Overview of medical care in adults with diabetes mellitus

Overview of medical care in adults with diabetes mellitus

Author
David K McCulloch, MD
Section Editor
David M Nathan, MD
Deputy Editor
Jean 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.
INTRODUCTION The 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 COMPLICATIONS Morbidity 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 examination Patients with diabetes are at increased risk for visual loss, related
both to refractive errors (correctable visual impairment) and to retinopathy.

Screening for diabetic retinopathy The 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).