37 Complications of Diabetes Mellitus Flashcards by Jim Paulo Sarsagat

Classify DSPN:
Symptoms or signs of DSPN only

Possible DSPN

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Presence of at least 2 of 3 the ff would classify DSPN as probable (3):

Neuropathic symptoms
Decreased distal sensation
Unequivocally decreased or absent ankle reflexes

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Classify DSPN:
Symptoms or signs with abnormality of nerve conduction

Confirmed DSPN

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Classify DSPN:
Symptoms or signs with small fiber neuropathy and normal nerve conduction

Subclinical DSPN

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Identify grade of small fiber neuropathy:
Length-dependent symptoms and/or clinical signs of small fiber damage

Possible SFN

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Identify grade of small fiber neuropathy:
Length-dependent symptoms
Clinical signs of small fiber damage
Normal sural nerve conduction

Probable SFN

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Identify grade of small fiber neuropathy:
Length-dependent symptoms
Clinical signs of small fiber damage
Normal sural nerve conduction
Altered intraepidermal nerve fiber density

Definite SFN

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Identify grade of small fiber neuropathy:
Length-dependent symptoms
Clinical signs of small fiber damage
Normal sural nerve conduction
Abnormal thermal thresholds at the foot

Definite SFN

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Classify DSPN:
No signs or symptoms
Abnormal nerve conduction

Subclinical DSPN

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Increased / decreased / unchanged:
Sural nerve conduction in small fiber neuropathy

Unchanged

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FDA-approved drugs for painful diabetic distal symmetric polyneuropathy (3)

Duloxetine
Pregabalin
Tapentadol

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Most significant persistent DNA methylation change in EDIC

Hypomethylation of TXNIP

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Earliest histologic effects (3) in diabetic retinopathy

Loss of retinal vascular pericytes
Thickening of vascular endothelium basement membrane
Alterations in retinal blood flow

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These retinal hemorrhages occur in the inner retina closer to the vitreous

Flame-shaped hemorrhages

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These retinal hemorrhages occur deeper in the retina

Dot-blot hemorrhages

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These retinal findings are caused by microinfarcts in the nerve fiber layer of the retina

Cotton-wool spots

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Among the cranial nerves affecting the extraocular muscles, mononeuropathies of this nerve is the least likely associated with diabetes

4th cranial nerve

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Definition of mild NPDR

Microaneurysms only

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Three features of PDR

Retinal neovascularization
Vitreous hemorrhage
Preretinal hemorrhage

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Four features of severe NPDR

> 20 intraretinal hemorrhages in each of the retinal quadrants
Definite venous beading in ≥2 retinal quadrants
Prominent IRMA in ≥1 quadrants
No PDR

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Primary therapy for neovascular glaucoma

Panretinal laser photocoagulation

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Risk factors (4) for cataract in patients with earlier onset diabetes

Duration of diabetes
Retinopathy status
Diuretic use
HbA1c levels

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Risk factors (4) for cataract in patients with later onset diabetes

Age
Lower IOP
Smoking
Lower DBP

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Treatment for CSME with excellent vision

Consider focal/grid laser photocoagulation

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Treatment for CSME with impaired vision

Focal/grid laser photocoagulation probably indicated

Minimum follow up for CSME

Every 3 months

Treatment for high risk characteristic PDR

Panretinal photocoagulation probably indicated

Treatment for severe NPDR or worse, without HRC PDR

Consider panretinal photocoagulation Follow up in 4 months or less

Follow-up for moderate NPDR

Every 4-8 months

Follow-up for mild NPDR

Every 8-12 months

Minimum follow-up for pregnant patients with diabetic retinopathy

Every 3 months

Definition of severe vision loss

Best corrected acuity of 5/200 or worse on 2 consecutive visits 4 months apart

First-line therapy for center-involved DME and DME-related visual impairment of 20/32 or worse

Intravitreous injection of VEGF inhibitors

Patients with hemoglobin level less than this value have a two-fold increased risk of retinopathy

<12 g/dL

Triad of diabetic nephropathy

Hypertension Proteinuria Renal impairment

Microalbuminuria or incipient nephropathy typically occurs how many years after the initial diagnosis of T1DM?

