OUTLINE OF DIABETES COURSE
Introductions and course preview
Part 1: Systemic Considerations
Epidemiology
Increasing prevalence of diabetes and pre-diabetes
Risk factors in diabetes (including risks contributing to growing prevalence)
Importance of undiagnosed diabetes
Screening for diabetes—considerations
Overview of Diabetes Mellitus globally and South Africa.
Classification
Type 1 autoimmune
Lack of insulin—insulin is required treatment
Risk for ketoacidosis
Multiple factors—genetics plus environment
Type 2 Insulin resistance + Insulin deficiency (may be relative deficiency considering
resistance)
Contributing lifestyle factors
Multiple options for treatment (often together): Oral Rx, insulin/other
injections,
lifestyle
MODY Maturity Onset Diabetes of the Young
Gestation Onset Diabetes
Risk for hyper-osmotic state (ketoacidosis uncommon)
Strong genetic contribution
Pharmacology overview
Overview of pharmaceutical for Diabetes and Co-morbidities
Knowledge of the general drug classes and approaches to therapy
Cadiovascular drug therapy and relevant physiology
- Adrenergic agents
- Diuretics
- Renin Angiotensin Agents
- Calcium channel blocker
Complications
Acute
Hyperglycemia
Clinical signs and symptoms including poly’s
Osmotic effects of high glucose levels  water loss in urine
Possible triggers for hyper e.g. infection, non-compliance with meds or
diet, etc.
Severe complication of poor control
Diabetic ketoacidosis—may be initial presentation in type 1
Lack of insulin, glucose cannot enter cells
Alternate energy sources generate ketones (and blood
acidosis)
increasing
Hyperosmotic, hyperglycemic state (w/o ketosis) in type 2
Continued volume loss with blood concentration and
glucose
Hypoglycemia
Clinical signs and symptoms (including hypo unawareness)
Inverse relationship of hypo incidence (more with tight control) to DM
complications
Avoidance
Treatment
Patient able to eat—oral sugar (glucose ideal) followed by
complex carbohydrate to prevent recurrent
hypoglycemia
Patient unconscious—glucagon injection or IV fluid with
dextrose
Long Term
Microvascular
Ocular
Focus as it relates to co-morbidity coincidence with other vascular
conditions
Renal
Onset in type 1 not before 5 years
Renal disease may be present in type 2 at diagnosis
Factors contributing to DM often renal disease comorbidities
(e.g.
HTN)
Renal disease (including proteinuria) is a risk factor for
cardiovascular mortality
Screening: Annual urine albumin/creatinine ratio for all diabetic
patients
Monitoring: If albuminuria is present, regular monitoring
Risk factor reduction: BP control, smoking cessation, DM control
Treatment for albuminuria/proteinuria to reduce risk of progression:
ACE-inhibitors or ARB (angiotensin II receptor blockers)
Correlation with retinopathy
Neurological
Peripheral neuropathy (“stocking/glove”)
Sensory loss, motor weakness, painful
Consequences: pressure sore, ulcer, infection, gangrene,
amputation
Autonomic neuropathy
Gastrointestinal, cardiovascular, genitourinary
Peripheral mononeuropathy
Management, prevention: Glucose control, vascular risk factor
reduction
Foot care and monitoring, never go barefoot
Macrovascular
Peripheral vascular disease
Ischemic cardiac disase
Cerebrovascular disease
For each:
Comorbidities
Presentations (symptoms, findings)
Treatment
Skin conditions (key conditions for exam focus)
Infectious
Metabolic
Complications of insulin therapy
Cardiovascular co-morbidities—atherosclerosis, hyperlipidemia, hypertension
Pathogenesis of atherosclerotic lesion; key concepts:
Fatty streak (initial lesion, onset may be early in life with risk factors)
Advanced atherosclerotic lesion develops fibrous cap which is prone to
rupture
Rupture results in platelet aggregation and potential vessel occlusion
resulting in ischemic event (e.g. heart attack)
Fibrous cap may stabilize and lower risk for rupture with control of lipids, BP,
improved lifestyle
Risk factors
Age/gender aggregate
Serum lipoproteins (clinical focus)
Clinical signs (focus on ocular)
Role of lipid lowering agents: Focus on statin drugs (primary and secondary
prevention)
Role of screening (guidelines vary, key issue—screening is recommended for
“at
risk” population)
General understanding of risk reduction schema (consider aggregate of
“traditional” risk factors)
More aggressive goals for higher risk; diabetes is considered in highest risk
strata
Aspirin therapy
Benefit of anti-platelet effects in cardiovascular risk reductions
Risk of adverse effects—primarily gastrointestinal ulceration and bleeding
(ulcers
or elsewhere)
Hypertension (HTN)
Substantial worldwide prevalence and increasing (epidemiologic #’s not critical for
exam)
Major risk for heart attack and stroke across the globe
Prevalence of:
Undiagnosed HTN and
Untreated HTN
Important to know BP cut-offs for pre-hypertension and stages 1 and 2
Hypertensive urgency (timely medical office visit) vs. malignant hypertension (call
medics- emergency)
Essential HTN
Secondary HTN
End organ effects of chronic HTN
Co-morbid risk factors (for risk stratification)
Treatment
Lifestyle modification (including low sodium diet)
Drug treatment—4 major drug classes in common clinical use (think ABCD)
A= ACE-inhibitors, Angiotensin 2 receptor-blockers (ARB)
B= Beta-blockers
C= Calcium channel blockers
D= Diuretics (thiazide class is major one in use)
Misc: Alpha (adrenergic)-blockers—useful also treating prostrate obstruction in older
men
Key factor in diabetes—lower BP treatment goal
---Metabolic syndrome
----Lifestyle
Evidence based Medicine in DM: Key clinical studies
Some examples
a.
