diabetes complications and management of T1D

Question 1

what are micro vascular complications of diabetes?

Answer 1

• diabetic retinopathy = leading cause of blindness in working-age adults
• diabetic nephropathy = leading cause of end-stage renal disease
• diabetic neuropathy = leading cause of non traumatic lower extremity amputations

Question 2

what are macrovascular complications of diabetes?

Answer 2

• stroke (2-4x increase in CV mortality and stroke)
• heart disease
• peripheral vascular disease

Question 3

how is diabetic retinopathy classified?

Answer 3

RMP system

R = retinopathy
M = maculopathy
P = photocoagulation

Question 4

summarise the R in the RMP system for diabetic retinopathy classification

Answer 4

Question 5

summarise the M in the RMP system for diabetic retinopathy classification

Answer 5

Question 6

summarise the P in the RMP system for diabetic retinopathy classification

Answer 6

Question 7

what is responsible for our central vision, most of the colour vision and detailed vision?

Answer 7

macual

Question 8

describe R3

Answer 8

• new vessels on disc or elsewhere
• fibrous proliferation on disc or elsewhere
• haemorrhages - pre-retinal, vitreous

Question 9

why do new vessels form in retinopathy (R3)?

Answer 9

due to ischaemia and secretion of growth factors

Question 10

prevention of diabetic retinopathy

Answer 10

• glycemic control
• BP control
• annual screening

Question 11

treatment of diabetic retinopathy

Answer 11

• photocoagulation
• anti-VEGF therapy (anti-vascular endothelial growth factor injections) eg. Ranibizumab, Aflibercept
• surgery to remove bleeding

Question 12

what are the 4 most common forms of diabetic neuropathy?

Answer 12

1. distal symmetrical sensorimotor polyneuropathy and small fibre neuropathy (lose sensation or develop pain distally)
2. radiculopathies
3. mononeuropathy - can affect cranial nerves - isolated nerve involvement
4. autonomic neuropathy - internal organs affected

Question 13

signs of peripheral neuropathy

Answer 13

• PAIN : burning, parasthesia , persistent hyperaesthesia, nocturnal exacerbation
• LOSS OF SENSATION : autonomic neuropathy — postural hypertension, diabetic gastroparesis, small bowel bacterial overgrowth, cardiac autonomic neuropathy, urogenital

Question 14

neuropathy treatment

Answer 14

often hard to treat

• 1st line agents for pain = duloxetine, pregabalin, gabapentin, amitriptyline
• gastroparesis = prokinetics (eg. domperidone, metoclopramide), botox to pylorus (facilitates gastric emptying), gastric pacemakers
• postural hypertension = fludocortisone, midodrine, compression stockings

Question 15

what is a diabetic foot due to?

Answer 15

neuropathy and ischaemia (peripheral vascular disease)

Question 16

where do ischaemic uclers tend to be?

Answer 16

in extremities

Question 17

foot complications in diabetes prevelance

Answer 17

• 20-40% have neuropathy
• 5% have a foot ulcer
• 5-7% 10 year cumulative incidence of amputation
• increased morbidity, mortality and reduced QoL

Question 18

how are foot uclers prevented?

Answer 18

• education
• good glucose control
• regular foot checks to identify high risk feet
• regular podiatry review of high risk feet
• appropriate footwear

Question 19

how are foot uclers treated?

Answer 19

• food MDT
• off-loading, debridement
• antibiotics to treat infection
• surgery
• revascularisaton

Question 20

what is the commonest cause of renal failure?

Answer 20

diabetes

Question 21

what % of T1DM + T2DM patients develop diabetic nephropathy?

Answer 21

30% of t1d and 40% of t2d

Question 22

what is diabetic nephropathy often associated with?

Answer 22

retinopathy

Question 23

what is the first sign of diabetic kidney disease?

Answer 23

small amounts of albumin in urine

Question 24

what are the values of moderately increased albuminuria: increased albumin creatinine ration (ACR) for men and women?

