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Endocrine > Complications of Diabetes > Flashcards

Complications of Diabetes Flashcards

1
Q

What are the microvascular complications?

A

Brain and cerebral circulation
Diabetic retinopathy
Diabetic neuropathy
Diabetic nephropathy

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2
Q

What are the macrovascular complications?

A

Stroke
Heart disease
Peripheral vascular disease

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3
Q

What is the pathophysiology of the complications?

A

Shunting of glucose down the polyol pathyway leads to inflammation
Advanced glyceration end-products and protein kinase C activation leads to increased vascular permeability
Shunting of glucose fown the hexosamine pathway leads to abnormal microvascular blood flow
All of these things cause the complications associated with diabetes

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4
Q

What are the risk factors for macrovascular disease?

A 
Obesity
Poor glycaemic control
Hypertension
Hyperlipidaemia
Smoking
Microalbuminuria
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5
Q

What is the cause of most deaths in T2DM?

A

75% deaths caused by CV disease

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6
Q

How should a diabetic patient with CV problems be managed?

A

Maintain blood glucose <11mmol/l in 24 hours following an acute MI
CABG superior to PCI if they have multivessle coronary artery disease

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7
Q

What risk factors increase risk of stroke?

A

Microalbuminuria

Features of metabolic syndrome

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8
Q

What kind of stroke is most common in diabetes patients?

A

Ischaemic rather than haemorrhagic

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9
Q

What are the Fontaine classification stages of PVD?

A

Stage 1 - asymptomatic
Stage 2 - intermittent claudication
Stage 3 - rest pain/night pain
Stage 4 - necrosis and gangrene

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10
Q

Which vessels are most commonly affected by PVD in diabetes?

A

Femoral-popliteal and tibial vessels

- less amenable to surgery than the normal place of aorto-iliac

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11
Q

What are the risk factors for developing PVD?

A

Age
Diabetes duration
Neuropathy (PVD often presents with ulcer/gangrene in diabetic patients)

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12
Q

What kind of therapy reduces CV risk?

A

Intensive multifactorial intervention

  • blood glucose (SGLT2 inhibitors and GLP-1 agonists)
  • RAAS blockade
  • antiplatelet
  • lipid lowering (statins)
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13
Q

What are the signs and symptoms of an ischaemic foot?

A 
Cold
Atrophic/hairless
Absent foot pulses
If ulcer is present, it is painful
History of claudication and/or rest pain
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14
Q

What are the signs and symptoms of a neuropathic foot?

A 
Warm
Dry skin
Present foot pulses
Painless ulcer (if present)
Callus over pressure points
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15
Q

What are the risk factors for a diabetic foot disease?

A 
PVD
Neuropathy
Previous amputation 
Previous ulceration 
Joint deformity 
Callus
Male
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16
Q

What are the general principles in treating foot disease?

A 
Education
Multidiscipplinary foot clinic
- podiatrist
- diabetes physician 
- orthotist 
- nurse specialist 
- surgical input 
Sensible footwear
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17
Q

What is the management of active foot disease?

A

Debridement
Pressure relief (total foot casting)
Antibiotics when indicated (High index of suspicion for osteomyelitis)
Arterial reconstruction where indicated
Charcot foot
- total contact cast and no weight bearing

18
Q

What is Charcot Foot?

A

Fracture and acute inflammation of the foot
Red, swollen, oedematous
Painful
Skin temperature is 2-8 degrees higher than the contralateral foot
Hard to distinguish from infection

19
Q

What are the symptoms of autonomic neuropathy?

A 
Gustatory sweating 
Cardiac denervation 
Postural hypotension 
Gastroparesis 
Diarrhoea 
Atonic bladder
Erectile dysfunction 
Atriovenous swelling
20
Q

What are the symptoms of somatic neuropathy?

A 
Ocular palsies
Carpal tunnel syndrome 
Small muscle wasting 
Amyotrophy
Painful neuropathy
Neuropathic foot
21
Q

What is a peripheral sensory neuropathy?

A

Insidious, often symmetrical
Affects all sensory modalities
- impaired vibration sense is an early sign
Wasting of intrinsic muscles/clawing of toes
Painful (sharp burning) neropathy in 5% of cases

22
Q

What is a mononeuropathy?

A 
Peripheral or cranial
Median nerve/carpal tunnel syndrome in 10%
Can affect the lateral cutaneous nerve 
Cranial palsies occur suddenly
- CN III or IV
23
Q

What is diabetic amyotrophy?

