Cliniczal Practice Guidelines:

Management of

Type 2 Diabetes Mellitus (5th Edition) 2015

Topic 14:

Management of Chronic Complications 2

Coronary Heart Disease

• Diabetic patient are at increased risk of CHD. They may

manifest as angina, myocardial infarction (MI), congestive

cardiac failure (CCF) or sudden death.

• Most frequent cause of death in T2DM.

• Characterised by its early onset, extensive disease at the time

of diagnosis, and higher morbidity and mortality after MI .

0.00

0.05

0.10

0.15

0.20

0.25

OASIS Study: Total Mortality E

ve

nt

Ra

te

Months

6 9 15 3 18 21 12

RR=2.88 (2.37–3.49)

Malmberg K et al. Circulation 2000;102:1014-1019.

24

RR=1.99 (1.52–2.60)

RR=1.71 (1.44–2.04)

RR=1.00

Diabetes/CVD (n = 1148)

No Diabetes/CVD (n = 3503)

Diabetes/No CVD (n = 569)

No Diabetes/No CVD (n = 2796)

Screening

• Typical symptoms: referral to cardiologist.

• May have atypical/vague symptoms especially trigger by

exertion.

• Asymptomatic: routine screening not recommended.

• On first and subsequent visit, CVD risk calculator such as

Framingham Risk Score (FRS) or SCORE should be

applied.

•

• Patient with other macrovascular complications should be

screen for CHD.

ASA and diabetes: 2008 JPAD

© 2011 - TIGC

Ogawa H et al. JAMA 2008 (300) 18; 2134-2141

ASA and diabetes: 2008

JPAD: Baseline clinical characteristics

Ogawa H et al. JAMA 2008 (300) 18; 2134-2141

ASA and diabetes: 2008

JPAD: Primary end point

Ogawa H et al. JAMA 2008 (300) 18; 2134-2141

ASA and diabetes: 2008

JPAD: Primary end point if 65 years or older

Ogawa H et al. JAMA 2008 (300) 18; 2134-2141

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Copyright © 2013 Canadian Diabetes Association

JPAD = Japanese Primary Prevention of Atherosclerosis

with Aspirin for Diabetes

POPADAD = Prevention of Progression of Arterial

Disease and Diabetes

PPP = Primary Prevention Project

ETDRS = Early Treatment Diabetic Retinopathy Study

PHS = Physicians’ Health Study

WHS = Women’s Health Study

De Beradis G, et al. BMJ 2009; 339:b4531.

ASA for 1⁰ Prevention in

Diabetes Meta analysis of 6 studies

(n = 10,117)

No overall benefit for:

• Major CV events

• MI

• Stroke

• CV mortality

• All-cause mortality

0.03 0.125 0.5 1 2

8

Favors ASA Favors control/placebo

JPAD

POPADAD

WHS

PPP

ETDRS

Total

68/1262

105/638

58/514

20/519

350/1856

601/4789

86/1277

108/638

62/513

22/512

379/1855

657/4795

0.80 (0.59-1.09)

0.97 (0.76-1.24)

0.90 (0.63-1.29)

0.90 (0.50-1.62)

0.90 (0.78-1.04)

0.90 (0.81-1.00)

Major CV events

No. of events/No. in group

ASA Control/placebo RR (95% CI) RR (95% CI)

JPAD

POPADAD

WHS

PPP

ETDRS

PHS

Total

28/1262

90/638

36/514

5/519

241/1856

11/275

395/5064

14/1277

82/638

24/513

10/512

283/1855

26/258

439/5053

0.87 (0.40-1.87)

1.10 (0.83-1.45)

1.48 (0.88-2.49)

0.49 (0.17-1.43)

0.82 (0.69-0.98)

0.40 (0.20-0.79)

0.86 (0.61-1.21)

Myocardial infarction

JPAD

POPADAD

WHS

PPP

ETDRS

Total

12/1262

37/638

15/514

9/519

92/1856

181/4789

32/1277

50/638

31/513

10/512

78/1855

201/4795

0.89 (0.54-1.46)

0.74 (0.49-1.12)

0.46 (0.25-0.85)

0.89 (0.36-2.17)

1.17 (0.87-1.58)

0.83 (0.60-1.14)

Stroke

JPAD

POPADAD

PPP

ETDRS

Total

1/1262

43/638

10/519

244/1856

298/4275

10/1277

35/638

8/512

275/1855

328/4282

0.10 (0.01-0.79)

1.23 (0.80-1.89)

1.23 (0.49-3.10)

0.87 (0.73-1.04)

0.94 (0.72-1.23)

Death from CV causes

JPAD

POPADAD

PPP

ETDRS

Total

34/1262

94/638

25/519

340/1856

493/4275

38/1277

101/638

20/512

366/1855

525/4282

0.90 (0.57-1.14)

0.93 (0.72-1.21)

1.23 (0.69-2.19)

0.91 (0.78-1.06)

0.93 (0.82-1.05)

All-cause mortality

Aspirin for Primary Prevention of Cardiovascular

Disease in People with Diabetes

• The Japanese Primary Prevention of Atherosclerosis

with Aspirin for Diabetes (JPAD) study showed that daily

low-dose aspirin failed to show a significant effect on

broad composite cardiovascular disease endpoints.