Answer 24

men : ACR >_ 2.5 mg/mmol
women : ACR >_ 3.5 mg/mmol

or urinary albumin conc >_ 20mg/L in men and women

Question 25

ACR and urinary albumin conc in nephropathy?

Answer 25

Question 26

relationship between ACR and GFR and risk of adverse outcomes

Answer 26

Question 27

how it diabetic nephropathy treated?

Answer 27

- BP control - RAS blockage eg. ACEI, ARB (eg. drugs like ramipril, irbesartan) - glycemic control - CVD risk management - management of the complications of renal failure - dialysis in end stage renal disease — haemodialysis, peritoneal - renal, pancreas and islet transplantation

Question 28

why are CHD symptoms in diabetics an unrelated guide to CHD severity and total ischaemic burden?

Answer 28

autonomic neuropathy, altered pain perception, possibly increased positive arterial remodelling

Question 29

what is the 1st presentation of CHD in DM in 50%?

Answer 29

angina sudden death more common in DM

Question 30

target SBP?

Answer 30

130

Question 31

what is the most common and feared adverse effect of insulin therapy?

Answer 31

hypoglycaemia

Question 32

what does hypoglycaemia result from in diabetics?

Answer 32

absolute or relative hyperinsulinaemia and / or defective glucose counter regulation

Question 33

what are the key defences against hypoglycaemia?

Answer 33

adrenaline and symptoms

Question 34

what is lost when glucose levels drop in t1d?

Answer 34

inhibition of insulin, glucagon secretion, adrenaline, symptoms

Question 35

what can severe hypoglycaemia cause?

Answer 35

coma, seizures, strokes, arrhythmias and even death

Question 36

what are acute implications of hypoglycaemia?

Answer 36

- negative effects on mood and emotions - impairs cognitive function; can affect performance of many activities - interference with balance, coordination, vision and level of consciousness can precipitate falls and injury

Question 37

what are the long term effects of hypoglycaemia?

Answer 37

- fear of hypoglycaemia, elevated HbA1c —> complications - reduced QoL - weight gain - restrictions on employment - driving licensing restrictions - personal relationships disrupted - acquired hypoglycaemia-induced syndromes - cognitive decline (if recurrent hypos happen)

Question 38

how does t1d pose a big burden on the individual?

Answer 38

- require life long insulin therapy - impose a heavy burden o the individual, family and healthcare systems - current treatment multiple daily injections or insulin pump therapy - requires multiple finger-stick measurements, carbohydrate counting and dynamic dose adjustments - many have poor control, glycaemic variability frustrates many; depression, anxiety and reduced QoL very common - impaired awareness of hypoglycaemia (IAH) affects 20-40% of T1DM, severe hypoglycaemia (SH) affects p to 30% of individuals with T1D

Question 39

what factors affect blood glucose?

Answer 39

Question 40

what factors contribute to high HvA1c sub-optimal diabetes (T1DM)?

Answer 40

- fear and burden of hypoglycaemia - lack of access/non-engagement with high quality structured education (self-management skills) - burden of carbohydrate counting, injections, time and life, work pressures - depression, anxiety and lack of motivation - not monitoring glucose - variable insulin absoprtion and problems with insulin injection sites - lack of access to technology/HCP - clinical inertia - lack of access to insulin (global perspective)

Question 41

what are common analogue insulins used in T1D?

Answer 41

- rapid-acting analogues (meal insulin) eg. novorapid, humalog, apidra - ultra-rapid acting analogue (meal insulin) - fiasp - long-acting insulins (16 to 24 hours) - levemir, lantus - ultra ling acting insulins (24+) - tresiba, toujeo

Question 42

what is an analogue insulin?

Answer 42

laboratory grown genetically modified sequence

Question 43

what is the current technology in type 1 diabetes?

Answer 43

Question 44

what is the target range for type 1 and 2 diabetes?

Answer 44

70-180 mg/dl = 3.9-10.0 mmol/L

Question 45

what is the HbA1c target for most adults?

Answer 45

<7% (<53mmol/mol)

Question 46

target SBP?

Answer 46

130mmHg for most adults, <130mmHg if tolerated, but not <120