case 6 - disease complications Flashcards
what is the epidemiology of diabetes 1
10% of global health expenditure is spent on diabetes - 80% spent on managing complications
1,110,100 children and adolescents have type 1 diabetes
what are the microvascular complications of type 1 diabetes
diabetic retinopathy
diabetes nephropathy
diabetes neuropathy
what are the macrovascular complications of type 1 diabetes
stroke
heart disease
peripheral vascular disease
what is the macula responsible for
responsible for out central vision, most of the colour vision and detailed vision
what is the diabetic retinopathy classification and what is the scale used
Retinopathy scale:
Goes from R0 —> R3
Maculopathy:
Goes from M0-M1
Photocoagulation:
Goes from P0 —>P1
Had previous surgery - photocoagulation scars for P1
what is the prevalence of exudates and haemorrhages (R1) in type 1 diabetes
Any retinopathy 77%
Proliferative retinopathy 32%
what is the prevalence of exudates and haemorrhages (R1) in type 2 diabetes
25% any retinopathy
3% proliferative retinopathy
what are the venous changes that can happen (R2)
beading, looping and reduplication
what are the proliferative changes (R3)
new vessels
On disc or elsewhere
fibrous proliferation
On disc or elsewhere
haemorrhages
Pre-retinal
Vitreous
what are the prevention methods for diabetic retinopathy
glycemic control (UKPDS, DCCT)
Blood pressure control
Annual screening
what are the treatment options for diabetic retinopathy
photocoagulation
anti-VEGF therapy
Surgery
what are the different diabetic neuropathy characteristics
Distal symmetrical sensorimotor polyneuropathy and small fibre neuropathy
Radiculopathies
Mononeuropathy - can affect cranial nerves
Autonomic neuropathy
what is the pain in peripheral neuropathy
Burning
Paraesthesia
Persistent hyperaesthesia
Nocturnal exacerbation
what is the loss of sensation in peripheral neuropathy
postural hypotension
Diabetic gastroparesis
Small bowel bacterial overgrowth
Cardiac autonomic neuropathy
Urogenetic
what are the first line agents for neuropathy pain
Duloxetine
Pregabalin
Gabapentin
Amitryptiline
what are the treatments for gastroparaesis
Prokinetics
Botox to pylorus,
gastric pacemakers
what are the treatments for postural hypotension
Fludrocortisone
Midodrine
Compression stockings
what is diabetic foot
neuropathy
Deformity increased pressure, ulcer
Ischemia - peripheral vascular disease
Infection
what are the statistics of foot complications in diabetes
20-40% have neuropathy
5% have a foot ulcer
5-7% 10 year cumulative incidence of amputation
Increased morbidity, mortality and reduced quality of life
what is the prevention for foot ulcers
education
Good glucose control
Regular foot checks to identify high risk feet
Regular podiatry review of high risk feet
Appropriate footwear
what is the treatment for foot ulcers
foot MDT
Off-loading, debridement
Antibiotics
Surgery
Revascularisation
what is the most common cause of renal failure
diabetes
what percentage of people with diabetes develop diabetic nephropathy
30% of T1DM and 40% of T2DM
how is diabetic nephropathy defined
moderately increased albuminuria:
Increased albumin creatine ratio (ACR)
ACR > 2.5mg/mmol (men)
ACR > 3.5mg/mmol (women)
OR: urinary albumin concentration >20mg/L in men and women
OR: positive microalbumintest results from 2 first morning urine specimens (sensitivity 93% specificity 80% )
nephropathy
Dipstick positive proteinuria
OR: ACR >30mg/mmol
OR: urinary albumin concentration >< 200mg/L
what is the treatment for diabetic nephropathy
blood pressure control
Renin aldosterone system (RAS) blockade
e.g ACEI, ARB (ramipril and irbesartan)
glycemic control
Cardiovascular disease risk management
Management of the complications of renal failure
Dialysis
Haemodialysis
Peritoneal
renal, pancreas and islet transplantation
what is the first manifestation of CHD in DM
angina - 50% - people with diabetes may not have classic angina therefore symptoms arent classic
what are the life years lost in relation to age at onset of type one diabetes
