Diabetes complications

Question 1

discuss the effects of diabetes on mortality and morbidity

Answer 1

1) Patients with diabetes have a reduced life expectancy
2) Increase mortality results from increased incidence of CVD and renal failure
3) increased morbidity results from increased incidence of blindness and amputation

Question 2

Complications from diabetes can be sub-divided into short-term or long-term complications. list some sort term and long term complications.

Answer 2

1) Short-term complications include :
- hypoglycaemia
- diabetic ketoacidosis (DKA)
- hyperosmolar hyperglycaemic state (HHS)

2) Long-term complications include:
- retinopathy
- cardiovascular disease
- nephropathy
- neuropathy
- Extremities (i.e. feet)

Question 3

one short term complication of diabetes is Hypoglycaemia. explain what Hypoglycaemia
is and what can happen if left untreated.

Answer 3

1) Occurs when blood glucose falls below 4mmol/L
2) Hypoglycaemic episodes affect approx. 10% of diabetics each year
3) Can become a medical emergency if not treated, leading to convulsions, unconsciousness, coma

Question 4

list the symptoms of hypoglycemia

Answer 4

1) sweaty
2) shaky
3) anxious
4) impaired vision
5) fast heart beat
6) fatigue
7) hunger
8) headache
9) irritable

Question 5

outline the Causes of hypoglycaemia

Answer 5

1) Too much insulin (patient, doctor, pharmacist error) or sulfonylureas
2) Altered insulin absorption (insulin is absorbed more rapidly from abdomen, lipohypertrophy at injection site)
3) Altered clearance of insulin (i.e. reduced clearance in renal failure)
4) Decreased insulin requirement (missed, small, delayed meals, exercise, alcohol)
5) Failure to recognise symptoms

Question 6

discuss the Treatment of hypoglycaemia

Answer 6

Key is to recognise signs and symptoms early and to treat immediately:

1) oral glucose (10-20g) if conscious and able to swallow (i.e. glucose rich foods and drinks, sugar cubes, glucose gel)
2) intramuscular or sub-cutaneous glucagon or intravenous glucose if unconscious or unable to swallow
- Glucagon mobilises the liver’s glycogen stores; once epioside is over must replenished them by administration of longer-acting carbohydrates.

Question 7

what is Nocturnal hypoglycaemia and what are the symptoms?

Answer 7

1) Night-time hypos are relatively common in diabetics (esp. insulin users). Symptoms are usually only realised once waking up from a hypo.
2) Signs of nocturnal hypo might include waking up tired or with a headache, wet from sweating

Question 8

discuss the advice that can be given to prevent hypoglycaemia

Answer 8

1) Look for patterns in when hypos occur (i.e. just before lunch, after sport) and adjust routine or insulin if necessary
2) Consider more regular blood glucose monitoring until glucose levels stabilise (i.e. after illness or stress)
3) Avoid triggers (i.e. alcohol can increase incidence of nocturnal hypo)
4) Ask your family, friends and colleagues to help you recognise signs
5) Be prepared (i.e. carry glucose tablets or sweets)
6) See Diabetes Care Team to review or alter treatment regime

Question 9

Chronically, uncontrolled hyperglycaemia can lead to diabetic ketoacidosis. what is Diabetic ketoacidosis?

Answer 9

1) potentially life-threatening complication of diabetes caused by a lack of insulin in the body. Lack of insulin means that the body is unable to use glucose as an energy source so the body seeks an alternative energy source, i.e. the breakdown of fatty acids.
2) Ketones can build up and cause the body to become acidic

Question 10

1) which age group does diabetic ketoacidosis occur in most commonly?
2) what is the most common cause of diabetic ketoacidosis?

Answer 10

1) Occurs more commonly in younger patients but risk of death is higher in older patients
2) Most commonly caused by caused by infections (up to 40% cases) but newly diagnosed diabetes (10-20%) and insulin errors, omissions and non-compliance (15-30%) can also contribute
- Common mistake is to stop taking insulin if feeling unwell and lose their appetite to prevent hypoglycaemia BUT infections can increase insulin requirements

Question 11

what are the Symptoms of diabetic ketoacidosis?

Answer 11

More severe version of the presenting symptoms of diabetes (thirst, frequent urination, tiredness, blurry vision); may also include cramp, laboured breathing, unconsciousness and postural hypotension and dehydration

Question 12

what is the treatment for diabetic ketoacidosis?

Answer 12

Treatment involves intravenous rehydration, insulin infusion and careful correction of electrolyte balance (potassium)

Question 13

Hyperglycaemic hyperosmolar state (HHS) is a short term complication of type II diabetes. explain what HHS is

Answer 13

1) Medical emergency that occurs in type 2 diabetics with very high blood glucose levels, often as a result of both illness and dehydration
2) Patient may have stopped medication as a result of their illness (i.e. nausea or swallowing difficulties) or usual anti-diabetic medication has reduced effects due to body’s response to illness

Question 14

why is a build up of ketones not seen in HHS like it is in DKA?

Answer 14

Unlike in DKA, ketones build up in urine is not seen in HHS, possibly because some insulin is produced in Type 2 diabetes.