A

Affects males with T2DM
Uncommon
Severe pain/parasthesia in the upper legs/thighs
Wasting/weakness of the quadriceps

24
Q

How is peripheral sensory neuropathy treated?

A

Tricyclic antidepressants (e.g. amytriptyline)
Other antidepressants
Anticonvulsants (e.g. gabapentin)
Opiate analgesia

25
Q

What is the treatment for a mononeuropathy?

A

Tends to resolve spontaneously over weeks/months

Decompressive surgery/splints for carpal tunnel

26
Q

What is the treatment for diabetic amyotrophy?

A

Often related to poor diabetes control, conversion to insulin is advised

27
Q

What is the treatment for autonomic neuropathy?

A

Support stockings with or without fludrocortisone for postural hypotension
Sildenafil or vacuum devices for impotence

28
Q

Describe gastroparesis (GI autonomic neuropathy).

A

Delayed gastric empyting due to
- reduced anal contraction
- anto-pyloro-duodenal incoordinance
These problems can also cause postprandial fullness, nausea and vomiting, bloating, poor glycaemic control and abdominal pain
- causes unexplained hypoglycaemic followed by hyperglycaemia

29
Q

What is the treatment for gastroparesis?

A 
Promotilic agents 
- metoclopramide before meals
- domperidone before meals
- erythromycin (acts as a motility agonist to increase gastric emptying)
Tailor their insulin regime
Gastric pacemakers
- pacing wires to the stomach to regulate contraction
- improves symptoms 
- last resort
30
Q

What are the main diabetic eye diseases?

A

Retinopathy
Maculopathy
Cataracts

31
Q

How common is diabetic eye disease?

A

90% at 30 years in T1DM
Is the presenting feature of 40% of T2DM cases
- 85% at 15 years

32
Q

Describe the retinopathy scale for the peripheral retina.

A 
Background (R1)
- dot haemorrhage 
- blot haemorrhage 
- hard exudates 
- cotton wool spots
Pre-proliferative (R2)
- venous beaing 
- intraretinal microvascular abnormalities 
- multiple deep, round haemorrhages 
Proliferative (R3)
- new blood vessel formation 
- preretinal/subhyaloid haemorrhage 
- vitreous haemorrhage 
Advanced retinopathy
- retinal fibrosis
- traction retinal detachment
33
Q

What do you expect to see on a maculopathy (central retina)?

A

Hard exudates within one disc-width of the macula
Lines or circles of hard exudates within two discs widths of the macula
Microanuerysms or retinal haemorrhages within 1 disc-width of the macula if associated with visual acuity of 6/12 or worse

34
Q

What general measures are done for diabetic retinopathy?

A 
Glycaemic control 
BP control
- ACEI have antiangiogenic effects
Lipid lowering 
- cholesterol >7mmol/l gives 4x greater risk of proliferative disease
35
Q

What specific therapies are available for diabetic retinopathy?

A

Laser therapy
Vitrectomy (for vitreous haemorrhage)
Cataract extraction
VEGF inhibitors

36
Q

What is the leading cause of end stage renal disease in the Western World?

A

Diabetic nephropathy

37
Q

Name the stages and features of diabetic retinopathy?

A 
Stage 1 - hyperfiltration 
Stage 2 - thickening of the GBM and mesangium
Stage 3 - microalbuminuria 
Stage 4 - macroalbuminuria 
Stage 5 - ESRD
38
Q

What is the pathophysiology of diabetic nephropathy?

A 
Mesangial expansion directly induced by hyperglycaemia 
- increased matrix production 
Thickening of the GBM
Glomerular sclerosis 
- caused by intraglomerular hypertension
- dilation of the afferent renal artery 
- hyperglycaemia induces the RAAS system
39
Q

What is the treatment for diabetic nephropathy?

A 
Blood pressure
- ACEI or ARB first line
- small decline in eGFR is normal 
Microalbuminuria 
- confirm in 2/3 samples
- ACEI or ARB even if BP is normal 
Blood glucose control 
- traget HbA1c of <7%
40
Q

Describe the use of hypoglycaemic drugs if the patient has chronic kidney disease

A 
Metformin
 - stop once eGFR <30
Sulphonylurea 
- risk of hypo = reduce dose
SGLT2 inhibitor 
- less effective at eGFR <30
GLP-1 agonist
- unclear 
- continue at eGFR <30
DPP-IV inhibitor 
- most stopped once eGFR <30
Insulin
- safe
41
Q

What drugs are good for control of both micro and macrovascular disease?

A

ACEI and ARBs

42
Q

When is tight BP and glucose lowering not recommended?

A

In older patients with pre-existing CV disease

Endocrine (9 decks)

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