Diabetes Complications Flashcards
Main complications of DM
Microvascular Macrovascular Opthamology Neuropathy Nephropathy OB
Microvascular complications
Damage to small vessels of organs
Esp. Diabetic opthalmopathy and diabetic nephropathy
Related to glycemic control
T1DM
Macrovascular
Arteriosclerosis of large vessels
CAD, MI, stroke, peripheral vascular disease
Related to both glycemic control and lipid/HTN
T2DM
Chronic complications of DM
Cigarette smoking
T1DM - high rates of ESRD and proliferative retinopathy
T2DM - high rates of MI and CVA
Lipid protein abnormalities in T1DM
Moderate hyperglycemia can cause SLIGHT elevation of LDL and TAG, little change in HDL
Not a big deal
Lipid protein abnormalities in T2DM
Distinct dyslipidemia develops
High serum TAGs
Low HDL cholesterol
High artherogenic LDL
Lipid goals DM
Who gets lifestyle coaching?
Prevention of macrovascular complications is dependent on control of dyslipidemia and HTN
All should have lifestyle coaching
First line treatment of dyslipidemia
Statins given at a moderate or high intensity dose
high risk DM
LDL and TG goals
LDL: <100 mg
TG: <150 mg
very high risk DM
LDL and TG goals
LDL: <70mg
TG: <150
CV complications of DM
diabetes is a coronary heart disease risk equivalent
T1 DM pts develop microvascular dz with congestive HF
T2 DM pts develop microvascular disease (CAD, CVA, PAD)
primary CVD recommendations
Lower BP <130/80
consider EC ASA
continued diet adherence
exercise 150 min/week
smoking cessation
lower LDL <100
two main categories of retinopathy
nonproliferation
proliferative
nonproliferation retinopathy
microaneurysms, exudates, intra-retinal hemorrhages, edema, arteriolar ischemia
manifested as cotton wool spots
proliferative retinopathy
neovascularization on retina, optic disc, or iris
leads to hemorrhage, fibrosis and retinal detachment
DM ocular complications
leaving cause of blindness in adults < 74
increased in AA and Hispanics
accelerated by poor glycemic control
presence of nephropathy is protective of retinopathy
20% of T2DM patients have retinopathy at time of diagnosis bc
insidious development
doesn’t come in to get tested until it is bad
rare in T1DM, but happens to all eventually
when is a dilated eye exam
annual
5 years after diagnosis (T1DM)
at time of diagnosis (T2DM)
ocular complication screenings early for which patients (3)
- pregnant women (+ 1yr postpartum)
- existing retinopathy
- treatment for macular edema
symptoms of retinopathy
floaters, blurred vision and loss of visual acuity
prevention of DM retinopathy
A1c levels at less than 7%
glycemic control, smoking cessation, HTN control
cataracts DM
longstanding diabetes as well as poorly controlled DM
req. surgical management and lens replacement
macular edema DM
20% of T2
fluid and protein collects in central retina (macula) causing blurring and loss of central vision
glaucoma DM
6% of DM
responsive to usual open angle therapy
diabetic nephropathy epidemiology
DM is leading cause of ESRD in US
more often in T1DM
detectable at first as microalbuminuria, then goes to proteinuria
DM nephropathy is caused by
glomerular basement membrane thickening mesangial sclerosis
diabetic glomeruloscreotic changes cause vascular stress, protein leak and GFR decline
first sign of nephropathy
microalbuminuria
30-300 mg/protein/day
potentially reversible
proteinuria
continued poor glucose control causes GFR decline
> 300 mg/24 hrs
diabetic nephropathy screening
done annually with albumin to creatine ratio (random urine sample)
preferred treatment for DM nephropathy
ACE inhibitors + control of HTN
can use ARBs
ACE inhibitors and ARBS
protect agains renal deterioration in T1DM with nephropathy
seem to improve glomerular hemodynamics
recommended for all DM patients with HTN or normotensive pts with microalbuminuria
only use one
must be stopped if Cr >2
persistent K+ >6 mEq/L
consequences of DM nephropathy
acceleration of coronary cerebral arteriosclerosis and hypertension
we can really only slow course to ESRD
microalbuminuria independently predicts CV morbidity
mc diabetic complication
neuropathy
- distal symmetric polyneuropathy
- isolated peripheral neuropathy
- painful diabetic neuropathy
- autonomic neuropathy
distal symmetric polyneuropathy
MC form
presents in stocking glove patterns due to axonal neuropathic process
sensory involvement - dulled perception of vibration, temperature, and pain
denervation of small muscles of foot
alter biomechanics of foot and increase plantar pressures
causes ulcerations
common sign of distal symmetric polyneuropathy
charcot’s foot
joint subluxation and periarticular fractures
if untreated progresses into rocker bottom
must do daily foot inspection, appropriate footwear distributing weight, meticulous hygiene
DM foot ulcers
in well vascularized limb
unloading
debridement of wound
potential need for ABX
DM foot ulcers
in poorly vascularized limb
revascularization
if infected -pt will need amputation
isolated peripheral neuropathy
sudden loss of function of nerve/nerves
subsequent slow recovery of all or most function
involves either one nerve (mononeuropathy) or multiple nerves in one area (mononeuropathy multiplex)
causes of isolated peripheral neuropathy
vascular ischemia and traumatic damage
cranial/femoral nerves freq. involved
predominance of motor abnormalities
painful DM neuropathy
hypersensitivity to light touch, occasionally severe burning pain, most often in lower extremities
occurs particularly at hight
diabetic neuropathic chacexia
profound and rapid weight loss and unrelenting pain
treat with insulin to improve DM control and analgesics (difficult to successfully treat)
general DM neuropathy treatments
no effective treatments to reverse DM neuropathy once present
better glycemic control, lipid, HTN control to prevent progression
protection of feet, thearpy/strengthening exercises and surgical deformities
drug treatment of painful DM neuropathy
anti epileptic drugs (pregabalin/lyrica)
antidepressants
topical agents
autonomic neuropathy
manifestations
postural hypotension
GI autonomic neuropathy
inability to fully empty bladder
erectile dysfunction
symptoms and treatment of autonomic neuropathy
postural hypotension
dizziness, orthostasis, syncope
TED hose, Florinef
symptoms and treatment of autonomic neuropathy
GI autonomic neuropathy
gastroparesis (slow emptying) E-mycin, gastric stimulator)
alternating diarrhea and constipation (antidiarrheals. clonidine, or fiber therapies)
symptoms and treatment of autonomic neuropathy
inability to fully empty bladder
urinary retention
bethanechol, self cauterization
peripheral vascular disease
both PAD and venous status
very important bc no blood flow = inability to carry antibiotics (limbs will die)
accelerated in large vessels
how does venous stasis manifest itself by
dryness and flakey skin
redness
prevention and treatment of PVD
smoking cessation
glycemic control
management of BP and lipids
screen PAD by checking pulses and ABI tests
gangrene of foot
why foot?
uncontrolled sugar (bacteria food)
decreased blood supply
neuropathy
more common in DM bc of endothelial issues
gangrene of food control
glycemic control
daily care of feet
proper footwear
avoidance of agents (i.e. tobacco)
HTN control
treatment of dyslipidemia
revascularization
