Complications of diabetes mellitus

pathophysiology II PHARM-D

1. DIABETES MELLITUS(DM) DEFINITION Diabetes mellitus(DM),commonly referred to as diabetes, is a group of metabolic disorders in which there are high blood sugar levels over a prolonged period. Diabetes is due to either the pancreas not producing enough insulin or the cells of the body not responding properly to the insulin produced. TYPES OF DIABETES MELLITUS Type 1 DM Type2DM Gestational DM

2. TYPE 1 DIABETES MELLITUS It was previously termed as juvenile- onset diabetes due to its occurrence in younger age. It was also known as insulin dependent DM.It constitutes about 10% cases of DM. These patients require insulin replacement as treatment. CAUSES: Auto immune destruction of insulin producing beta cells in the pancreas

3. TYPE 2 DIABETES MELLITUS It was previously called as maturity-onset diabetes, or non-insulin dependent diabetes mellitus(NIDDM) It comprise about 80%cases of diabetes mellitus. It begins with insulin resistance, a condition in which cells fails to respond to insulin properly . CAUSES obesity lack of exercise genetics

4. GESTATIONAL DIABETES MELLITUS Woman without diabetes develops high blood sugar level during pregnancy. These woman's are prone to DM in later life CAUSES Not enough insulin in the setting of insulin resistance

5. Acute complications: Ketoacidosis The hyperglycemic hyperosmolar nonketotic syndrome Hypoglycemia Late systemic complications: M icrovascular complications Neuropathies Nephropathies Retinopathies Macrovascular complications cardiovascular diseases peripheral vascular diseases Foot ulcers Complications of diabetes mellitus

6. It occurs when ketone production by the liver exceeds cellular use and renal excretion. Most commonly occurs in a person with type 1 diabetes, in whom the lack of insulin leads to mobilization of fatty acids from adipose tissue because of the unsuppressed adipose cell lipase activity that breaks down triglycerides into fatty acids and glycerol. The increase in fatty acid levels leads to ketone production by the liver. Stress increases the release of gluconeogenic hormones and predisposes the person to the development of ketoacidosis. DKA often is preceded by physical or emotional stress, such as infection, pregnancy, or extreme anxiety. In clinical practice, ketoacidosis also occurs with the omission or inadequate use of insulin. DIABETIC KETOACIDOSIS (DKA)

7. CLINICAL FEATURES Anorexia Nausea Vomiting Deep and fast breathing Mental confusion Coma Excessive urination Dehydration

8. TREATMENT Fluid Replacement : Provide fluids either by mouth or through vein(intravenously) until you’re rehydrated and it will helps in diluting the excess sugar in blood . Electrolyte replacement : Electrolytes includes sodium potassium and chloride. The absence of insulin lower the level of several electrolytes in blood. To compensate the lost electrolyte, electrolyte replacement is necessary . Insulin therapy Insulin reverses the processes that cause diabetic ketoacidosis . Thus it is administered intravenously .

9. HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME Hyperglycemic hyperosmolar nonketotic syndrome is characterised by hyperglycemia (blood glucose >600mg/dl),hyperosmolarity(plasma osmolarity>310mOsm/l)and dehydration,absence of ketoacidosis and depression of sensorium. It is usually a complication of type 2 DM. It causes severe dehydration from sustained hyperglycemic diuresis. The loss of glucose in urine is so intensed that the patient is unable to drink sufficient water to maintain urinary fluid loss. Thrombotic and bleeding complications are frequent due to high viscosity of blood.

10. CLINICAL FEATURES Excessive thirst Dry mouth Increased urination Warm, dry skin Fever Drowsiness Confusion Hallucination

11. PATHOGENESIS

12. TREATMENT Fluid replacement : In hyperosmolar hyperglycemia the mean fluid loss is about 9L. Thus rapid fluid replacement is preferred. Insulin therapy Blood glucose level is reduced using insulin .

13. HYPOGLYCEMIA Hypoglycemia,also known as low blood sugar , is when blood sugar decreases to below normal level. It may develop in patients with type 1 DM. The most common cause include the medications of diabetes mellitus such as insulin and sulfonylureas. Other causes may include kidney failure, certain tumors such as insulinoma, liver disease, hypothyroidism, starvation etc.

14. CLINICAL FEATURES Heart palpitations Fatigue Pale skin Shakiness Anxiety Sweating Hunger

15. PATHOPHYSIOLOGY

16. TREATMENT Dietary therapy : Provide 15g of fast-acting carbohydrates such as fruit juice,candy,glucose tablet etc.. Intravenous glucose therapy Alpha glucosidase inhibitor (acarbose, miglitol) These drugs cause reversible inhibition of pancreatic alpha amylase and membrane bound intestinal alpha glucoside hydrolase enzyme. This inhibition results in delayed glucose absorption.

