Complications of Diabetes- Pales Flashcards
Chronic Complications of Diabetes Mellitus - Microvascular
Neuropathy
- Peripheral (Sensory, Motor, Mononeuropathy multiplex)
- Autonomic
Nephropathy (DNS)
- Chronic kidney disease
Retinopathy
- Blindness
Chronic Complications of Diabetes Mellitus - Macrovascular
Atherosclerosis of big arteries Coronary---->MI Cerebral/Carotid---> Stroke LE--->LE amputation Renal---> HTN---> MI/Stroke Mesenteric Bowell ischemia
Ocular complications of diabetes
Diabetic retinopathy
Develops 15-30 years after diagnosis
Leading cause of blindness in the United States
2 types of retinopathy
Nonproliferative (“background”) retinopathy
Proliferative retinopathy
(more in Type 1 diabetics because type II don’t have time to develop it)
course of ocular problems
Early changes
- loss of retinal supporting cells (pericytes)
- basement membrane thickening
- retinal blood flow changes
Damage in retinal capillaries –> leakage of protein, red blood cells, and lipids –> retinal edema.
Capillary occlusion –> Chronic retinal hypoxia –> neovascularization –> Retinal hemorrhage, inflammation, and scarring –> retinal detachment and permanent vision loss
Nonproliferative (“background”) retinopathy
The most common cause of visual impairment in patients with type 2 diabetes Earlier stage Changes in microvasculature: Microaneurisms Dot hemorrhages Retinal edema.
Proliferative retinopathy
Growth of new capillaries and fibrous tissue within the retina due to ischemic retinal infarcts (cotton wool spots)
More common in type 1 DM
In severe cases leads to vitreous hemorrhage or retinal detachment.
Other ocular complications
Lens swelling (reversible) Diabetic cataracts
Diabetic nephropathy- stages
- hyperfiltration (hyperfunctiona nd hypertrophy)
- silent stage (thickened BM , expanded mesangium)
- Incipient stage (microalbuminuria)
- overt diabetic nephropathy (macroalbuminuria)
- Uremic (ESRD)
Diabetic neuropathy
Peripheral neuropathy:
Often the first complication that develops.
Sensory nerves, especially long nerves of the lower extremities are affected the most
Distal symmetric polyneuropathy
Stocking-glove pattern
Positive and negative symptoms
- Burning pain, parasthesia
- Hyposthesia and decrease temperature and vibratory sensation, loss of Achilles refluxes
Motor neuropathy in advanced cases, not as common
Mononeuropathy/mononeuropathy multiplex
Isolated nerve/nerves affected Likely ischemic in nature Cranial nerves (often III, IV, or VI). Usually gets better in 2-3 months Femoral nerve - Diabetic amyotrophy - Severe pain on the front of thigh and Quadriceps weakness - May last for months and even few years Any nerve(s) may be affected
Charcot foot defn and 4 conditions
deformity of feet from collapse of the midfoot arch due to charcot neuropathic arthropathy
4 conditions of Charcot foot formation Loss of sensation Initial trauma Repetitive traumas Good blood flow to feet.
Autonomic Neuropathy- areas affected
Postural hypotension
Diabetic Gastroparesis
Diarrhea/Constipation
Neurogenic bladder
Impotence
Profuse sweating/temperature disregulation
Postural hypotension
- Dizziness/fainting with changing position
- Labile blood pressure
- Diagnosed with checking orthostatics
Diabetic Gastroparesis
(stomach not emptying)
- Nausea/vomiting
- Abdominal pain
- Weight loss/malnutrition
- Diagnosed by GES (gastric emptying study)
Neurogenic bladder
Urinary retention –> post-renal renal failure
Incontinence
Frequency
Accelerated Atherosclerosis- causes
Hyperglycemia Hyperlipidemia Abnormalities of platelet adhesiveness Hypertension Oxidative stress Inflammation.
