Outlines. Prevention and Management of DM Complications. Prevention of Cardiovascular disease. Type 2 Diabetes: Complications หญ งไทยอาย 60 ป อาช พ คร
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1 Prevention and Management of DM Complications พ.ญ. พรรณท พย ต นต วงษ ร.พ.มหาราชนครราชส มา Outlines Screening of DM complications Prevention of DM complications Management of DM complications หญ งไทยอาย 60 ป อาช พ คร Underlying DM type 2, HT มา 5 ป เคยร กษาแล ว loss f/u เร มม ขาบวม ตาม ว ป สสาวะบ อยโดยกลางค น 5-6 คร ง ต อค น ม ปวดออกร อนฝ าเท า เป นมากกลางค น ปฏ เสธโรคประจ าต วอ น ๆ ไม ม ประว ต เบาหวานในครอบคร ว PE BP 160/90 mmhg, P 80/min, BW 76 kg, Ht 156 cm, pitting edema 2+ both legs, heart & lung & abdomen - normal ค าถาม ท านจะให การตรวจใดเพ มเต ม? ท านจะให การร กษาอย างไร? Type 2 Diabetes: Complications Diabetic retinopathy Leading cause of blindness in working-age adults 1 Diabetic nephropathy Leading cause of end-stage renal disease 2 Stroke 1.2 to 1.8-fold increase in stroke 3 Cardiovascular disease 75% diabetic patients die from CV events 4 Diabetic neuropathy Leading cause of non-traumatic lower extremity amputations 5 1 Fong DS, et al. Diabetes Care 2003;26(Suppl. 1):S99 S Molitch ME, et al. Diabetes Care 2003;26(Suppl. 1):S94 S98. 3 Kannel WB, et al. Am Heart J 1990;120: Gray RP & Yudkin JS. In Textbook of Diabetes Mayfield JA, et al. Diabetes Care 2003;26(Suppl. 1):S78 S79. Problem lists หญ งไทยอาย 60 ป อาช พ คร DM type 2 (Poor compliance) HT Obesity Vascular complications : DR?? DN?? Painful neuropathy ท านจะให การตรวจใดเพ มเต ม? ประเม นป ญหาการด แลตนเอง ประเม น Glycemic control : BS, HbA1C ประเม น DM complications Cardiovascular disease Microvascular complications Prevention of Cardiovascular disease Aspirin Smoking cessation 1
2 Blood pressure should be measured at every visit. If BP > 120/80 mmhg: advised on lifestyle changes. If BP > 140/80 mmhg: prompt initiation and timely subsequent titration of pharmacological therapy in addition to lifestyle therapy. Atherogenic lipoprotein ในเบาหวาน High VLDL-triglycerides Low HDL cholesterol Increase small dense LDL cholesterol การค ดกรองภาวะไขม นในเล อดส งในเบาหวาน Measure fasting lipid profiles at least annually. Repeat every 2 years if normal LDL < 100 mg/dl, HDL > 50 mg/dl, TG <150 mg/dl Treatment Strategies for Diabetic Dyslipidemia Primary Strategy - Lower LDL cholesterol Secondary Strategy - Raise HDL cholesterol - Lower triglycerides Chait A, Brunzell JD. Diabetes Mellitus. A Fundamental and Clinical Text. Philadelphia: Lippincott Raven, 1996; ; European Diabetes Policy Group Diabet Med. 1999;16: Recommendations for aspirin therapy Secondary prevention : DM with history of MI, vascular bypass procedure, stroke or TIA, PAD, and/or angina Primary prevention : DM with age > 50 years in men and age > 60 years in women(10-year CHD risk > 10%) who have at least one additional major risk factor: Family history of CAD Smoking Albuminuria 2