17. MICROVASCULAR COMPLICATIONS . Microvascular complications mainly include: Nephropathy Neuropathy Retinopathy Diabetic nephropathy : It is a progressive kidney disease involving damage to the capillaries in the kidney’s glomeruli because of long standing diabetes mellitus. SYMPTOMS Albumin or protein in urine Ankle and leg swelling, leg cramps

18. High blood pressure High BUN and serum creatinine Morning sickness, nausea and vomiting TREATMENT Lowers the blood pressure Angiotensin converting enzyme inhibitor eg:captopril, enalapril,lisinopril,ramipril Angiotensin II receptor blocker eg:telmisartan,candesartan Calcium channel blocker eg : amlodipine,verapamil

19. Severe cases Dialysis Kidney transplantation Diabetic neuropathy Diabetic neuropathy is a type of nerve damage that can occur if you have diabetes. High blood sugar can injure nerve fibers throughout your body, but diabetic neuropathy most often damages nerves in your legs and feet SYMPTOMS Numbness or reduced ability to feel pain or temperature changes Tingling or burning sensation. Sharp pains or cramps, muscle weakness Increases sensitivity to touch

20. TREATMENT Anti seizure medications eg:gabapentin,pregabalin, carbamazepine Anti depressants eg:amitriptyline, desipramine, imipramine Diabetic retinopathy Diabetic retinopathy is a diabetic complication that affects eye. It is caused by damage to the blood vessels of the light sensitive tissue at the back of the eye(retina) SYMPTOMS Spots or dark strings floating in your vision Blurred vision Fluctuating vision

21. Impaired colour vision Dark or empty areas in your vision Vision loss TREATMENT Laser treatment Eye injections Eye surgery

22. PATHOPHYSIOLOGY OF MICROVASCULAR COMPLICATIONS

23. MACROVASCULAR COMPLICATIONS These mainly includes CARDIO VASCULAR DISEASE Coronary heart disease Hypertension Angina pectoris Stroke PERIPHERAL VASCULAR DISEASE Atherosclerosis

24. CORONARY HEART DISEASE Coronary heart disease is a disease in which a waxy substance called plaque builds up inside the coronary arteries. These arteries supply oxygen rich blood to heart muscle. SYMPTOMS chest pain Heart burn Tachycardia Dyspnoea sweating

25. TREATMENT Aspirin or other anti platelets to help prevent blood clots. ACE inhibitors and beta blockers Statins to help lower cholesterol level HYPERTENSION Hypertension also known as high blood pressure is a long-term medical condition in which the blood pressure in the arteries is elevated.

26. TREATMENT Thiazide diuretics Calcium channel blockers ACE inhibitors Angiotensin receptor blockers SYMPTOMS Headache Vertigo Anxiety Cushing syndrome Moon face palpitation

27. ANGINA PECTORIS A condition marked by severe pain in the chest, often also spreading to the shoulders ,arms and neck owing to an inadequate blood supply to the heart . SYMPTOMS Dyspnoea Fatigue Dizziness Profuse sweating Anxiety

28. TREATMENT Nitroglycerin which relieves pain associated with stable angina. Angioplasty Open heart surgery Coronary artery bypass graft STROKE A sudden disabling attack or loss of consciousness caused by an interruption in the flow of blood to the brain especially through thrombosis . SYMPTOMS Weakness or numbness of the face arm or leg on one side of the body Loss of vision Loss of speech Loss of balance

29. TREATMENT Aspirin Intravenous injection of tissue plasminogen activator Carotid endarterectomy Angioplasty and stents Surgical clipping Intracranial bypass Stereotactic radio surgery

30. ATHEROSCLEROSIS Narrowing of artery characterised by the deposition of fatty material on their inner walls . SYMPTOMS Chestpain Shortness of breath palpitation Difficulty In speaking blurred vision arrhythmia

31. TREATMENT Statins Antiplatelet drug ACE inhibitors Angioplasty Coronary artery bypass grafting

32. FOOT ULCER Diabetic foot ulcer is the major complication of diabetic mellitus.DM impairs the normal step in wound healing process. The prolonged inflammatory phase is due to the delay in formation of mature granulation tissue and a parallel reduction in wound tensile strength. PHYSICAL APPEARANCE It looks like a red crater in the skin mostly located in the side or bottom of foot ,or top or tip of a toe.

33. PATHOPHYSIOLOGY

34. TREATMENT Antibiotic Antiplatelet drug.

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