Type 2 Diabetes

Florence.travert@bch.aphp.fr

Basic knowledge about type 2 diabetes

Diabetes complications
Lessons from large scale trials
Training

Basic knowledge
Type 2 diabetes
1.The disease
2.The treatment
3.The prognosis

THE DISEASE

Is type 2 diabetes another world ?

What for a
diabetologist
Deathprevention!

Ketoacidosis
Chronic complications
Microvascular

MI, sudden death

Chronic complications
Macrovascular

Type 2 diabetes is our today's challenge

And it is complex to treat
westernisation
is leading to the rapid
spread of type 2 diabetes,
especially in developing
countries

Increasing prevalence
of type 2 diabetes

population (million)

Increasing
155

Prevalence of diabetes
worldwide

150
145
140
135
130
125
0

1995

2000
year

Diabetes:2003prevalenceand
projectedincreaseby2025
38.2M
16%

25.0M
59%

10.4M
88%
Zimmetet al.Diab Med
2003;20:693702

13.6M
98%

18.2M
97%

81.8M
91%

1.1M
World prevalence 59%

2003: 189 million

2025: 324 million
72% increase

THE PROGNOSIS

PROGNOSIS

Genetics
Hypertension
Smoking
Diabetes

What for a
diabetologist ?

Complications
of type 2 diabetes

The story of a vascular disease .

Complications
of type 2 diabetes
What they suffer from?
Incidence /prevalence
Check up and detection
Impact on morbi-mortality

Complications
of type 2 diabetes
What they suffer from?
Incidence /prevalence
Check up and detection
Impact on morbi-mortality

Sufferingornot?
Patientsdonotsufferdirectlyfrom
theirhyperglycemia(highblood
glucoselevel)
Buttheysufferfromsomeofthe
chronicoracutecomplications

Sufferingornot?
Acutehyperglycemia
Ketoacidosisisduetoalackofinsulin,
itstheapanageoftype1dabetes,
Intype2polyuropolydipsy(cardinal
syndrom)canbeseen
Glycosuria,weightloss,asthenia)

Sufferingornot?
Acutehypoglycemia
neveroccursinanormalsubject
occursonlyifthepatientreceivescertain
drugtargetingthestimulationofinsulin
secretion

Sufferingornot?
Acutehypoglycemia
thefirstsignsareanadrenergicreactionincluding:
sweating,palenesstremordizziness,fatigue.
Neurologicalsignsoccurthenasvisual,hearing,readingor
writingtroubles,elocutiondisorders,concentrationand
progressivelossofconsciousnessandfinallycoma

Complications
Patientsdonotsufferdirectlyfrom
theirhyperglycemia(highblood
glucoselevel)
Buttheysufferfromsomeofthe
chronicoracutecomplications

Where are located these complications

eyes

Rtinopathy, glaucoma,
cataract

Blindness

Heart & Vessels

CHD
Vascular cerebral attack
Periph arteriopathy
Hypertension
Cardiomyopathy
Cardiac failure

Death
MI
Hemiplegia
Amputation

Kidney

Renal failure

Dialysis
transplantation

Nerves

peripheral neuropathy
autonomic neuropathie

pain
Various
consequences

others

Infection, tees, foot

Erectile dysfonction

Various
consequences

DIABETES .

today

Mainly a vascular disease

Macroangiopathy

Coronary
arteries

Carotid
arteries

Periperal
arteries
Low
limbs

Cerebral
arteries

Microangiopathy

eyes

kidney

nerves

skin

Macro angiopathy
artery diameter > 200 m.

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 mdia and of the external limit
of the vessels

Atherosclrosis :
Intima

Media

Adventice

Erythrocytes
platelets

Monocyte
Lipoprotins

1)
2)
3)
4)

accumulation of LDL in intima

inc ome of monocytes and fibroblasts
prolifration of mucular cells

Intensified by tissular and circulating (oxidative stress)

Endothlium
Mucle cells

Consequences

Coronary Heart disease

Hypertension
Cardiac failure
Diabetic myocardiopathy
Peripheral arteriopathy
Cerebrovascular attack

Coronary
Heart Disease
30% of ischemia are
painless (silent)

Non typical symptoms

When present (jaw,
stomach)

Possible onset :