5-15 years

In DKD, microalbuminuria is defined as urinary albumin excretion rate of:

20-200 mcg/min OR 30-300 mg/24 hours

Factors (4) independently associated with regression of microalbuminuria in diabetes

Microalbuminuria of short duration HbA1C <8% SBP <115 mmHg Low levels of both cholesterol and triglycerides

Macroalbuminuria or overt nephropathy typically occurs how many years after the initial diagnosis of T1DM?

10-15 years

Hematocrit target in DKD

>35%

Modest renal benefits have been suggested with these two (2) DPP4 inhibitors

Saxagliptin Linagliptin

This biomarker may predict likelihood to progression of renal disease in patients with borderline microalbuminuria

Serum prorenin

First line treatment for blood pressure reduction inT2DM patients with over proteinuria

Angiotensin receptor blockers

Low protein diets of this quantity may retard the progression of renal disease

0.75 mg/kg/day

Use of this treatment for anemia in CKD is associated with 2x ⬆️ in cerebrovascular events

Darbepoetin

Side effect of avosentain which reduced enthusiasm for the use of this agent as treatment for DKD

Fluid retention

Recommended diagnostic workup in all patients suspected of having SAPN

Serum protein electrophoresis with immunofixation B12 level Thyroid function tests

When no clear objective evidence of small or large fiber dysfunction is present on examination, this diagnostic test can be considered

Skin biopsy

Most sensitive of all tested neuropathy scales

Modified Toronto Clinical Neuropathy Score

Most specific (2) of all tested neuropathy scales

Michigan Diabetic Neuropathy Score Neuropathy Disability Score

Treatment of diabetic polyradiculoneuropathies, which typically affects older T2DM male patients, is usually supportive. Use of this agent is reporter to accelerate the resolution of symptoms.

Intravenous immunoglobulin

Possible adjuncts (3) for hypoglycemia unawareness

Beta-2 adrenergic agents Caffeine Serotonin reuptake inhibitors

Initial dose of pregabalin for DSPN

25-75 mg QD-TID

Initial dose of gabapentin for DSPN

100-300 mg QD-TID

Effective dose of pregabalin for DSPN

300-600 mg/day

Effective dose of gabapentin for DSPN

900-3600 mg/day

In patients with diabetes, what is the proportional reduction in all-cause mortality per mmol/L reduction in LDL cholesterol?

In patients with diabetes, what is the proportional reduction in major vascular events per mmol/L reduction in LDL cholesterol?

21%

ApoCIII antisense therapy that was rejected by FDA due to concerns for thrombocytopenia

Volanesorsen

Depression of this glucose transporter in the heart is postulated to cause diabetic catdiomyopathy

GLUT4

Classify grade according to Wagner classification: Gangrene of whole foot

Grade 5

Classify grade according to Wagner classification: Partial gangrene

Grade 4

Classify grade according to Wagner classification: Deep ulcer with bone involvement, osteitis

Grade 3

Classify grade according to Wagner classification: Deeper ulcer, penetrating tendons, no bone involvement

Grade 2

Classify grade according to Wagner classification: Superficial full-thickness ulcer

Grade 1

Classify grade according to Wagner classification: No ulcer, but high-risk foot

Grade 0

Classify grade according to UT classification: Wound penetrating bone or joint

Grade 3

Classify grade according to UT classification: Deep ulcer to tendon or capsule

Grade 2

Classify grade according to UT classification: Superificial ulcer

Grade 1

Classify grade according to UT classification: Preulcer or postulcer lesion; no skin break

Grade 0

Classify stage according to UT classification: -infection -ischemia

Stage A

Classify stage according to UT classification: -infection +ischemia

Stage C

Classify stage according to UT classification: +infection -ischemia

Stage B

Classify stage according to UT classification: +infection +ischemia

Stage D

Most common cause of nonhealing neuropathic foot

Failure to remove pressure from the wound

Strongest evidence for efficacy of NPWT

Postoperative diabetic foot wounds