• Fatal coronary or cerebrovascular events was

significantly decreased in the aspirin group in those

above the age of 65.

• Low dose aspirin (100 mg) in those aged 65 or older has

been shown to reduce atherosclerotic events.

Cerebrovascular Disease

• Risk are increase twice of ischaemic stroke compared to

those without diabetes.

• The risk of stroke is higher in women than in men.

• Dyslipidaemia, endothelial dysfunction and platelet or

coagulation abnormalities are among the risk factors that

promote the development of carotid atherosclerosis in

diabetics.

Diabetic Foot

• Ulcerations and amputations are major causes of morbidity

and mortality.

• Prevalence of lower limb amputation was 4.3%.

• Risk factors for foot ulcers: – Previous amputation

– Past foot ulcer history

– Peripheral neuropathy

– Foot deformity

– Peripheral vascular disease

– Visual impairment

– Diabetic nephropathy (especially patients on dialysis)

– Poor glycaemic control

– Cigarette smoking

Prevention of Foot Ulcers

• Starts with examination of the feet (shoes and socks

removed) and identifying those at high risk of ulceration.

Assess the peripheral neuropathy and peripheral pulses.

• At-risk patients are then given relevant education to

reduce the likelihood of future ulcers.

• The feet should be examined at least once annually or

more often in the presence of risk factors.

Treatment

• An ulcer in a patient with any of the above risk factors

will warrant an early referral to a specialist for shared

care.

• Cellulitis will require antibiotics.

• A multidisciplinary approach is recommended for

patients with foot ulcer and high-risk feet (e.g. dialysis

patients, those with charcot’s foot, prior ulcers or

amputation).

Erectile Dysfunction

• Definition: Inability to achieve, maintain or sustain an

erection firm enough for sexual intercourse.

• Prevalence of ED among diabetic men varies from 35%

to 90%.

• Factors associated:

– Advancing age, duration of diabetes, poor glycaemic

control, presence of other diabetic complications,

hypertension, hyperlipidaemia, sedentary lifestyle and

smoking

Screening and Diagnosis

• All adult diabetic males should be asked about ED.

• Screened for any symptoms or signs of hypogonadism.

•

• Screening can be done using the 5-item version of the

International Index of Erectile Function (IIEF)

questionnaire.

Treatment

• Optimisation of glycaemic control, management of other

comorbidities and lifestyle modifications.

• Psychosexual counseling for patient and partner is

recommended.

• Avoid medications that may cause or worsen ED such as

thiazides, beta-blockers, calcium channel blockers,

methyldopa etc.

• Phosphodiesterase-5 (PDE-5) inhibitors should be offered as

first-line therapy.

• Referral to a urologist may be necessary for those not

responding.

Female Sexual Dysfunction

• Occur in 24–75% in diabetic women.

•

• Age, duration of diabetes, poor glycaemic control,

menopause, microvascular complications, and

psychological factors are associated with FSD.

Screening and Diagnosis

• Diagnosis of FSD can be established by using the FSFI questionnaire that consists of 19 questions covering all domains of sexual dysfunction available at www.fsfiquestionnaire.com. The validated Malay version is also available.

Treatment

• Emphasis should be made to treat psychosocial

disorders and relationship disharmony.

• Avoid drugs that may affect sexual function: – Beta-blockers, alpha-blockers, diuretics

– Tricyclic antidepressants, SSRIs, lithium, neuroleptics

– Anticonvulsants

– Oral contraceptive pills

• In postmenopausal women, tibolone has been

associated with significant increases in sexual

desire and arousal.

Mental Health Issues in Diabetes

• Symptoms to look for may include the prolonged period

of moodiness with any or all of the following:

– Appetite changes

– Loss of interest in daily activities

– Feeling of despair

– Inappropriate sense of guilt

– Sleep disturbance

– Weight loss

– Suicidal thoughts

Indications for referral to a mental health

specialist may include:

– Depression with the possibility of self-harm

– Debilitating anxiety (alone or with depression)

– Indications of an eating disorder

– Cognitive functioning that significantly impairs

judgment