Sudden death, MI

classical acute proximal lesion

Coronary artery atherosclerosis

Diffuse distal disease of diabetes

To detect silent myocardial

infarction Perform systematic
annual ECG

Coronary angiograms
Dr Archer Broughton, Cardiology, The Alfred

Transluminal
Angioplasty

coronarography before / after stenting

Coronary
Bypass

Venous
bridges

Obstructed
Coronary
arteries

Blood Hypertension
Associated pathology or
consequence

Vascular stiffness is characteristic

from diabetes

more often and more serious

Blood pressure Objective

Average 10 mmHg of SBP
risk decrease
Myocardial
infarction

21 %

Stroke

44 %

Microangiopathy
UKPDS

37 %

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: 70313.

Systolic Blood Pressure and CV death

250
225

Goal : 130/80 mmHg

200
175
Cardiovascular
150
deaths
rate/10 000 125
sub/year
100

Non diabetics
Diabetics

75
50
25
0

< 120

120139

140159

160179

180199

Systolic Blood pressure (mmHg)

Care. 1993;16:434-444.
Stamler J et al. Diabetes

200

Heart failure

Incidence x 2 to 6 in diabetic population

Shorten the life
May cause sudden death
Results from 2 others :
CHD
HTA

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

Peripheral arteriopathy
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

Cerebrovascular attack

Stroke risk x 2

Brain scan : left infarction (sylvien territory)

Microangiopathy

Diabetic retinopathy
Diabetic nephropathy
Diabetic neuropathy
Diabetic foot

Diabetic retinopathy
Background:

Increased capillar permeability

dema microexsudates

Retinal ischemia:

micro aneurysms
punctiformes haemorrhages

Proliferative retinopathy:
Neovessels

Ruptures causing haemorrhages

Development of glial tissu
Retina retraction and detachment

Macular oedema
cataract

Diabetic nephropathy
40% of type 2 diabetics
have at least background
lesions in their course

Hollenberg NK. J Hypertens 1997,15(S7): 7-13.

Diabetic nephropathy
STAGES

Time of occurence

Hypertrophy &
early
hyperfiltration

Kidney
histologic lesions

Microalbuminuria
backround

nephropathy
Proteinuria
Nphropathy
(clinical)

Renal failure

diagnosis
2 - 3 years
7 - 15 years
10 - 30 years
20 - 40 years

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

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

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

Autonomic Neuropathy
Unawareness of Hypoglycemia
Heart and Circulatory System
Digestive System
Urinary Tract and Sex Organs
Sweat Glands
Eyes

Diabetic foot
macrovascular
mIcrovascular
infection
Skin disease

neuropathy

Complications
of type 2 diabetes
What they suffer from?
Incidence /prevalence
Check up and detection
Impact on morbi-mortality
ADVANCE what for ?

Complications
of type 2 diabetes
What they suffer from?
Incidence /prevalence
Check up and detection
Impact on morbi-mortality

 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

Complications
of type 2 diabetes
What they suffer from?
Check up and detection
Impact on morbi-mortality

Type 2 diabetes means

RiskforCoronaryheartdiseasex2-4

Not decreased
during the last
30 years

RiskforStrokex1.4-2.2
RiskforArteriopathyx10

1st cause of blindness < 50 years (500 1000 /year)

15 % of MI (30 000 / year)
50 % of amputations (8500 /year)
20 - 30 % of hmodialysis (2500 /year)

THE TREATMENT

I dont 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 clinics

Cardiovascular risk
Glucometers
Diet
Exercise
More than 10 tablets/day
Insulin injections
never forget that you have a
serious disease !!!!

Treatment (1)
Suphonylurea
Glinide
Metformin
GLP1
Acarbose
Insulin
Pump
..
Molecules in
development

Whatever you
prescribe
The only points you
have to consider is:
1) Compliance
2) HbA1c

Barriers to insulin therapy

Patient

Needle anxiety
Hypoglycemia
Weight gain

Health Professional

? CV Risks
Hypoglycemia
Weight gain

Date

Presentationtitle

57

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?

Oral Diabetes Medication

What are the target ranges for home blood
glucose monitoring?
Fasting
Pre-meals
2 hours after meals
What factors would you need to take
into consideration
before starting oral diabetes medication?

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?