3 Screening and prevention of microvascular complications Diabetic retinopathy Diabetic nephropathy Diabetic neuropathy Foot care Classification of Diabetic Retinopathy Non-proliferative Diabetic Retinopathy Nonproliferative DR Mild NPDR Moderate NPDR Severe NPDR Proliferative DR Macular edema NPDR was characterized by an increase in vascular permeability or vascular closure Such as : Microaneurysm Dot blot hemorrhage Hard exudate Soft exudate Ophthalmology. 2003;110: Ophthalmology. 2003;110: Proliferative Diabetic Retinopathy Macular Edema PDR was vasoproliferation of new vessels occurred on or within the retina including its complications Exudate at macular area Neovascularization Vitreous/Preretinal hemorrhage Ophthalmology. 2003;110: Ophthalmology. 2003;110:
4 Diabetic Retinopathy Ophthalmologic examination schedule Patient group Recommended first examination Minimum routine follow-up* -Type 1 diabetes Within 3-5 years after diagnosis Yearly of diabetes once patient is age 10 years or older -Type 2 diabetes At time of diagnosis of diabetes Yearly -Pregnancy in Prior to conception and during depending results preexisting diabetes first trimester of first trimester exam *Abnormal findings necessitate more frequent follow-up. Some evidence suggests that the prepubertal duration of diabetes may be important in the development of microvascular complications; therefore, clinical judgment should be used when applying these recommendations to individual patients. การว น จฉ ย ในระยะแรก จะไม ม อาการ ต องอาศ ยการตรวจป สสาวะหาอ ลบ ม น (ไข ขาว) ไมโครอ ลบ ม นในป สสาวะ (Microalbuminuria) เป นการตรวจท ไวท ส ดในการว น จฉ ย ค อ ไมโครอ ลบ ม น มก. ต อว น ซ งจะไม พบจากการตรวจป สสาวะแบบปกต โปรต นในป สสาวะ (Macroalbuminuria) ด วยว ธ ตรวจป สสาวะแบบธรรมดา พบความผ ดปกต เม อโปรต นเก น 300 มก. ต อว น อาจม อาการบวมร วมด วย Serum BUN, Creatinine ส งข น (Renal insufficiency) แสดงถ งไตเส อมจน การข บถ ายของเส ยทางไตผ ดปกต End Stage Renal Disease (ESRD) ม อาการคล นไส อาเจ ยน ม กรดค ง แนวทางเวชปฏ บ ต ส าหร บโรคเบาหวาน 2554 การป องก นภาวะ Diabetic Nephropathy การตรวจค ดกรองประจาป In type 1 diabetic patients with duration of 5 years In all type 2 diabetic patients Urine dipstick ตรวจโดยใช dipstick ผลบวก ให การร กษา Macroalbuminuria ผลลบ ตรวจหาภาวะ Microalbuminuria แนวทางเวชปฏ บ ต ส าหร บโรคเบาหวาน
5 Diabetic Nephropathy To be intended to emphasize the continuous nature of albuminuria as a risk factor, the terms microalbuminuria and macroalbuminuria will no longer be used Category Spot collection (µg/mg cr) Normal < 30 Increased urinary albumin excretion* (persistent albuminuria) การเก ดแผลท เท าจากโรคเบาหวาน Diabetic foot ulcer Poor diabetes control Neuropathic Ulcer Ischemic Ulcer Polyneuropathy Insensate, deformed and dry feet Infection Vascular occlusion Foot ulcer Amputation - รองเท าท ไม เหมาะสม - เท าแตกแห ง - สายตาท ผ ดปกต - เท าผ ดร ป - การต ดเล บเท าท ไม ถ กต อง - การแช เท าด วยน าร อนจ ด - การเด นระยะทางไกล การตรวจเท าผ ป วยเบาหวาน ตรวจอย างน อยป ละหน งคร ง การด เท าหร อเล บท ผ ดร ป ประเม นอาการชาเท าจากเบาหวาน Autonomic neuropathy Light touch : Semmes-Weinstein Monofilament (10 g) ประเม นการไหลเว ยนหลอดเล อดท เท า Pulses Ankle Brachial Index (ABI) 5
