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Endocrinology > Complications of Diabetes > Flashcards

Complications of Diabetes Flashcards

1
Q

What percentage of the NHS cost is spent on management of the complications of diabetes?

A

10% of the annual budget

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2
Q

How much money is spent to cover the cost managing the complications of diabetes every hour?

A

£4.5 million

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3
Q

State the three micro-vascular complications of diabetes.

A

Retinopathy
Nephropathy
Neuropathy

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4
Q

State the two macro-vascular complications of diabetes.

A

Effects on blood pressure (Hypertension)
Effects on blood lipids (Hyperlipidemia)

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5
Q

What are the similarities and differences between arising micro and macro-vascular complications?

A

Micro-vascular complications affect small blood vessels whereas macro-vascular complications affect large blood vessels. However both types of complications arise as a result of atherosclerosis (narrowing of arteries).

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6
Q

What are some of the complications of atherosclerosis and how do they occur?

A

Narrowed arteries often as a result of plaque formation but can eventually burst and lead to the formation of a blood clot. This blood clot can travel to other parts of the body and depending where they deposit can lead to heart attacks and strokes.

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7
Q

Why do patients with Type 2 diabetes can present with the complications of diabetes but Type 1 diabetes don’t?

A

Complications of diabetes (both micro and macro-vascular) arise from uncontrolled blood glucose levels over a sustained period of time. Patients with Type 2 diabetes can develop insulin resistance gradually over a number of years and therefore symptoms associated with hyperglycaemia are not as noticeable as patients with Type 1 diabetes whose insulin secretion is depleted by 90% over a number of days to a week.

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8
Q

What percentage of patients with Type 2 diabetes present with the complications of diabetes at the point of diagnosis?

A

Retinopathy 21%
Nephropathy 18.1%
Neuropathy -

Erectile dysfunction 20%
Absent foot pulses 13%
Ischaemic skin changes 6%
Abnormal vibration threshold 7%

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9
Q

What is the second major cause of death in patients with diabetes?

A

Cerebrovascular disease (stroke)

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10
Q

What is the prevalence of those with diabetes developing cerebrovascular disease?

A

They are 2-3 times more likely to suffer from a major stroke, and 7% of patients with Type 2 diabetes have already had a stroke prior to their diabetes diagnosis.

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11
Q

What is the cardiovascular prevalence among patients with Type 2 diabetes prior to diagnosis?

A

Abnormal ECG (which indicates heart disease) is found in 18% of patients prior to diagnosis and 35% already have hypertension.

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12
Q

What is the increased likelihood of a patient with diabetes suffering from a heart attack?

A

2-4 times more likely compared to a patient without diabetes.

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13
Q

What is the increased likelihood of a patient with diabetes having to have an amputation?

A

15 times more likely due to intermittent claudication (reduced blood flow to the calves).

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14
Q

What is the peripheral vascular disease prevalence among patients with Type 2 diabetes prior to diagnosis?

A

4.5%

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15
Q

What are some of the complications of intermittent claudication of prior to amputation?

A

Gangrene
Foot ulcers

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16
Q

What are the two major risk factors for the development of complications of diabetes?

A

Persistent uncontrolled blood glucose levels
Persistent uncontrolled blood pressure levels

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17
Q

What is the relationship between HbA1c and development of macro-vascular complications?

A

If your HbA1c value is just 1% over the recommended there is:
21% increase risk of a diabetes related death
14% increase risk of suffering a heart attack
43% increase risk in peripheral vascular disease

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18
Q

What is the relationship between HbA1c and development of micro-vascular complications?

A

If your HbA1c value is just 1% over the recommended there is:
37% increase risk of developing micro-vascular complications

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19
Q

Why are the eyes, kidneys and nerves most vulnerable damage from hyperglycaemia?

A

Ordinarily, most cells in the body are impermeable to glucose and require presence of insulin to bind to receptors to initiate a downstream signalling pathway that opens GLUT-4 transporters, allowing the uptake of glucose into cells. However retinal, renal and nerve cells enable the uptake of glucose even without the presence of insulin and therefore are most susceptible to damage and there is no regulation to the uptake of glucose in these cells.

