[12] Diabetic Complications Flashcards
What are the macrovascular complications of diabetes?
MI
PVD
CVA
Why might MI as a complication of diabetes be ‘silent’?
Due to autonomic neuropathy
How might PVD as a complication of diabetes manifest?
Claudication
Foot ulcers
How is the risk of macrovascular complications in diabetes minimised?
Manage CV risk factors
What CV risk factors should be managed in diabetes?
BP
Smoking
Lipids
HbA1c
What BP should be aimed for in diabetes?
<130/80
What is the effect of good glycaemic control in diabetes?
It prevents both macro- and micro-vascular complications
What screening is given in diabetes to check for complications?
Fundoscopy
Albumin:creatinine ratio
Foot checks
What happens in diabetic feet?
Ischaemia
Neuropathy
What can result from ischaemia in diabetic feet?
Critical toes
Absent pulses
Ulcers
How do ischaemic ulcers on diabetic feet present?
Painful
‘Punched-out’
Where do diabetic foot ulcers due to ischaemia occur?
Foot margins and pressure points
What is the problem with neuropathy in diabetic feet?
Loss of protective sensation
What can neuropathy in diabetic feet lead to?
Deformity
Injury or infection over pressure points
Ulcers
What deformities can result from neuropathy in diabetic feet?
Charcot’s joints
Pes cavus
Claw toes
Where do diabetic foot ulcers caused by neuropathy occur?
Metatarsal heads and calcaneum
What is involved in the conservative management of diabetic feet?
Daily foot inspection, e.g. with mirror
Comfortable/therapeutic shoes
Regular chiropody to remove calluses
When is medical management of diabetic feet required?
When there is infection
What antibiotics are used when diabetic feet are infected?
Benpen + fluclox + met
When is surgical management of diabetic feet indicated?
Abscess or deep infection
Spreading cellulitis
Gangrene
Suppurative arthritis
What is the pathophysiology of diabetic nephropathy?
Hyperglycaemia leads to nephron loss and glomerulosclerosis
What is considered to be microalbuminuria in diabetic nephropathy?
Urine albumin : creatinine ratio = >30mg/mM
What should be done if microalbuminaemia is present in diabetes?
Give ACEi or angiotensin receptor blocker
What is the pathogenesis of diabetic eye disease?
Microvascular disease leads to retinal ischaemia. This causes increased VEGF production, leading to new vessel formation
What are the constituents of diabetic eye disease?
Retinopathy and maculopathy
Cataracts
Rubeosis iris
CN palsies
What is rubeosis iris?
New vessels on the iris
What can rubeosis iris lead to?
Glaucoma
What is the importance of diabetic retinopathy and maculopathy?
It is the most common cause of blindness up to 60 years
When should a patient be referred with diabetic retinopathy and maculopathy?
If they have pre-prolierative retinopathy/maculopathy
How is diabetic retinopathy/maculopathy investigated?
Fluorescein angiography
How is diabetic retinopathy/maculopathy managed?
Laser photocoagulation
What will be found on fundoscopy in diabetic background retinopathy?
Microaneurysms
Blot haemorrhages
Hard exudates
What are hard exudates?
Yellow lipid patches
What will be found on fundoscopy in pre-proliferative retinopathy?
Cotton-wool spots (retinal infarcts)
Venous beading
Haemorrhages
What will be found on fundoscopy in proliferative retinopathy?
New vessels
Pre-retinal or vitreous haemorrhage
What will be found on fundoscopy in maculopathy?
Hard exudates within one disc width of macula
What might be the only sign of maculopathy?
Reduced acuity
What are the components to the pathophysiology of diabetic neuropathy?
Metabolic
Ischaemic
What are the metabolic factors in diabetic neuropathy?
Glycosylation
ROS
Sorbital accumulation
What are the ischaemic factors in diabetic neuropathy?
Loss of vasa nervorum
What are the types of neuropathy in diabetes?
Symmetric sensory polyneuropathy
Mononeuropathy/mononeuritis multiplex
Femoral neuropathy/amyotrophy
Autonomic neuropathy
What are the clinical features of symmetric sensory polyneuropathy?
Glove and stocking neuropathy
Absent ankle jerks
Numbness, tingling, and pain which is worse at night
What is lost in glove and stocking neuropathy?
All modalities
How may symmetric sensory polyneuropathy be managed?
Paracetamol
Amitriptryline, gabapentin, or SSRI
Capsaicin cream
Baclofen
Give an example of a mononeuropathy in diabetes
CN3/6 palsies
What happens in femoral neuropathy?
Painful asymmetric weakness and wasting of quads, leading to loss of knee jerks
How is a diagnosis of femoral neuropathy made?
Nerve conduction and electromyography
What are the symptoms of autonomic neuropathy in diabetes?
Postural hypotension Gastroparesis Diarrhoea Urinary retention Erectile dysfunction
How is postural hypotension caused by diabetic autonomic neuropathy managed?
Fludrocortisone
What are the symptoms of gastroparesis?
Early satiety
GORD
Bloating
How is diarrhoea caused by diabetic autonomic neuropathy managed?
Codeine phosphate
