Diabetes- Complications 2 - Neuropathy, Diabetic Foot & Macrovascular

Question 1

What is Diabetic Neuropathy?

Answer 1

Is when diabetes causes damage to your nerves. It can affect different types of nerves in your body, including in your feet, organs and muscles.

Question 2

What symptoms are experienced with Diabetic Neuropathy?

Answer 2

• Numbness occurs in both legs
• Pain may or may not be present
• Paraesthesia (e.g. tingling, itching)
• Impaired sense of position leading to the patient being unsteady on their feet
• Decreased vibration sense

Question 3

What is motor neuropathy?

Answer 3

Neuropathy of the autonomic nerves

Question 4

What are the symptoms of motor neuropathy?

Answer 4

• Erectile dysfunction in men
• Low blood pressure when standing (Orthostatic hypotension)
• Delayed emptying of the stomach causing bloating, occasional nausea and vomiting (Gastroporesis)
• Diabetic diarrhoea

Question 5

What are the treatment options for diabetic neuropathy?

Answer 5

1. Optimise control of blood sugar - Possible worsening of symptoms at first then improves
2. Pain modifying agents
   • Simple analgesics e.g. paracetamol
   • Analgesics for nerve pain e.g. Amitriptyline, Carbamazepine or Gabapentin

Question 6

What percentage range of diabetic patients have neuropathy?

Answer 6

23-42%

Question 7

What percentage range of diabetic patients have vascular disease?

Answer 7

9-23%

Question 8

What percentage of diabetic will get a foot ulcer at some point in their life?

Answer 8

15%

Question 9

What percentage range of diabetic patients with neuropathy/vascular disease/foot ulcer will eventually require amputation?

Answer 9

5-15%

Question 10

Diabetic foot has a significant impact on quality of ____.

Answer 10

Quality of life

Question 11

What is Cellulitis?

Answer 11

• An infection of the deep layers of skin and underlying tissues.
• It can be serious if not treated promptly
• The infection develops suddenly and can spread through the body quickly

Question 12

What is Gangrene?

Answer 12

• A serious condition where a loss of blood supply causes body tissues to die.
• It can affect any part of the body but typically starts in the toes, feet, fingers and hands.

Question 13

Diabetic foot contributes to which 5 complications/disabilities?

Answer 13

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

Question 14

What percentage range of all amputations are on diabetic patients?

Answer 14

40-60%

Question 15

Diabetic foot does not contribute to premature mortality. True or False

Answer 15

False - It does contribute to premature mortality

Question 16

What are the 2 causes of diabetic foot?

Answer 16

• Peripheral vascular disease (Macrovascular)
• Peripheral neuropathy (Microvascular)

Question 17

What is peripheral vascular disease?

Answer 17

The reduced circulation of blood to a body part, other than the brain or heart, and ischaemia of lower limb due to a narrowed or blocked blood vessel.

Question 18

What does peripheral vascular disease (Macrovascular) cause?

Answer 18

• Problems with healing of infection
• Problems getting antibiotics to the sit of action in sufficient concentration to be effective
• Leading to DIABETIC FOOT

Question 19

How does peripheral neuropathy cause diabetic foot?

Answer 19

Due to reduced sensation of pain meaning that the ulcer can be very severe and the patient may be totally unaware.

Question 20

Risk of diabetic foot is increased by what factors?

Answer 20

• Previous foot ulceration or amputation
• Presence of callus or deformity of joint, foot or nail
• Orthopaedic problems such as arthritis
• Visual impairment of poor mobility preventing self-care
• Increased duration of diabetes
• Poor control of blood glucose or blood pressure
• Poorly fitting footwear
• Social deprivation or social isolation

Question 21

What are the management options for diabetic foot?

Answer 21

• Wound management (cleaning, dressings)
• Reduce the risk of recurrence
• Referral
  -Systemic antibiotics
• Check the blood flow to the affected area

Question 22

How can you reduce the risk of recurrence of diabetic foot?

Answer 22

• Check footwear
• Regular inspection of feet
• No foot products containing acids
• No abrasive foot products designed to remove hard skins e.g. foot files
• Optimisation of BP control and blood sugar control

Question 23

When should referral be considered with diabetic foot?

Answer 23

Urgent referral to a specialist diabetic foot care team if the patient has ulceration, swelling, cellulitis or discolouration of the skin

Question 24

Why may systemic antibiotics be given for diabetic foot?

Answer 24

For cellulitis or bone infection
- covers gram positive, gram negative and anaerobic bacteria
- High dose, possible IV, therapy to ensure penetration

Question 25

Why may systemic antibiotics be given for diabetic foot?

Answer 25

For cellulitis or bone infection - covers gram positive, gram negative and anaerobic bacteria - High dose, possible IV, therapy to ensure penetration

Question 26

With diabetic foot, what can be done if blood flow is restricted?

Answer 26

- Surgery such as blood vessel graft to bypass the affected area of the artery - Drug treatment to dissolve blood clots (fibrinolytic such as alteplase)

Question 27

How can diabetic foot be prevented?

Answer 27

- Patient education: Be aware and seek medical help immediately if problem is identified - Don't use OTC chiropody products eg Verrucae treatment - Regular review - at diagnosis and at least annually

Question 28

What is microvascular disease?

Answer 28

Macrovascular disease is a disease of any large (macro) blood vessels in the body.

Question 29

What percentage of deaths from diabetes is due to Cardiovascular Disease?

Answer 29

60%

Question 30

There's excess mortality rate for cardiovascular disease for type 1 or type 2 diabetes?

Answer 30

Type 1 diabetes

Question 31

Risk of cardiovascular disease in type 1 diabetes is 2-4x higher than in non-diabetics. True of False

Answer 31

False - Type 2 diabetes

Question 32

How can the risk of Cardiovascular Disease be reduced?

Answer 32

- Use of statins - Other drug therapy e.g. Antihypertesive or Aspirin - Lifestyle changes/advice

Question 33

Why are patients aged >40 years with type 1 or type 2 diabetes prescribed with statins?

Answer 33

All patients aged >40 years with type 1 or type 2 diabetes are considered at high risk of cardiovascular disease and should receive a statin (e.g. Atorvastatin 20mg)

Question 34

What are the risk factors for Cardiovascular disease?

Answer 34

- Retinopathy - Nephropathy including persistent microalbuminuria - Persistent poor glycaemic control - Elevated BP needing antihypertensive therapy - Total serum cholesterol >6mmol/L - Premature CVD in a first degree relative - Features of metabolic syndrome - Central obesity - Fasting triglycerides >1.7mmol/L - Non-fasting triglycerides >2mmol/L - HDL cholesterol <1.0mmol/L in men - HDL cholesterol <1.2mmol/L in women -PATIENTS AGED 18-39 WITH TYPE 1 OR 2 DIABETES SHOULD BE CONSIDERED FOR A STATIN IF THEY HAVE ANY OF THE RISK FACTORS

Question 35

What other drug therapy other than statins can be used for reducing the risk of Cardiovascular Disease?

Answer 35

- Add antihypertensive (first line ACEI) - If BP is persistently > 130/80mmHg in Type 1 - If BP is >140/90 (<80yrs) or >150/90 (>80yrs) in Type 2 - Aspirin- DO NOT OFFER to either Type 1 or Type 2 unless they have established cardiovascular disease

Question 36

What lifestyle advice can be given to reduce the risk of cardiovascular disease?

Answer 36

- Weight reducing diet if BMI > 25 - Diet: 5 a day/ Oily fish x2 a week/ Reduced saturated fat intake/ Good control of blood sugar - Exercise - 30 mins 5 times a week - Stop smoking