6 Monofilament Testing Dorsalis pedis pulse Posterior tibialis pulse Ankle-Brachial Index (ABI) Diagnostic criteria for interpretation Normal Mild obstruction Moderate obstruction < 0.40 Severe obstruction > 1.30 Poorly compressible American Diabetes Association Position Statement, Diabetes Care, Dec 2003 หญ งไทยอาย 60 ป ท านจะให การตรวจใดเพ มเต ม? ประเม น DM complication CV disease : HT, lipid profiles (LDL, HDL, TG), aspirin Microvascular complications UA, creatinine ส งตรวจ Digital camera fundoscopy ส งตรวจ DM foot examination หญ งไทยอาย 60 ป อาช พ คร Lab FBS 240 mg/dl, HbA1C 9.0 %, creatinine 1.2 mg/dl, UA protein 2+, sugar 3+, no cell, LDL 190 mg/dl, TG 300 mg/dl, HDL 42 mg/dl Fundoscopy : Mild NPDR both eyes Foot exam: no foot deformity, no ulcer, dorsalis pedis pulses: present and equal both, monofilaments: intact sensation 6
7 หญ งไทยอาย 60 ป อาช พ คร การปร บเปล ยนพฤต กรรม Diagnosis Type 2 DM Obesity ท านจะให การร กษาอย างไร?? Mild NPDR both eyes Diabetic nephropathy Painful neuropathy ลดการบร โภคเกล อ ให น อยกว า 1,500 mg/day ลดการบร โภค saturated fat, trans fat และ cholesterol เพ มการบร โภค n-3 fatty acids, fiber และ plant stanol เพ มการร บประทานอาหารท ม กากใย ลดน าหน กต วส วนเก น เพ มการออกกาล งกาย หล กเล ยงเคร องด มประเภท alcohol, หย ดส บบ หร ควบค มระด บน าตาลให ด ในรายท ม triglycerides ส ง เม อว น จฉ ยโรค FPG < 180 และ HbA1C < 8 % FPG mg/dl สปสช51, endocrine society 51 Thai guideline 2554 ข นตอนในการร กษาเบาหวานชน ดท 2 ปร บเปล ยนพฤต กรรม โภชนบำบ ด ออกกำล งกำย เร ยนร เบำหวำน และ กำรด แลตนเอง 1-3 เด อน ถ ำย งไม ได ตำมเป ำหมำย ให เร มร กษำด วยยำ ก นยาลดระด บน าตาล พ จารณาตามล กษณะของผ ป วย Metformin ล กษณะด ออ นซ ล น -BMI >23 กก/ม2 หร อ รอบเอวเก น -ม Acanthosis nigrican -BP >130/80 หร อม HT -Elevated TG, low HDL Sulfonylurea ล กษณะขาดอ นซ ล น -BMI <23 กก/ม2 และ รอบเอวไม เก น -ม อาการน าตาลส งช ดเจน ยาท เป นทางเล อก Glitazone, Repaglinide, AGI, DPP-4 inhibitors Thiazide Combination with ACEI Useful in Elderly Use in Systolic HTN Diagnosis of Hypertension > 140/80 mm Hg Non Pharmacologic Therapy ACE Inhibitor/ ARB Drugs of choice Limits progression of nephropathy Lowers CVD risk Beta - Blockers Effective Post MI Avoid if severe hypoglycemia Calcium channel Blockers Useful in combination Central a Blockers Vasodilators as Combination Rx Avoid if orthostasis Treatment and Recommendation Goals Add STATIN, regardless of baseline lipid levels, who With overt CVD Without CVD who are > 40 y and have one or more other CVD risk factors For lower-risk patients than the above (<40 y, without CVD), consider statin with lifestyle therapy if LDL>100 mg/dl or those with multiple risk factors. Statin therapy is contraindicated in pregnancy Treatment and Recommendation Goals GOAL: Individual without overt CVD: primary LDL goal < 100 mg/dl Individual with overt CVD: lower LDL goal of < 70 mg/dl If not reach the target, an alternative goal is reduce LDL ~ 30-40% from baseline Triglycerides < 150 mg/dl and HDL > 40 mg/dl in men and > 50 mg/dl in women 7