Action to Control Cardiovascular risk in Diabetes (ACCORD)
b.
Action in Diabetes and Cardiovascular Disease (ADVANCE)
c.
d.
e.
United Kingdom Prospective Diabetes Study (UKPDS)
Diabetes Control and Complications Trial/Epidemiology of Diabetes
Interventions and Complications (DCCT/EDIC)
Steno Diabetes Center- Copenhagen
Primary care of diabetes
Review overlap with specific management of diabetes complications, co-morbidities
and
therapies including:
Tobacco
Diet and weight management
Drug treatments (see above)
Lifestyle management options
Pulmonary
Risk for pneumonia and influenza complications
Role of vaccination in prevention
Dental
Role of chronic dental infections in complicating diabetes control
Role of poorly controlled diabetes in making dental infections more
difficult to control
Case studies are used to illustrate principles of medical intervention and increased
optometric participation in co-managed patient care.
Part 2: Ocular Consideration
Epidemiology and overview of DM related to Ocular complications
I.
Diabetes Mellitus and Blindness
a. Vision loss from Diabetes Retinopathy
1. Non-resolving Vitreous Hemorrhage
2. Fibrovascular Proliferation with Traction Retinal Detachment
3. Diabetic Macular Edema
b. Incidence and Prevalence Statistics
Part 2A:Ocular Considerations – Non-retinal Ocular Complications
1.
II.
Review of Anterior Segment Complications of DM
a.
Orbital/periorbital- xanthalasma, peri-orbital edema, mucormycosis
b.
Cornea – corneal abrasions, recurrent erosions, contact lens, lasik surgery
c.
Iris- complication
d.
Lens/cataract extraction
e.
Glaucoma
f.
Mono-neuropathy – pupil and cranial nerve III and VI
Part 2B: Ocular Considerations - Retinal Ocular Complications
III.
Clinical Risks Factors (influencing rate of progression of diabetic eye disease)
a. Duration of Diabetes
i. Type 1
ii. Type 2
b. Control of Hyperglycemia – DCCT
c. Diabetic Nephropathy
d.
e.
f.
g.
Hypertension
Pregnancy
Ocular Surgery
Serum Cholesterol
IV.
Clinical Pathologic Processes in Diabetic Retinopathy
a. Loss of pericytes of retinal capillaries
b. Out-pouching of capillary walls to form microaneurysms
c. Closure of retinal capillaries and arterioles
d. Breakdown of the blood/retinal barrier with increased vascular permeability of
retinal capillaries
e. Proliferation of new vessels and fibrous tissue
f. Contraction of vitreous and fibrous proliferation with subsequent vitreous
hemorrhage and retinal detachment.
V.
Implications of Lesions of Diabetic Retinopathy
a. Venous Caliber Abnormalities
b. Intraretinal Microvascular Abnormalities (IRMA)
c. Cotton Wool Spots (Soft Exudates)
d. Hemorrhages and Microaneurysms (H/Ma)
e. Hard Exudates
f. Non-perfusion of the Retina
g. Macular Edema
VI.
Laser Photocoagulation of the Retina and Choroid
a. Basic Information
b. Photocoagulation
c. Therapeutic Rationale
d. Ocular Chromophores
e. Ophthalmic Laser Characteristics
f. Clinical Application
g. Laser Delivery Systems
g.
Vein Occlusion Study
h.
Focal Laser Treatment
i.
Scatter (PRP) Treatment
j.
Patient Care
k.
Follow-up care
l.
Complications of laser surgery
VII.
Clinical Considerations
a. Levels of Diabetic Retinopathy
i. ETDRS Standard Photographs
ii. Risk/Rate of Progression by Levels to PDR and High Risk PDR
iii. High Risk Characteristics (HRC)
iv. Diabetic Macular Edema--May be present at any level of Diabetic
Retinopathy
v. Clinically Significant Macular Edema (CSME)
VIII.
