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ENDO 2 Exam II (2017) > Complications of Diabetes- Pales > Flashcards

Complications of Diabetes- Pales Flashcards

1
Q

Chronic Complications of Diabetes Mellitus - Microvascular

A

Neuropathy

  • Peripheral (Sensory, Motor, Mononeuropathy multiplex)
  • Autonomic

Nephropathy (DNS)
- Chronic kidney disease

Retinopathy
- Blindness

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2
Q

Chronic Complications of Diabetes Mellitus - Macrovascular

A 
Atherosclerosis of big arteries
Coronary---->MI
Cerebral/Carotid---> Stroke
LE--->LE amputation
Renal---> HTN---> MI/Stroke
Mesenteric  Bowell ischemia
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3
Q

Ocular complications of diabetes

A

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)

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4
Q

course of ocular problems

A

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

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5
Q

Nonproliferative (“background”) retinopathy

A 
The most common cause of visual impairment in patients with type 2 diabetes
Earlier stage
Changes in microvasculature:
Microaneurisms
Dot hemorrhages
Retinal edema.
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6
Q

Proliferative retinopathy

A

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.

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7
Q

Other ocular complications

A 
Lens swelling (reversible)
Diabetic cataracts
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8
Q

Diabetic nephropathy- stages

A
  1. hyperfiltration (hyperfunctiona nd hypertrophy)
  2. silent stage (thickened BM , expanded mesangium)
  3. Incipient stage (microalbuminuria)
  4. overt diabetic nephropathy (macroalbuminuria)
  5. Uremic (ESRD)
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9
Q

Diabetic neuropathy

A

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

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10
Q

Mononeuropathy/mononeuropathy multiplex

A 
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
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11
Q

Charcot foot defn and 4 conditions

A

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.
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12
Q

Autonomic Neuropathy- areas affected

A

Postural hypotension

Diabetic Gastroparesis

Diarrhea/Constipation

Neurogenic bladder

Impotence
Profuse sweating/temperature disregulation

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13
Q

Postural hypotension

A
  • Dizziness/fainting with changing position
  • Labile blood pressure
  • Diagnosed with checking orthostatics
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14
Q

Diabetic Gastroparesis

A

(stomach not emptying)

  • Nausea/vomiting
  • Abdominal pain
  • Weight loss/malnutrition
  • Diagnosed by GES (gastric emptying study)
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15
Q

Neurogenic bladder

A

Urinary retention –> post-renal renal failure
Incontinence
Frequency

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16
Q

Accelerated Atherosclerosis- causes

A 
Hyperglycemia
Hyperlipidemia
Abnormalities of platelet adhesiveness
Hypertension
Oxidative stress
Inflammation.
17
Q

Heart Disease and diabetes

A

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

18
Q

Stroke and diabetes

A

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

19
Q

Diabetes and PVD

A

Intermittent claudication

Ischemic changes/ulcers/gangrenes

20
Q

Metabolic Complications of diabetes

A

Dyslipidemia:
High LDL cholesterol
High triglycerides
Low HDL cholesterol

21
Q

Dermatological complications of diabetes

A

Chronic pyogenic infections
Yeast infections
Necrobiosis Lipidoica Diabetorum
Acantosis Nigricans- not caused by diabetes but frequently associated with it

22
Q

Measures of Glycemic control

A

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.

23
Q

Hemoglobin A1c

A

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)

24
Q

why is hemoglobin A1c a good test?

A

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

25
Q

Factors affecting Glycohemoglobin

A

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

26
Q

Continuous blood sugar monitoring.

A

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

27
Q

Diabetes Control and Complication Trial

A

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 %

28
Q

United Kingdom Prospective Diabetes Study

A

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

29
Q

Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial

A

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

30
Q

ADVANCE Trial

A

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:

31
Q

ADVANCE Trial. Results

A 
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

32
Q

VADT (Veteran Administration Diabetes Trial)

A

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.

33
Q

Final conclusions of all studies

A

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

34
Q

Prevention of retinopathy

A

Optimize glycemic and blood pressure control

Yearly retinal exam

35
Q

Prevention of neuropathy

A

Optimize glycemic control

Annual foot exam (including monofilament) and visual inspection at every visit

36
Q

Prevention of nephropathy

A

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

37
Q

Prevention of macrovascular disease

A

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

38
Q

DM Management Plan

A

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

ENDO 2 Exam II (2017) (19 decks)

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