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20
Q

What are some of the presentations of diabetic eye disease?

A

Blurred or double vision
Experiencing cataracts at an earlier age
Glaucoma which is resistant to treatment
Most commonly retinopathy

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21
Q

How common is diabetic retinopathy?

A

It is the most common cause of blindness in people aged between 30-60 years in the UK.

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22
Q

How does the incidence of diabetic retinopathy differ between patients with Type 1 diabetes and those with Type 2?

A

Within 20 years of diagnosis it is present within almost all of patients with Type 1 diabetes
Affects about 60% of patients with Type 2 diabetes

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23
Q

What is the function of the retina?

A

The retina is the light sensitive layer of cells at the back of the eye, that converts the light seen into electrical signals to be sent to the brain and converted them into the images that we see.

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24
Q

What feeds into the retina?

A

Small blood vessels (micro-vascular vessels) provide a constant source of blood flow to the retina. It is these blood vessels that are damaged when there is persistently high levels of glucose.

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25
Q

Aside from having diabetes what are some of the other risk factors for the development of diabetic retinopathy?

A

Having diabetes for a long time
Uncontrolled blood glucose levels
Hypertension
Hyperlipidemia
Pregnant
Asian or Afro-Caribbean descent*
Already have diabetic nephropathy
If they have raised triglyceride levels
Smoking
Any rapid improvement in the control of blood glucose (stabilise the retina first before stabilising blood glucose levels).

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26
Q

Describe the progression of development of diabetic retinopathy.

A

It begins with the formation of haemorrhages or exudates (hardened spots) made of proteins and lipids. This can then progress to infarction of the retina (limited or no blood supply). In order to compensate angiogenesis occurs but these new blood vessels are very fragile and can bleed into the retina.

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27
Q

What vision does a patient with diabetic retinopathy have?

A

Black spots on their vision which can then develop into complete blindness
Lose of visual acuity (blurred lines)

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28
Q

What are the three methods to prevent the development of diabetic retinopathy?

A

Good glycaemic control
Good control of hypertension
Avoidance of smoking

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29
Q

What is one of the main issues regarding the management of diabetic retinopathy and how is it overcome?

A

Often the symptoms can only present when the condition is rather advanced.
To overcome this every body over the aged of 12 with either type of diabetes is screened at the point of diagnosis (maybe just Type 2) and then invited to attend annual retina eye screening to monitor any developments of retinopathy.
If there appear to be high risk or have started to develop the complications they can be screened more regularly.

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30
Q

Why are children with diabetes not invited to attend diabetic eye screening?

A

Children regardless of duration of their diabetes, rarely experience sight-threatening retinopathy.

However puberty can accelerate the progression of retinopathy and hence why screening begins at the age of 12.

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31
Q

If the patient is found to have diabetic retinopathy what treatment is recommended?

A

Laser treatment whcih can seal off the leaking blood vessels.

32
Q

What is the leading cause of end stage renal failure?

A

Diabetic nephropathy

33
Q

When is the incidence of diabetic nephropathy the highest?

A

Normally 15-25 years after being diagnosed with diabetes

34
Q

What is often the outcome of those with established and progressed diabetic nephropathy?

A

1/3 of patients with diabetic nephropathy are put on dialysis and hope for a kidney transplant.

35
Q

What is the monitoring parameter for diabetic nephropathy?

A

Protein in the urine (normally albumin) which is a well established indicator of renal disease.

36
Q

How often are urine tests done to monitor for nephropathy?

A

Normally annually from the point of diagnosis for patients with Type 2 diabetes. Often can wait 5 years after diagnosis for Type 1.

37
Q

How do the urine tests work for detecting diabetic nephropathy?

A

A urine dipstick tests indicates whether there is a presence of protein (albumin). A repeated positive result will then result in a 24 hour urine collection to quantify the amount of protein present within the urine samples.

