Diabetes Complications Flashcards
complications
-microvascular
-macrovascular
-dementia
-ED
-psychiatric
screening
At annual review=
-Digital Retinal Screening
-Foot Risk Assessment
-Urine Albumin:Creatinine Ratio; Creatinine
microvascular comps
Neuropathy
Nephropathy
Retinopathy
Diabetic Eye Disease (5)
-Diabetic Retinopathy
-Diabetic Macular Oedema (Maculopathy)
-Cataract- clouding of the lens (develops earlier in people with diabetes)
-Glaucoma- increase in fluid pressure in the eye leading to optic nerve damage. 2 x more common in diabetes
-Acute hyperglycaemia- visual blurring (reversible)
terminology (4)
Haemorrages: Dot/ Blot/ Flame
Cotton Wool Spots: Ischaemic Areas
Hard Exudates: Lipid break down products
IRMA: Intra-retinal microvascular abnormalities (abnormalities of blood vessels/ precursor to neovascularisation but blood vessels are patent (not leaking))
Retinopathy- STAGES (5)
R0- no disease
R1-Mild non-proliferative (Background)
R2-Moderate non-proliferative
R3-Severe non-proliferative
R4-Proliferative
R0 (2)
no disease
rescreen in 24 motnhs
R1(4)
mild
microanuerysms
flame exudates
over 4 blot haemorrhages in one or both hemifields
and/ or cotton wool spots
rescreen in 12 months
R2 (2)
over 4 blot haemorrhages in one hemifield
rescreen n 6 months
R3 (4)
over 4 blot haemorrhages in both hemifields
intra-retinal microvasc comps (IRMA)
venous bleeding
refer
R4 (5)
NVD
NVE
vitreous haemorrhage
retinal detachment
refer
Retinopathy Treatment (6)
Laser – pan retinal photocoagulation
-Crude but effective
-Mainstay of treatment
-Reduces oxygen requirement of retina
-Reduces ischaemia that is driving the retinopathy
Vitrectomy – if a vitreal haemorrhage
Diabetic macular oedema (3)
-Optical Coherence Tomography is used to
assess oedema
-Intravitreal Anti-VEGF is now mainstay of treatment
(Vascular Endothelial Growth Factor)
-Grid laser to macula may be required
Nephropathy
progressive kidney disease caused by damage to the capillaries in the kidneys’ glomeruli. It is characterized by proteinuria and diffuse scarring of the glomeruli
Consequences of Diabetic Nephropathy (3)
-Development of hypertension
-Relentless decline in renal function
reduction in GFR of 1 ml/min/month if untreated
-Accelerated vascular disease
ACR + PCR (2)
ACR = Albumin:Creatinine Ratio
PCR = Protein:Creatinine Ratio
Urinary Proteinuria (3)
ACR <3.5 (female); <2.5 (male)- normal
ACR <30, PCR <50- microalbuminuria
ACR >30 PCR>50- Proteinuria (overt nephropathy)
How to interpret urine protein measures
Measure protein:creatinine ratio
-Assume daily creatinine excretion is 10mmol, so ratio 100mg/mmol = 1g/day
-SO MULTIPLY BY 10
ACR vs PCR
-Albumin is a component of total protein
-ACR is lower than PCR for a given degree of proteinuria
treatment for nephropathy (3)
ACE/ARB as first line
Diabetic patients with microalbuminuria should be started on an SGLT2i (irrespective of HBA1c)
Manage other vascular complications e.g. discourage smoking, assess fasting lipid profile, screen for cardiovascular disease and hypertension
prevention nephropathy
Good glycaemic control (53mmol/mol) in patients with T2DM should be maintained to reduce the risk of developing diabetic neuropathy (depending on age and other risk factors
Neuropathy types (4)
Peripheral e.g. pain/ loss of feeling in feet, hands
Proximal e.g.pain in the thighs, hips or buttocks leading to weakness in the legs (Amyotrophy)
Autonomic e.g. changes in bowel, bladder function, sexual response, sweating, heart rate, blood pressure
Focal Neuropathy e.g. sudden weakness in one nerve or a group of nerves causing muscle weakness or pain e.g. carpal tunnel, ulnar mono neuropathy, foot drop, bells palsy, cranial nerve palsy
Risk factors for Neuropathy (8)
Increased length of diabetes
Poor glycaemic control
Type 1 diabetes > Type 2 diabetes
High Cholesterol/ Lipids
Smoking
Alcohol
Inherited Traits (genes)
Mechanical Injury
Peripheral Neuropathy symptoms
Distal symmetric or sensorimotor neuropathy
“glove & stocking distribution”
Peripheral Neuropathy symptoms (5)
Numbness/ insensitivity
Tingling/ burning
Sharp pains or cramps
Sensitivity to touch
Loss of balance and coordination
Peripheral Neuropathy consequences (3)
-charcot foot
-foor ulcer
-painless ulcer
Painful Neuropathy treatment (2)
amitriptyline (off-label), duloxetine, gabapentin, or pregabalin; combinations not recommended. Titrate up as needed.
If localized neuropathic pain and patient wishes to avoid, or cannot tolerate, oral treatments then topical Capsaicin Cream
Proximal Neuropathy
Diabetic amyotrophy
Starts with pain in the thighs, hips, buttocks or legs, usually on one side of the body. More common in elderly T2D. Proximal muscle weakness. Often associated with marked weight loss.
Autonomic Neuropathy
Autonomic neuropathy affects the nerves regulating heart rate and blood pressure as well as control of internal organs such as those involved in gastric motility, respiratory function, urination, sexual function and vision.
Autonomic Neuropathy – the gut (4)
Digestive System
Gastric slowing/ frequency- Constipation/ Diarrhea (sometimes both).
Gastroparesis (slow stomach emptying) -persistent nausea and vomiting, bloating, and loss of appetite.
Can make blood glucose levels fluctuate widely, due to abnormal food digestion.
Oesophagus nerve damage- may make swallowing difficult, digestive system can lead to weight loss
Gastroparesis Treatment (8)
Improved glycaemic control
Dietary - smaller, more frequent food portions. Low fat. Low in fiber. If severe may need liquid meals
Promotility drugs such as metoclopramide, domperidone, and erythromycin
anti-nausea medications such as prochlorperazine and serotonin antagonists such as ondansetron.
Abdominal pain in gastroparesis include nonsteroidal anti-inflammatory drugs (NSAIDs), low dose tricyclic antidepressants, gabapentin, tramadol and fentanyl.
Consider a trial of metoclopramide, domperidone, or erythromycin
Botulinum Toxin
Gastric Pacemaker
Autonomic Neuropathy Sweat Glands (4)
Autonomic neuropathy can affect the nerves that control sweating- prevents the sweat glands from working properly.
The body cannot regulate its temperature as it should. Nerve damage can also cause profuse sweating at night or while eating.
‘Gustatory Sweating’
Extremes of anhidrosis and hyperhidrosis occur in 10% to 75% of people with diabetic autonomic neuropathy.
Treatment: Topical glycopyrrolate, clonidine, botulinum toxin
Autonomic Neuropathy - Heart and Blood Vessels (3)
Cardiovascular system nerve damage interferes with the body’s ability to adjust blood pressure and heart rate.
Blood pressure may drop sharply after sitting or standing, causing a person to feel light-headed/ faint.
Heart rate may stay high, instead of rising and falling in response to normal body functions and physical activity
Mononeuropathy
VI cranial nerve palsy
Carpal tunnel syndrome