development of type 1 diabetes before 10 years of age resulted in a loss of 17 life-years for women and 14 life years for men
what does hypoglycaemia result from
Absolute or relative hyperinsulinemia
And/or defective glucose counter-regulation
what are the acute implications of hypoglycaemia
hypos disrupt everyday activities, provokes unpleasant symptoms
Severe hypoglycaemia can cause coma, seizures, strokes, arrhythmias and even death
negative effects on mood and emotions
Impairs cognitive function; can affect performance of many activites
Interference with balance, coordination, vision and level of consciousness can precipitate falls and injury
what are the long term effects of hypoglycaemia
fear of hypoglycaemia, elevated HbA1c —> complications
Reduced quality of life
Weight gain
Restrictions on employment
Driving licensing restrictions
Personal relationships disrupted
Acquired hypoglycaemia-induced syndromes
Cognitive declines
what are the factors that contribute to high HbA1c sub optimal diabetes
fear and burden of hypoglycaemia
Lack of access/non-engagement with high quality structured education
Burden of carbohydrate counting, injections, time and life pressures
Depression, anxiety and lack of motivation
Not monitoring glucose
Variable insulin absorption and problems with insulin injection sites
Lack of access to technology
Clinical inertia
Lack of access to insulin
what is DAFNE
dose adjustment for normal eating
structured patient education: provide vital knowledge and skills to manage T1D
Carbohydrate counting, hypoglycaemia, dynamic insulin adjustment
Dealing with exercise, inter-current illness, alcohol, partying, sex, pregnancy, periods, anxiety and depression
what has DAFNE shown to improve
HbA1c and reduces hypoglycaemia
what are the rapid acting analogues (meal insulin)
Novorapid
Humalog
Apidra
what are the long acting insulins (16 to 24 hours)
levemir
lantus
what is an example of ultra-rapid acting analogue (meal insulin)
fiasp
what are examples of ultra long acting insulins (24hrs+)
Tresiba
Toujeo
what is an analogue insulin
laboratory grown and genetically modified sequence
what is the current technology used to treat type one diabetes
Insulin delivery:
insulin pen
Insulin pump
Conventional pump
Patch pump
Glucose sensing:
capillary blood glucose
Continuous glucose monitoring
Flash glucose monitoring
Conventional
Implantable
Data management:
health care professional centred
Data and/or web portals
patient centred
Data and/or web portals
Remote monitoring
Mobile apps
Glucose responsive insulin delivery:
threshold based suspension
Predictive low glucose suspension
Hybrid single hormone closed loop
what are the benefits of insulin pumps
CSII allows more physiological replacement of basal insulin requirements
On demand modulation of basal insulin to match individual needs; e.g exercise or stress
Lower variability of absorption of basal insulin
NICE TA151 - CS11
Continuous subcutaneous insulin infusion or insulin pump therapy is recommended as a possible treatment for adults and children 12 years and over with type 1 diabetes mellitus if:
- attempts to reach target haemoglobin A1c levels with multiple daily injections result in the person having disabling hypoglycamia
or
Hb1Ac levels have remained high (8.5% or above) with multiple daily injections despite the person and/or their carer carefully trying to manage their diabetes
what are smart glucose meters
majority of patients either do not correct for high glucose at all or et the calculations wrong
Meter programmed with insulin:carb ratio and correction factor. Each bolus consists of insulin for carbs and insulin for correcting high glucose
Studies have shown improved HbA1c, reduced hypos and improved quality of life
what are sensory augmented pumps
continuous glucose monitoring data are displayed on the pump screen
predictive low glucose suspend technology
what is the closed loop system compontents
autonomous, graduated modulation of insulin delivery to achieve target glucose
Hybrid = meal bolus still required