38
Q

What is the significance of monitoring and detecting microalbuminauria?

A

As it suggests microalbuminauria is tiny amounts of albumin within the urine and is a very early indicator of diabetic nephropathy and kidney disease.
It is detected using specialist equipment such as microalbustix.

39
Q

When microalbuminauria is detected should patients be treated instantly?

A

You can interpret the quantity of albumin present into the albumin : creatinine ratio.

When this ratio is greater than:
2.5mg/mmol in men
3.5mg/mmol in women
Treatment should be initiated

40
Q

What is the incidence of microalbuminauria and proteinuria in Type 1 diabetes?

A

40% of Type 1 after 30 years of diagnosis will have developed microalbuminuria

20% of Type 1 after 25 years of diagnosis will have developed proteinuria

41
Q

What percentage of Type 2 diabetics develop nephropathy?

A

25-30%

42
Q

What percentage of Type 2 diabetics develop proteinuria?

A

20% of those with microalbuminauria will after 10 years develop proteinuria

43
Q

What is the target HbA1c level?

A

At least 7% with a target of 6%

44
Q

What are the blood pressure targets for patients with diabetes?

A

Type 1: 130/80 mmHg
Type 2: same as non-diabetics

Under 80: 140/90mmHg
Over 80: 150/90mmHg

45
Q

Why is ACE and ARB the first line blood pressure treatment?

A

Due to its reno-protective effects (prevents the development and progression of renal disease).

46
Q

If blood pressure alone is not controlled by ACE or ARB alone, which drugs should be added next?

A

Calcium channel blockers or diuretics
Amlodipine and felodipine have been shown to have additional reno-protective action.

47
Q

If a patient has been shown to be at high risk of diabetic nephropathy, aside from medication what else can be done?

A

Low sodium diet (100 mmol a day) which will also help to lower and control blood pressure.

48
Q

How might ACE inhibitors and ARBs be increasingly used in the future in terms of the complications of diabetes?

A

Currently ACE inhibitors and ARBs are used to control blood pressure and prevent the development of the complications. However it is believed in the future it can be given to all patients with diabetes who have a positive test of microalbuminauria regardless of whether they have high blood pressure or not.

49
Q

What is diabetic neuropathy?

A

The progressive loss of peripheral nerve fibres resulting in nerve dysfunction.

50
Q

What are some of the symptoms of diabetic neuropathy?

A

Numbness in both legs
Pain may or may not be present
Unusual feelings without a cause e.g. tingling, itching (paraesthesia)
Impaired sense of position, become unsteady on the feet
Decreased vibration sense

51
Q

What are some of the complications of motor neuropathy (autonomic nerves)?

A

Erectile dysfunction
Orthostatic hypotension (low blood pressure on standing)
Gastroporesis (delayed emptying of the stomach)
Diabetic diarrhea

52
Q

What is the first line treatment for diabetic neuropathy?

A

Optimising blood sugar control
Pain relief (paracetamol, carbamazepine, gabapentin, amitriptyline)

53
Q

What is a diabetic foot disease a complication of?

A

Diabetic neuropathy but also due to peripheral vascular disease (macro-vascular complications)

54
Q

What percentage of patients with diabetes have diabetic neuropathy and peripheral vascular disease?

A

23-42% have diabetic neuropathy and 9-23% have peripheral vascular disease

55
Q

What percentage of diabetics will get a foot ulcer at some point in their life and will require amputation?

A

15% will get a foot ulcer and 5-15% will require amputation at some point during their life.

56
Q

What is the largest cause of diabetic hospital bed days?

A

Infected foot ulcers

57
Q

What percentage of amputations are with patients with diabetes?

A

40-60%

58
Q

What can be some of the complications of diabetic foot ulcers?

A

Deep ulceration
Uncontrolled infection
Cellulitis
Gangrene
Amputation

59
Q

How does peripheral vascular disease contribute to diabetic foot disease?

