Complications of DM 2 W1

Question 1

Diabetic neuropathy

Answer 1

• Numbness occurs in both legs
• pain may or may not be present
• Accompanied by unusual feelings without any obvious calls e.g. tingling/itching (paraesthesia)
• Impaired centre position leading to the patient being unsteady on their feet
• Decreased vibration sense

Question 2

Treatment of diabetic neuropathy

Answer 2

• Optimise control of blood glucose (possible worsening of symptoms initially and then improvement)
• Pain modifying agents such as simple analgesicss (paracetamol) or analgesic for nerve pain (amitriptyline)

Question 3

Other types of diabetic neuropathy

Answer 3

Motor neuropathy

Neuropathy of the autonomic nerves leading to:
- Erectile dysfunction
- Low blood pressure when standing (orthostatic hypertension)
- Delayed emptying of the stomach causing bloating, nausea and vomiting (gastroporesis)
- Diabetic diarrhoea

Question 4

Diabetic foot

Answer 4

10% of diabetics will get a foot ulcer in their life

Of this 5 to 15% eventually require amputation

• Deep ulceration
• Uncontrollable infection
• Cellulitis
• Gangrene
• Amputation

40 to 60% of all amputations are on diabetic patients

Question 5

Diabetic foot cause

Answer 5

Peripheral vascular disease (macrovascular)
- Circulation and ischaemia of lower limb causes problem with healing of infection and problems getting antibiotic to the site of action to be effective

Peripheral neuropathy (microvascular)
- Reduce sensation of pain means also can be very severe and the patient may be totally unaware

Question 6

Risk of diabetic foot is increased by

Answer 6

• Previous foot ulceration or amputation
• Presence of callous or deformity of the joint foot or nail
• Orthopaedic problems such as arthritis
• Visual impairment or poor mobility preventing self-care
• Poorly fitting footwear

Question 7

Prevention of diabetic foot

Answer 7

Patient education
- Regular inspection of feet
- Seek medical help if identify a problem
- Check footwear
- No OTC chiropody product containing acids e.g. Salicylic acid
- No abrasive products to remove hard skin e.g. foot file

Question 8

Management of diabetic foot

Answer 8

• Wound management cleaning and dressing
• Urgent referral to a specialist if the patient has ulceration, swelling, cellulitis or discolouration of the skin
• Systemic antibiotics for cellulitis or bone infection
• Check blood flow to the infected area

Question 9

Microvascular complications

Answer 9

Cardiovascular disease accounts were up to 60% of all deaths from diabetes

Excess mortality is most pronounced in type one diabetics

Risk cardiovascular disease and type two diabetes is 2 to 4 times higher than a non-diabetics

Question 10

Cardiovascular risk reduction - settings

Answer 10

T2
Offer atorvastatin in 20 mg daily to all type two diabetics with a 10 year QRISK3 score of greater than 10%

T1
Offer atorvastatin 20 mg daily to all type one diabetics who are older than 40 or have had diabetes to more than 10 years or have established neuropathy or have other CBD risk factors

Question 11

Risk factor factors for CVD

Answer 11

• Retinopathy
• Neuropathy, including persistent microalbumnuria
• Persistent poor glycaemic control (HbA1c<9%)
• Elevated BP needing antihypertensive therapy
• Total serum cholesterol of more than 6mmol/L

Question 12

CV risk reduction – other drug therapy

Answer 12

Control hypertension with a first line ACEI/ARB

Do not offer aspirin to type one or type two diabetes for primary prevention

Question 13

CV risk reduction – others

Answer 13

Lifestyle advice
- Weight reducing diet if BMI is over 25
- Encourage regular exercise of 30 minutes, five times a week
- Stop smoking