Question 15

summarise the Signs and symptoms of Hyperglycaemic hyperosmolar state

Answer 15

1) Excessive urination & Thirst
2) Nausea and vomiting
3) Visual impairment, Confusion, Drowsiness
4) Unconsciousness
5) Very high blood glucose levels (>30mmol/L)
6) Low ketone levels in urine (<3mmol/L)
7) No or mild acidosis
8) hyperosmolality

Question 16

outline the Treatment of Hyperglycaemic hyperosmolar state

Answer 16

HHS is less common than DKA but is associated with increased mortality:

1) Rehydration and replacement of electrolytes (IV fluids)
2) Normalise water-electrolyte balance (osmolality)
3) Normalise blood glucose levels (low dose insulin IV)
4) Anti-coagulant prophylaxis with low MW heparins (HHS associated with arterial or venous thrombosis i.e. MI, stroke)
5) Prevention of foot ulceration (HHS increases susceptibility to pressure sores)

Question 17

outline the long term Macrovascular and Microvascular complications of diabetes

Answer 17

1) Macrovascular complications:
- Cardiovascular Disease and stroke
- Extremities (i.e feet)
2) Microvascular complications
- Eye
- Kidney
- Nerves
- Skin

Question 18

discuss how diabetes can affect the cardiovascular system

Answer 18

1) Diabetes is associated with an increased risk of cardiovascular events
2) Diabetes is an independent risk factor for CVD
3) Type II diabetes common in those with other risk factors for CVD (i.e. obesity, hypertension, dyslipidemia): known as metabolic syndrome.

Question 19

how can the risk of complications affecting

the cardiovascular system be reduced?

Answer 19

1) Maintain a healthy weight
2) Exercise
3) Achieve and maintain recommended LDL and HDL levels
- Statins recommended for diabetic patients from 40 years.
4) Maintain blood pressure in normal range (<130/85 mm Hg)
5) Stop smoking

Question 20

discuss why diabetics experience complications in their feet

Answer 20

1) Poorly controlled diabetes can lead to nerve damage and poor circulation
2) Neuropathy can leads to loss of feeling in feet; may not notice injury
3) Skin of diabetics is often dry, cracked and lacking elasticity; more prone to injury and infection
4) Poor circulation means that any wounds are slow to heal; may require amputation

Question 21

how can diabetics avoid complications affecting

their feet

Answer 21

1) Regularly monitor sensitivity of feet to touch i.e. Ipswich Touch Test or “Touch the Toes” test
2) Look after your feet: wash with soap and dry, keep nails trimmed , Wear well fitting shoes
3) Attend annual clinical foot examination

Question 22

Diabetic complications affecting the eyes is a long term problem. explain why complications occur in diabetic patients

Answer 22

1) Diabetes is associated with retinopathy (damage to the retina)
2) Retinopathy is the leading cause of blindness in the UK
3) Blood vessels supplying the retina become blocked and/or leaky, leading to damage and reduced function

Question 23

how can complications affecting the eyes be avoided?

Answer 23

1) Annual eye screening to monitor retina
2) Keep blood glucose within normal limits
3) Achieve and maintain recommended LDL and HDL levels
4) Maintain blood pressure in normal range (<130/85 mm Hg)
5) Seek medical advice if notice changes affecting vision

Question 24

what is the treatment for diabetic retinopathy?

Answer 24

1) Laser surgery to improve circulation to retina and stop leaky or inappropriate vessel growth
2) Anti-VEGF intra-ocular injection to prevent inappropriate vessel growth
3) Corticosteroid implant (i.e. fluocinolone) to inhibit inflammation and VEGF

Question 25

outline the diabetic complications affecting the kidneys

Answer 25

1) Diabetes is associated with nephropathy (damage to the kidney)
2) Between 25-50% diabetics will develop nephropathy
3) Hyperglycaemia damages the small blood vessels supplying the kidneys, which affects kidney function (filtration) and leads to nephropathy

Question 26

how can complications affecting the kidneys be avoided?

Answer 26

1) Annual kidney function test
- Protein present can indicate damage
2) Keep blood glucose within normal limits
3) Stop smoking
4) Maintain blood pressure in normal range (<130/85 mm Hg)
5) Seek medical advice if notice changes affecting vision

Question 27

what is the Treatment for diabetic nephropathy?

Answer 27

1) Managing blood pressure is important: ACE inhibitors and angiotensin II receptor antagonists can be used to prevent further kidney damage
- May be used even if BP is normal as effects are independent of hypotensive actions (ACE inhibitors only)
2) Diet modification (i.e. low salt, limited protein etc) to ensure that kidney function is not overloaded
3) Dialysis may be necessary if kidney function is poor

Question 28

what is diabetic neuropathy and why does it occur?

Answer 28

Diabetes and poor glycaemic control eventually affects the blood vessels supplying the nerves, leading to neuropathy (nerve damage)

Question 29

Symptoms and signs of neuropathy depend on nerves affected. outline the different types of neuropathy associated with diabetes

Answer 29

1) Sensory neuropathy: lack of feeling in extremities (pain, temperature etc)
2) Autonomic neuropathy: incontinence, erectile dysfunction, irregular heart rate, abnormal sweating , gastroparesis
3) Motor neuropathy: muscle weakness, muscle wasting, muscle twitching and cramp

Question 30

how can diabetic neuropathy be avoided?

Answer 30

1) Annual foot examination
2) Keep blood glucose within normal limits
3) If sensory neuropathy, avoid situations that may lead to injury (i.e. avoid walking barefoot, friction from poorly fitted shoes)
4) Seek medical advice if notice signs of neuropathy
i. e. tingling and numbness, shooting or burning pain, insensitivity to temperature or pain, loss of coordination etc

Question 31

outline the treatment for diabetic neuropathy

Answer 31

1) Analgesia (sensory neuropathy)
2) Sildenafil for erectile dysfunction (autonomic neuropathy)
3) Antiemetics for nausea and vomitting (gastroparesis)