A

Thinning of the arteries restricts the blood flow to the lower limbs (ischaemia).
This means there are issues getting the antibiotics to the site of infection and also delays healing.

60
Q

How does diabetic neuropathy contributing to the worsening of diabetic foot ulcers?

A

Reduced sensation in the lower limbs means that the ulcer can be very severe and the patient is fully unaware.

61
Q

What are some of the risk factors for diabetic foot disease?

A

Previous ulceration
Presence of callus
Poorly controlled blood glucose or blood pressure
Visual impairment preventing self-care
Poorly fitted footwear
Social deprivation
Increased duration of diabetes
Orthopedic problems such as arthritis

62
Q

What are the three main management points when somebody has diabetic foot disease?

A

Wound management (cleaning and dressings)
Reduce the risk of recurrence
Referral to diabetic foot care team

63
Q

How can you reduce the risk of recurrence of diabetic foot disease?

A

By checking they have suitable footwear
Making sure they have regular inspection of their feet
Should be optimising blood pressure and blood glucose control

64
Q

Which foot products are patients with a history of diabetic foot disease not allowed?

A

Not foot products containing acids (no verruca treatment containing salicylic acid)
No abrasive foot products (hard skin files)

65
Q

When should you refer to a diabetic foot care team?

A

Any ulceration
Any discolouration of the skin
Any swelling
Any cellulitis

66
Q

Is cellulitis has occurred what treatment is normally given?

A

High dose normally IV antibiotics to cover Gram positive, Gram negative and anaerobic bacterium

67
Q

If blood flow is said to be restricted to the affected area what normally occurs?

A

Surgery such as a blood vessel graft to bypass the affected area of the artery
Treatment to dissolve blood clots ( by using fibrinolytic such as alteplase)

68
Q

What is the major prevention strategy for diabetic foot disease?

A

Patient education:
They need to be aware and seek medical help immediately
Can’t use OTC chiropody products
Regular review at diagnosis and then annually

69
Q

What percentage of diabetics die from cardiovascular related deaths?

A

60% (more common in Type 1)

70
Q

What is the increased likelihood of a patient with Type 2 diabetes suffering for CVD compared to a non-diabetic?

A

2-4 times more likely (also depends on genetic, cultural and ethnic backgrounds)

71
Q

When should patients with diabetes be initiated on statin therapy?

A

Aged 40 or above with Type 1 or Type 2 diabetes that have a QRISK2 above 10% or

Aged 18-39 with Type 1 or Type 2 have that one of the following risk factors.

72
Q

What are some of the additional risk factors for CVD in patients with/without diabetes?

A

If they have retinopathy
Nephropathy and persistent microalbuminauria
Poor glycaemic control (HbA1c above 9%)
Elevated blood pressure
Elevated cholestrol (greater than 6mmol/L)
Premature CVD in a first degree relative
Features of metabolic syndrome

73
Q

What would be considered some of the features of metabolic syndrome?

A

Central obesity
Fasting triglycerides above 1.7 mmol/L or above 2 mmol/L when not
HDL cholestrol less than 1.0mmol/L in men and less than 1.2mmol/L in females

74
Q

Aside from Atorvastatin what other drug therapy is introduced to lower the CVD risk?

A

Blood pressure is above the respective targets for Type 1 (>130/80mmHg) and Type 2 diabetes (either >140/90 mmHg or >150/90 mmHg) initiate regardless of age on ACE inhibitors or ARBs

75
Q

Should aspirin be given in the prevention of CVD?

A

Not in the prevention, only if they have established CVD.

76
Q

What is some of the lifestyle advice that can be provided for patients with diabetes to reduce the CVD risk?

A

Ideally want BMI to be below 25 (consider 600kcal deficit)
Diet: less saturated fat
Oily fish twice a week
5 portions of fruit and veg daily
Good blood glucose control
150 minutes of moderate exercise weekly (30 mins x 5 a week)
STOP smoking

Endocrinology (13 decks)

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