Chronic Complications of Diabetes

Question 1

What should you monitor every year?

Answer 1

• Check injection sites
• Assess for CVS risk factors (smoking, waist circumference, blood glucose control, BP, lipid profile, fhx of CVD)
• Screen for eye disease, kidney disease, foot problems
• Screen for thyroid disease (T1DM)

Question 2

What should you do if you see diabetic retinopathy?

Answer 2

Refer to an ophthalmologist if pre proliferative changes or if any uncertainty at or near the macula

Question 3

What is background retinopathy?

Answer 3

Microaneurysms (dots)
Haemorrhages (blots)
Hard exudates (liquid deposits)

Question 4

What is pre proliferative retinopathy?

Answer 4

Cotton wool spots (infarcts)
Haemorrhages (venous bleeding)

• These are the signs of retinal ischaemia and needs urgent referral

Question 5

What is proliferative retinopathy?

Answer 5

New vessels form

• Needs urgent referral

Question 6

What is maculopathy?

Answer 6

Suspect if decreased visual acuity

• Needs urgent laser, intravitreal steroids, or anti-angiogenic agents if macula oedema

Question 7

What is the pathogenesis of maculopathy?

Answer 7

• Capillary endothelial change causes vascular leaks
• Leads to microaneurysms which occludes capillaries
• Leads to local hypoxia and ischaemia so new vessels have to form

Question 8

What other eye complication occurs with diabetes?

Answer 8

Cataracts

Question 9

What injection complications should you look for and how do you stop this?

Answer 9

• Infection/lipohypertrophy

- Advise on rotating injection sites if present

Question 10

How do you assess for diabetic nephropathy?

Answer 10

• Microalbuminuria is when urine dipstick is -ve for protein but urine albumin:creatinine ratio is over >3mg/mmol (3-30 is micro)
• Bring morning urine sample and send for ACR
• Check serum creatinine to check for eGFR too

Question 11

What are the target BP’s for a type 1 diabetic?

Answer 11

Treat if BP >135/85 unless albuminuria or 2+ features of metabolic syndome, then it should be <130/80

Question 12

What are the target BP’s for a type 2 diabetic?

Answer 12

Target BP <140/90 or <130/80 if kidney, eye or cerebrovascular damage

Question 13

What should you prescribe for erectile dysfunction?

Answer 13

A PDE-5 inhibitor - sildenafil

Question 14

What is diabetic neuropathy?

Answer 14

• Loss of sensation in a stocking distribution

Question 15

What are some signs of diabetic neuropathy?

Answer 15

• No sensation with a 10g monofilament fibre
• Absent ankle jerk reflexes
• Neuropathic deformity (charcot joint)
• Claw toes
• Rocker bottom sole

Question 16

How do foot problems occur in diabetes?

Answer 16

• Diabetic neuropathy means they don’t have the pain sensation
• Increased mechanical stress and repeated joint injury
• Causes swelling, instability and deformity

Question 17

How do you manage diabetic foot ischaemia?

Answer 17

• If foot pulses cannot be felt, do Doppler pressure assessments
• Educate by making the patient do a daily foot inspection
• Wear comfortable shoes
• Regular chiropody to remove callus as hemorrhage and necrosis can occur below
• Treat fungal infections

Question 18

How do you assess a diabetic foot ulcer?

Answer 18

Assess degree of:

• Neuropathy
• Ischaemia (clinically plus Doppler +/- angiography)
• Bony deformity (clinically and X-ray)
• Infection (swabs, blood cultures, probe ulcer to reveal depth)

Question 19

What is the management for a diabetic foot ulcer?

Answer 19

Mild - Oral flucloxacillin QDS for 14 days
Moderate - Flucloxacillin, ciprofloxacin, metronidazole for 14 days
Severe - IV piperacillin plus IV vancomycin for 7 days

Question 20

What is the management for charcot joint?

Answer 20

• Bed rest, crutches, total contact cast
• Until oedema and local warmth reduce and bony repair is complete
• About 8 weeks

Question 21

What are the indications for surgery on a diabetic foot ulcer?

Answer 21

• Abscess or deep infection
• Spreading anaerobic infection
• Gangrene
• Rest pain
• Suppurative arthritis

Question 22

What is the surgery for a diabetic foot ulcer, if required?

Answer 22

Amputation

Question 23

What is the management for symmetric sensory polyneuropathy? (glove and stocking)

What symptoms will the patient describe if they have this?

Answer 23

• Paracetamol
• Amitryptyline 10-25mg at night, increase if required
• Duloxetine
• Opiates
• Numbness, tingling, pain that is worse at night

Question 24

What is mononeuritis multiplex?

Answer 24

A painful, symmetrical, asynchronous sensory and motor peripheral neuropathy involving isolated damage to at least 2 seperate nerve areas

Question 25

What is the treatment for mononeuritis multiplex?

Answer 25

Hard

If sudden or severe, immunosuppression may help (corticosteroids)

Question 26

What are the 4 types of diabetic neuropathy?

Answer 26

1. Symmetrical polyneuropathy
2. Mononeuropathy
3. Diabetic amyotrophy (symmetrical pain, weakness and wasting of proximal leg muscles due to lumbosacral plexus problems)
4. Autonomic neuropathy (postural hypotension, urine retention, impotence, diarrhoea, gastroparesis)

Question 27

What can you prescribe to prevent CVD?

Answer 27

• Smoking cessation
• Nutritional support
• Statin as anti-lipid therapy
• Blood pressure control

Question 28

How does diabetic neuropathy occur?

Answer 28

• Hyperglycaemia damages nerves and impairs ability to send signals
• High blood sugar weakens walls of capillaries, impairing blood supply to the nerves