Heart Disease and diabetes
Adults with diabetes are two to four times more likely to have heart disease or a stroke than adults without diabetes.
Micro and macro-vascular coronary artery disease
More common to have heart attacks, arrhythmias, congestive heart failure
Stroke and diabetes
Incidence of stroke increases up to 4 folds in patients with diabetes
Large artery thrombosis, embolic (carotid artery stenosis and atrial fibrillation related), and lacunar infarcts
Diabetes and PVD
Intermittent claudication
Ischemic changes/ulcers/gangrenes
Metabolic Complications of diabetes
Dyslipidemia:
High LDL cholesterol
High triglycerides
Low HDL cholesterol
Dermatological complications of diabetes
Chronic pyogenic infections
Yeast infections
Necrobiosis Lipidoica Diabetorum
Acantosis Nigricans- not caused by diabetes but frequently associated with it
Measures of Glycemic control
Blood sugar/finger stick:
Fasting/before meals
- 90-130 (ADA)
- Below 110 (AACE)
2 hour after meals
- Less than 180 (ADA)
- Less than 140 (AACE)
Hemoglobin A1c (glycohemoglobin)
Continuous blood sugar monitoring.
Hemoglobin A1c
Hemoglobin is one of the proteins that get glycosylated by glucose
The higher glucose level in the blood, the higher percentage of protein molecules will be glycosylated
Measurements of HbA1c correspond to the blood sugar control over the last 8-12 weeks
Well correlated with the rate of complications
Goal is 7.0 (ADA), 6.5 (AACE)
why is hemoglobin A1c a good test?
not only does it give a longer-term picture of blood glucose levels, but there is a direct correlation between elevated A1C and diabetic complications
Factors affecting Glycohemoglobin
Conditions that shorten erythrocyte life span will decrease Hemoglobin A1C
- Hemolytic anemia
- Hypersplenism
- Frequent transfusions
Diseases in which lack of new reticulocytes entering the pool results in aged RBCs being in circulation will cause hemoglobin A1C to progressively rise
- Aplastic anemia
Continuous blood sugar monitoring.
Quite new and not well studied yet method
Done over 72 hours or combined with insulin pumps
Not very reliable for a precision of individual numbers, but useful to follow trends
Diabetes Control and Complication Trial
A ten-year study of 1,441 type 1 patients in 29 centers
Intensive therapy (patients’ average HbA1c was 7.2) versus conventional therapy (patients’ average HbA1c was 9.0)
Retinopathy decreased by up to 76 %
Nephropathy decreased by up to 56 %
Neuropathy decreased by up to 60 %
United Kingdom Prospective Diabetes Study
5,102 patients with Type II DM in 23 centers in the U.K.
New diabetics
Duration – 15 years
Intensive vs. conventional treatment -> HbA1c 7.9 to 7.0 Microalbuminuria down 33%, Sensory neuropathy decreases 40% 1 point less in HbA1c --> decreases of: 17% in All-Cause Mortality 18% in MI 15% in CVA 35% in all Microvascular Endpoints 18% in Cataract extraction 23% in All Diabetes related endpoints
Annual incidence of major hypoglycemic events in patients treated with insulin—– 2.3% patients/year
One death from hypoglycemia out of 27,000 patient-years of intensive therapy
No increase in CV. events with sulfonuria or with insulin
Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial
Over 10000 DM pts. ages 40-79 (mean 62)who
had cardiovascular disease or
had evidence of significant atherosclerosis, albuminuria, or LVH or
at least two additional risk factors for cardiovascular disease (dyslipidemia, hypertension, current status as a smoker, or obesity).
2 randomized groups
- Targeting HbA1c of 7-8 (achieved average of 7.5)
- Targeting HbA1c of 6 (achieved average of 6.4)
Baseline Hb A1c was 8.1
Physicians could use any oral or injectable diabetic medications in any combination
Trial stopped earlier
Intervention group had a relative increase in mortality of 22% and an absolute increase of 1.0% after a mean of 3.5 years.