Diabetic Effects on Macular Structure and Function
a. Macular Edema
b. Non-perfusion of parafoveal capillaries, with or without intraretinal fluid
c. Traction in the macula by fibrous tissue proliferation causing dragging of the
retinal tissue, surface wrinkling, or detachment of the macula
d. Intraretinal or pre-retinal hemorrhage in the macula
e. Lamellar or full thickness retinal hole formation
f. Combination of the above
IX.
Treatment modalities for Diabetic retinopathy
X.
Considerations for vitrectomy
m.
Non-resolving vitreous hemorrhage
n.
Traction retinal detachment threatening the macula
o.
Severe vascular and/or fibrous proliferations
p.
Unsatisfactory response to laser surgery
q.
Psycho-social considerations
Part 2C. Evidence-based diabetes care on retina
I.
Diabetic Retinopathy: Clinical trials and science behind the care
a. Diabetic Retinopathy Study (DRS)
i. Inclusion/exclusion criteria
ii. Outcomes measures/endpoints
iii. Results/endpoints
b. Early Treatment Diabetic Retinopathy Study (ETDRS)
i. Laser for macular edema
ii. Early treatment for diabetic retinopathy
iii. Aspirin effects on progression of retinopathy
II.
Diabetic Retinopathy Clinical Research Network (DRCR.net) – newer studies
a. NEI funded diabetes eye research collaborative
b. Established in 2002
c. Summary of DRCR Recently completed studies
i. A Pilot Study of Laser Photocoagulation for Diabetic Macular Edema
ii. A Randomized Trial Comparing Intravitreal Triamcinolone Acetonide
and Laser Photocoagulation for Diabetic Macular Edema
iii. Evaluation of Vitrectomy for Diabetic Macular Edema Study
iv. A Pilot Study of Peribulbar Triamcinolone Acetonide for Diabetic
Macular Edema
v. Temporal Variation in Optical Coherence Tomography Measurements
of Retinal Thickening in Diabetic Macular Edema
vi. A Phase 2 Evaluation of Anti-VEGF Therapy for Diabetic Macular
Edema: Bevacizumab
vii. An Observational Study of the Development of Diabetic Macular
Edema Following Scatter Laser Photocoagulation
viii. Subclinical Diabetic Macular Edema Study
Part 3: Non -Pharmacological Treatments
Part 3A: Nutrition
Fundamentals of nutrition
Treat to target goals: Blood pressure, A1C%, cholesterol etc.
Effectiveness of Medical Nutrition Therapy (MNT). guidelines
Short and long term affects of weight loss and clinical outcomes
Nutrients: micro and macronutrients and affect
Affect of food on blood glucose
Portions and how much should one eat: carbohydrate, protein, fat
Meal planning and carbohydrate counting
Insulin and carbohydrate calculations
Affects of Alcohol
Part 3B: Physical activity
Affects in Preventing related diabetes and other comorbidities
Younger and Aging adult
Type 1 diabetics and affects of physical activity
Type 2 diabetics and affects of physical activity
Acute benefits and risks of physical activity on DM
Long term complications of diabetes and affects of physical activity on DM
Aerobic, Anaerobic, strength training, muscle toning – affects
Part 3C: Behavior Change Strategies
How does Diabetes affect the patient?
Patient centered approach and guidance/support
Develop a plan with the patient
Commitment to the plan
What should a patient do if they encounter low blood sugar?
Technology support for change strategies
Part 3D: Interdisciplinary aspects and importance of community care and screening
Resources within South Africa
.
Part 4A and 4B
Workshops: Diabetic retinopathy image acquisition/image review workshop
Workshop designed to prepare and certify the eye care professional in all aspects of digital
image acquisition, interpretation and diagnosing level of diabetic retinopathy.
Workshop designed review the lesions and clinical levels of diabetic retinopathy and diabetic
macular edema to determine clinical management. This portion of the program prepares the
primary care optometrist to make appropriate diagnostic decisions and to provide guidelines
in managing various levels of diabetic retinopathy and diabetic macular edema.
Part 5A and B
Workshops: From theory to Practice: Diet management, monitoring and maintenance
of blood glucose levels
Workshop A: Diet control, carbohydrate counting and self monitoring
These are important component of diabetes self management. This interactive workshop is
designed to instruct the primary care optometry on various elements of diabetes self
management. Integrate the material from lecture on nutrition and help them with meal planning
Healthy heart meal planning
Monitoring matters: pattern management
Workshop B: Monitoring Matters: Pattern
Management
The participant will learn how to test blood glucose levels with conventional glucometers, and
test their ability to inject physiological saline in place of insulin.
They will develop an understanding of what tools can be used: pump, pen, needles
a.
b.
c.
i.
ii.
iii.
iv.
v.
Introduction to self-management
Types of glucometers
1. Glucometer strips
2. Standardized measurements
3. Calibration
Review of types of insulin
Types of administration
Complications
1. Injection site
1. Hypoglycemia
2. Emergency management and treatment
Carbohydrate counting
1. Nature of carbohydrates
2. Instructing the patient
3. Insulin use and meals
Costs, availability, disposability
Foot management, guidelines and management.