Overview of medical care in adults with diabetes mellitus

Overview of medical care in adults with diabetes mellitus

AuthorDavid K McCulloch, MD

Section EditorDavid M Nathan, MD

Deputy EditorJean E Mulder, MD

Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Oct 2012. | This topic last updated: Sep 27, 2012.

INTRODUCTIONThe estimated prevalence of diabetes among adults in the United States ranges from 4.4 to 17.9 percent (median 8.2 percent) [1]. However, because of the associated microvascular and macrovascular disease, diabetes accounts for almost 14 percent of US health care expenditures, at least one-half of which are related to complications such as myocardial infarction, stroke, end-stage renal disease, retinopathy, and foot ulcers [2,3].

Numerous factors, in addition to directly related medical complications, contribute to the impact of diabetes on quality of life and economics. Diabetes is associated with a high prevalence of affective illness [4]and adversely impacts employment, absenteeism, and work productivity [5].

This review will provide an overview of the medical care for patients with diabetes (table 1). Detailed discussions relating to screening, evaluation, and treatment of the individual complications of diabetes are discussed separately. Guidelines from the American Diabetes Association for health maintenance in diabetics are published yearly [6]. Consensus recommendations for the management of glycemia in type 2 diabetes were published in 2006 and updated in 2009 [7,8].

EVALUATION FOR DIABETIC COMPLICATIONSMorbidity from diabetes is a consequence of both macrovascular disease (atherosclerosis) and microvascular disease (retinopathy, nephropathy, and neuropathy). In type 2 diabetes, disease onset is insidious, and diagnosis is often delayed. As a result, diabetic microvascular complications may be present at the time of diagnosis of diabetes [9], and their frequency increases over time (figure 1). The progression of these complications can be slowed, but probably not stopped, with interventions such as aggressive management of glycemia, laser therapy for retinopathy, and administration of an angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) for nephropathy. (See "Prevention and treatment of diabetic retinopathy"and "Microalbuminuria in type 1 diabetes mellitus"and "Microalbuminuria in type 2 diabetes mellitus"and "Treatment of diabetic nephropathy".)

Routine eye examinationPatients with diabetes are at increased risk for visual loss, related both to refractive errors (correctable visual impairment) and to retinopathy.

Screening for diabetic retinopathyThe efficacy of laser photocoagulation surgery in preventing loss of vision is the major reason to screen regularly for diabetic retinopathy. (See "Prevention and treatment of diabetic retinopathy", section on 'Panretinal photocoagulation'.)

Recommendations for the type and frequency of routine eye examinations vary, based upon the type of diabetes mellitus and the presence of specific eye findings (table 2) [6]. Serial examinations are indicated because of the increased incidence of retinopathy over time in patients with either type 1 or type 2 diabetes (figure 2).