Equivalent to one extra death for every 95 patients
Patients in both groups had lower mortality than reported in epidemiologic studies of similar patients.
Cause of increased mortality is unknown
ADVANCE Trial
A randomized trial of blood pressure lowering and intensive glucose control in 11,140 patients with type 2 diabetes
Inclusion criteria Type 2 diabetes mellitus Age 55 years or older Additional risk of vascular event Age ≥ 65 years History of major macrovascular disease History of major microvascular disease First diagnosis of diabetes >10 years prior to entry Other major risk factor Any level of blood pressure Any level of glucose control but no definite indication for long-term insulin
Intensive control arm
Gliclazide MR (sulfonylurea) in all participants
Unrestricted additional therapy to achieve
target HbA1c≤6.5%
Standard control arm
Sulfonylurea other than Gliclazide MR
Unrestricted additional therapy according to
standard local guidelines
All other treatment at discretion of treating physician
Intensive glucose control strategy
More frequent visits
Emphasis on lifestyle management
Drug titration at physician’s discretion based on HbA1c and FBG levels:
ADVANCE Trial. Results
Hemoglobin A1c at final visit 7.3 vs. 6.5 Combined primary outcomes of Major macro or microvascular event Relative risk reduction--10%, p=0.013 Major macrovascular events Relative risk reduction--6%, p=0.32 Major microvascular events Relative risk reduction--14%, p=0.015 All-cause mortality Relative risk reduction - 7%: p=0.28
Intensive glucose control resulted in:
10% reduction in combined primary outcome
14% reduction in microvascular events
21% reduction in nephropathy
No significant effects on macrovascular events
No significant effects on all-cause or cardiovascular mortality
Consistent treatment effects in patient subgroups
Conclusions on safety: Intensive glucose lowering was safe
No excess mortality
No weight gain
No excess of serious sequelae from hypoglycemia
Death or disability
Cognitive function
VADT (Veteran Administration Diabetes Trial)
1791 patients from age 50 to 69 years with type 2 diabetes
Standard (HbA1c 8.4%) vs intensive glucose control(HbA1c 6.9%)
97% of the subjects were men.
Only macrovascular complications were measured
No significant difference in the primary outcome
Subgroup of patients with low coronary calcium score showed a reduced number of cardiovascular events with intensive therapy.
Final conclusions of all studies
Intensive control of diabetes mellitus has a definite positive effect on the rate of microvascular complications
Intensive control of diabetes mellitus has a modest positive effect on the rate of macrovascular complications only in a newly diagnosed diabetics and those with no or early macrovascular complications
Effect of hypoglycemia (including occult hypoglycemia) is unclear
Goal of Hb A1c of 7 remains the goal for most patients
Multifaceted approach to prevention of complication including glucose, blood pressure and lipids control is more appropriate for this multifaceted disease
Prevention of retinopathy
Optimize glycemic and blood pressure control
Yearly retinal exam
Prevention of neuropathy
Optimize glycemic control
Annual foot exam (including monofilament) and visual inspection at every visit
Prevention of nephropathy
Optimize glucose and blood pressure control
Annual serum Creatinine/GFR calculation and microalbuminuria determination
Limit protein intake to 0.8-1.0 g/kg in earlier stages, and 0.8 g/kg in later stages
Prevention of macrovascular disease
Aspirin for patients over 40 or those with more than 1 risk factor
Smoking Cessation
Manage HTN and Hyperlipidemia
Assess for PVD with pedal pulses and ABI
ACEI/ARBS with HTN or without if over 55
Silent ischemia may be a problem, so may need to be proactive with cardiac testing
DM Management Plan
Statement of short- and long-term goals
Individualized nutrition recommendations and instructions, preferably by a registered dietitian
Recommendations for appropriate lifestyle changes
Medications
Regular lab workups.
Blood glucose monitoring instructions
Consultations for specialized services
Agreement on continuing support, follow up and return appointments