8 Recommendations for aspirin therapy Aspirin dose : mg/day Contraindication : ASA allergy, bleeding tendency, anticoagulant, recent GI bleed, active liver disease Not recommend for age under 30 years Contraindicated in patient under age of 21 years Clopidogrel Adjuctive therapy in the first year after acute coronary syndrome in very high risk patients Alternative therapy in aspirin intolerant patients การตรวจค ดกรองภาวะแทรกซ อนประจ าป ควบค มระด บน าตาลในเล อด ระด บความด นโลห ต และระด บ ไขม นในเล อดให ด ส งพบจ กษ แพทย เม อพบภาวะ macular edema, severe NPDR และ PDR Laser photocoagulation therapy ม บทบาทในการลดการส ญเส ย การมองเห นในผ ท ม ภาวะ high-risk PDR, macular edema และ severe NPDR Retinopathy ไม ใช ข อจ าก ดในการใช ASA therapy ACEIs or ARB for the primary prevention of DKD is not recommended in diabetic patients with normal BP and albumin excretion < 30 mg/24h. Either ACEIs or ARBs (but not both in combination) are recommended for the treatment of the non-pregnant patient with modestly elevated ( mg/24 h) or high level (> 300 mg/24 h) of urinary albumin excretion. Patients with DKD (albuminuria > 30 mg/24 h), reducing the amount of dietary protein below usual intake is not recommended. ** When ACEIs, ARBs, or diabetics are used, monitor serum creatinine and potassium levels **. Consider referral to experienced physicians when GFR < 60 ml/min/1.73 or difficult to control BP Consult with nephrologists when Stages of CKD GFR < 30 ml/min/1.73m2 First aim of management is to optimize glycemic control Medication for relief of specific symptoms related to neuropathy are recommended, to improve the quality of life of patient Standard of medical care ADA หญ งไทยอาย 60 ป อาช พ คร Diagnosis Type 2 DM Obesity Mild NPDR both eyes Diabetic nephropathy Painful neuropathy ท านจะให การร กษาอย างไร? Advice: goal of treatment, life style modification and self management Reduce BW Medication : Metformin 500 mg bid Losartan 50 mg od Simvastation 10 mg hs Amitryptylline 10 mg hs Aspirin 81 mg od Follow up: One month with FBS, Cr, K, UA, LDL 8
9 FDA Drug Safety Communication: US FDA recommended limiting the use of simvastatin 80 mg because of increased risk of muscle damage Risk appear to be higher during the first year of treatment (5/1,000 for myopathy and 2/1,000 for rhabdomyolysis) Simvastatin 80 mg should not be started in new patients Should be use only in patients who have been taking this dose more than 12 months without SE New Simvastatin lebel Contraindicated: itraconazole, ketoconazole, erythromycin, clarithromycin, HIV protease inhibitors, nefazodone, cyclosporin, gemfibrozil, danazol Do not exceed 10 mg of simvastatin: amiodarone, verapamil, diltiazem Do not exceed 20 mg of simvastatin: amlodipine, ranolazine FDA Drug Safety Communication: FDA Drug Safety Communication: Outlines Screening of DM complications Prevention of DM complications Management of DM complications Take home messages!! Glycemic Control alone is not enough! There is a need for Global Treatment of Vascular Risk Factors in DM type2!! The Need for Global Treatment to Reduce the Risk of Compications Hyperglycemia Obesity and Diet Physical Inactivity Smoking Cessation Anti-platelet Therapy Annual Screening/Tx - Health education - Nephropathy screening for albuminuria - Retinopathy fundoscopy - Neuropathy comprehensive foot exam THANK YOU FOR YOUR ATTENTION. 9
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