Diabetes Chronic Complications Exam 2 Flashcards
UKPDS clinical trials
↓ glycemia = ↓ MICROvascular complications
DCCT/EDIC clinical trials
↓ glycemia = prevention/delay MICROvascular complications
UKPDS Follow-Up clinical trials
↓ glycemia = ↓ MACRO and MICROvascular complications
ACCORD clinical trials
↓ glycemia = Increased MACROvascular complications
ADVANCE clinical trials
- No difference in macrovascular events for intense group (P=0.32)
- No difference in death from CV cause (P=0.12)
- Difference for nephropathy (microvascular) (4.1% vs. 5.2%; P=0.0006)
- ↓ glycemia = decreased MICROvascular complications
VADT clinical trials
↓ glycemia = ↓ MICROvascular complications
DCCT/EDIC Follow-Up clinical trials
↓ glycemia = prevention/delay MACRO and MICROvascular complications
Microvascular Complications
- Nephropathy (kidneys)
- Neuropathy (nerves)
- Retinopathy (eyes)
Macrovascular Complications
- HTN
- Lipid management
- Antiplatelet
- Think: CVD, CAD, PAD
What are other chronic complications other than the micro / macro - vascular complications?
- Dental care
- Celiac
- Thyroid disorders
- Immunizations
Screening requirements for diabetic kidney disease
- DM II: at diagnosis
- DM I: within 5 years of diagnosis
- DM I WITH HTN: at diagnosis
Explain the monitoring for diabetic kidney disease
Annually
- urine test to measure albumin/Cr ratio (measures albuminuria)
- eGFR
- SCr
What can cause a albumin/Cr ratio to be high?
- short term hyperglycemia
- exercise
- UTI
- marked HTN
- CHF
- acute febrile illness
spot collections in relation to albuminuria
two out of three spot collections over 3-6 month period must show elevations
What are the goals for albuminuria?
< 30 mg/g creatinine
What is the treatment for diabetic kidney disease?
- first line: ACEI or ARB (ACEI decreases progression to albuminuria by 55%)
- if ACEI or ARB maxed, may add on these therapies to achieve BP goal: diuretics, CCB, BB
- Restrict dietary protein 0.8g/kg body weight/day
- Optimize blood pressure and glycemic control
What are the prevention measures from diabetic kidney disease?
- glycemic control
- BP controll
- don’t smoke
- early intervention with ACEI or ARB but do not add if there is no sign of HTN or microalbuminuria
Symptoms of Peripheral Neuropathy
- pain described as burning, stabbing, electric shocks
- protective sensation gone
- cold and hot discrimination reduced / absent
- pinprick sensation reduced / absent
- numbness, tingling
- poor balance
- sensations reduced / absent
Symptoms of Autonomic Neuropathy
- Orthostatic hypotension
- resting tachycardia (>100 bpm)
- exercise intolerance
- Constipation
- Gastroparesis
- Erectile dysfunction
- Bladder dysfunction (UTIs, pyelonephritis, incontinence)
- Autonomic failure in response to hypoglycemia (lack of glucagon response)
Screening requirements for Neuropathy
- DM II: at diagnosis
- DM I: within 5 years of diagnosis
Explain the monitoring for Neuropathy
Annually
- pressure sensation using a 10-g monofilament AND
- tests of pinprick sensation OR
- temperature OR
- vibration sensation
What are the components of a foot exam?
- Visual Inspection
- Vascular Inspection
Foot Exam: Visual Inspection
Presence of:
- dry skin
- absence of hair
- ingrown toenails
- interspace maceration
- ulceration
- ulcers
- corns or calluses
- deformities (prominent metatarsal heads, hammertoes, claw toes)
- ill-fitting shoes
Foot Exam: Vascular Inspection
Palpation of dorsalis pedis and posterior tibial pulses and ankle-brachial index (ABI < 0.9 is consistent with peripheral arterial disease)
When should neuropathy be treated?
if pt is experiencing symptoms
What is the treatment for Neuropathy?
