetics
Diabetics
Stamler J et al. Diabetes Care. 1993;16:434-444.
Goal : 130/80 mmHg
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Heart failure
• Incidence x 2 to 6 in diabetic population•Shorten the life•May cause sudden death•Results from 2 others :
• CHD• HTA
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Peripheral arteriopathy 8% at diagnosis, 15% (10 years) 45% ( 20 years).
• Atheroma plaques more scattered, more distal• Associated risk factors Smoking, HTA, obesity, renal transplantation• Risk of amputation = 10,3 (male) 13,8 (female)• 1 /3 proximal (+ HTA/ dyslipidemia/ smoking)• 1/3 distal below the knee (hyperglycemia / duration of diabetes)• - 1/3 both
-
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•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
Peripheral arteriopathy
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Cerebrovascular attack
Stroke risk x 2
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Brain scan : left infarction (sylvien territory)
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Microangiopathy
•Diabetic retinopathy•Diabetic nephropathy•Diabetic neuropathy•Diabetic foot
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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
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Diabetic nephropathy
40% of type 2 diabetics
have at least background
lesions in their course
Hollenberg NK. J Hypertens 1997,15(S7): 7-13.
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STAGES Time of occurence
Hypertrophy & early
hyperfiltrationKidney
histologic lesionsMicroalbuminuria
backround
nephropathyProteinuria
Néphropathy (clinical)
Renal failure
1
2
3
4
5
diagnosis
2 - 3 years
7 - 15 years
10 - 30 years
20 - 40 years
NDiabetic nephropathy
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Diabetic neuropathy
• An estimated 50 percent of those with diabetes have
some form of neuropathy, but not all with neuropathy have symptoms.
• The highest rates of neuropathy are among people who have had the disease for at least 25 years.
• Neuropathy can affect nerves throughout the body, causing numbness and sometimes pain in the hands, arms, feet, or legs, and problems with the digestive tract, heart, and sex organs.
• Mechanism is very complex
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Peripheral Neuropathy
Peripheral neuropathy affects the nerves in arms, hands, legs, and feet.
• numbness or insensitivity to pain or temperature
• a tingling, burning, or prickling sensation• sharp pains or cramps • extreme sensitivity to touch, even a light
touch
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Peripheral Neuropathy
• loss of balance and coordination • These symptoms are often worse at night.• Peripheral neuropathy may also cause
muscle weakness and loss of reflexes, especially at the ankle, leading to troubles in walking
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Autonomic Neuropathy
Unawareness of HypoglycemiaHeart and Circulatory SystemDigestive SystemUrinary Tract and Sex OrgansSweat GlandsEyes
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Diabetic foot
infection
neuropathy
Skin disease
mIcrovascular
macrovascular
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Complications of type 2 diabetes
What they suffer from?Incidence /prevalenceCheck up and detectionImpact on morbi-mortalityADVANCE what for ?
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Complications of type 2 diabetes
What they suffer from?Incidence /prevalenceCheck up and detectionImpact on morbi-mortality
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« Detection attitude »In diabetes population = any vascular complication look for all other types
- eye examination- Urinary tests, kidney function-ECG, exercise test, myocardial scintigraphy-Vascular echo-doppler-Nerves lesions detection-Focus on foot
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Complications of type 2 diabetes
What they suffer from?Check up and detectionImpact on morbi-mortalityImpact on morbi-mortality
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Risk for Coronary heart disease x 2-4Risk for Coronary heart disease x 2-4
Risk for Stroke x 1.4-2.2 Risk for Stroke x 1.4-2.2
Risk for Arteriopathy x 10Risk for Arteriopathy x 10
Type 2 diabetes means
Not decreased Not decreased during the last during the last 30 years30 years
1st cause of blindness < 50 years (500 – 1000 /year)
50 % of amputations (8500 /year)
20 - 30 % of hémodialysis (2500 /year)
15 % of MI (30 000 / year)
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THE TREATMENT
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“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 clinicsCardiovascular riskGlucometersDietExerciseMore than 10 tablets/dayInsulin injections
“never forget that you have a serious disease !!!!”
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Treatment (1)SuphonylureaGlinideMetforminGLP1AcarboseInsulinPump…..Molecules in development…
Whatever you prescribe …
The only points you have to consider is:
1) Compliance2) HbA1c
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Barriers to insulin therapy
Patient
Needle anxiety
Hypoglycemia
Weight gain
Health Professional
? CV Risks
Hypoglycemia
Weight gain
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Date Presentation title 57
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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?
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Oral Diabetes Medication
What are the target ranges for home blood glucose monitoring?
FastingPre-meals
2 hours after meals
What factors would you need to take into consideration
before starting oral diabetes medication?
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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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