- Pregabalin (Lyrica)
- Duloxetine (Cymbalta)
- Tapentadol
What are the prevention measures from neuropathy ?
- glycemic controls
- foot care education
Symptoms of Retinopathy
– Blurry vision – Floaters – Fluctuating vision – Distorted vision – Dark areas in vision – Poor night vision – Impaired color vision – Partial or total loss of vision
Screening requirements for Retinopathy
- DM II: at diagnosis AND after BS stabilizes
- DM I: within 5 years of diagnosis
Explain the monitoring for Retinopathy
- if no retinopathy, repeat every 2 years
- if retinopathy present, repeat every year
- if retinopathy worsens, monitor more frequently
What are the goals for Retinopathy?
- Prevent the progression of diabetic retinopathy and vision loss
- provides an opportunity to treat when vision loss can still be prevented or reversed
What is the treatment for Retinopathy?
- Laser photocoagulation surgery
- Anti–vascular endothelial growth factor injections (Anti VEGF)
Retinopathy: Laser photocoagulation surgery
– Disadvantages: Destructive, peripheral vision loss, night vision loss, does not restore vision loss
– Advantages: less expensive, 1 or 2 treatments
Retinopathy: Anti VEGF
– Drugs: Ranibizumab, Bevacizumab, Aflibercept
– Advantages: Highly effective, superior visual outcomes in head to head trials
– Disadvantages: Expensive, invasive, fear
What are the prevention measures from HTN?
- BP control
- glycemic control
- improved lipid profile
Screening requirements for HTN
at every routine visit
What are the goals for HTN?
- target
- <140/<90 mmHg per ADA and JNC 8 Recommendations
What are lifestyle treatments that can help in blood pressure reduction
- Weight loss
- DASH diet
- Physical activity
- Sodium restriction
- Alcohol consumption
Average SBP Reduction in Weight Loss
5-20 mmHg
Average SBP Reduction in the DASH diet
8-14 mmHg
Average SBP Reduction in Physical Activity
2-8 mmHg
Average SBP Reduction in Sodium Restriction
4-9 mmHg
Average SBP Reduction in Alcohol Consumption
2-4 mmHg
What is the treatment for HTN?
- ACEI or ARB if concomitant increased urinary albumin excretion (>30)
- reduce CV risk in patients with diabetes (thiazide diuretics, ACEI, ARB, non-DHP CCB) if no albuminuria
What are the prevention measures from HTN?
- maintain BP control
- UKPDS: 10mmHg decrease = risk and event of complications, deaths related to DM, reduction in MI
Screening requirements for Dyslipidemia
at diagnosis for both types
Explain the monitoring for Dyslipidemia
- annual lipid profile for ages 40-75
- if age <40 and lipid panel normal and not initiating statin, reassess every 5 years
What are the high-intensity lipid therapies?
- atorvastatin
- rosuvastatin
What are the moderate-intensity lipid therapies?
- atorvastatin
- rosuvastatin
- simvastatin
- pravastatin
- lovastatin
- fluvastatin
- pitavastatin
What are the prevention measures from Dyslipidemia?
– Weight loss
– Increased physical activity
– Medical nutrition therapy
Celiac disease
- Screen children at diagnosis
- If normal, don’t recheck unless symptomatic
Hypothyroidism
- Screen children at diagnosis
- If normal, recheck every 1-2 years
Dental Care
- Periodontal disease is more severe, not necessarily more prevalent
- Dental exam every 6-12 months
immunization recommendations
- Hepatitis B
- Pneumonia
- Influenza
Hepatitis B
Series is 3 injections total given at 0, 1 and 6 months
Pneumonia
- PPSV23 before 65
- PCV13 after 65
- PPSV23 after 65
- PPSV23 5 years apart
- PPSV23 and PCV13 12 months apart
Influenza
- start at 6 months of age
- two doses in pt’s under 9 years old
Overall Prevention
- Glycemic Control
- Reduce Complications
- Control Blood Pressure
