diabetes complications and management of T1D Flashcards
what are micro vascular complications of diabetes?
- 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
what are macrovascular complications of diabetes?
- stroke (2-4x increase in CV mortality and stroke)
- heart disease
- peripheral vascular disease
how is diabetic retinopathy classified?
RMP system
R = retinopathy
M = maculopathy
P = photocoagulation
summarise the R in the RMP system for diabetic retinopathy classification
summarise the M in the RMP system for diabetic retinopathy classification
summarise the P in the RMP system for diabetic retinopathy classification
what is responsible for our central vision, most of the colour vision and detailed vision?
macual
describe R3
- new vessels on disc or elsewhere
- fibrous proliferation on disc or elsewhere
- haemorrhages - pre-retinal, vitreous
why do new vessels form in retinopathy (R3)?
due to ischaemia and secretion of growth factors
prevention of diabetic retinopathy
- glycemic control
- BP control
- annual screening
treatment of diabetic retinopathy
- photocoagulation
- anti-VEGF therapy (anti-vascular endothelial growth factor injections) eg. Ranibizumab, Aflibercept
- surgery to remove bleeding
what are the 4 most common forms of diabetic neuropathy?
- distal symmetrical sensorimotor polyneuropathy and small fibre neuropathy (lose sensation or develop pain distally)
- radiculopathies
- mononeuropathy - can affect cranial nerves - isolated nerve involvement
- autonomic neuropathy - internal organs affected
signs of peripheral neuropathy
- PAIN : burning, parasthesia , persistent hyperaesthesia, nocturnal exacerbation
- LOSS OF SENSATION : autonomic neuropathy — postural hypertension, diabetic gastroparesis, small bowel bacterial overgrowth, cardiac autonomic neuropathy, urogenital
neuropathy treatment
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
what is a diabetic foot due to?
neuropathy and ischaemia (peripheral vascular disease)
where do ischaemic uclers tend to be?
in extremities
foot complications in diabetes prevelance
- 20-40% have neuropathy
- 5% have a foot ulcer
- 5-7% 10 year cumulative incidence of amputation
- increased morbidity, mortality and reduced QoL
how are foot uclers prevented?
- education
- good glucose control
- regular foot checks to identify high risk feet
- regular podiatry review of high risk feet
- appropriate footwear
how are foot uclers treated?
- food MDT
- off-loading, debridement
- antibiotics to treat infection
- surgery
- revascularisaton
what is the commonest cause of renal failure?
diabetes
what % of T1DM + T2DM patients develop diabetic nephropathy?
30% of t1d and 40% of t2d
what is diabetic nephropathy often associated with?
retinopathy
what is the first sign of diabetic kidney disease?
small amounts of albumin in urine
what are the values of moderately increased albuminuria: increased albumin creatinine ration (ACR) for men and women?
men : ACR >_ 2.5 mg/mmol
women : ACR >_ 3.5 mg/mmol
or urinary albumin conc >_ 20mg/L in men and women
ACR and urinary albumin conc in nephropathy?
relationship between ACR and GFR and risk of adverse outcomes
how it diabetic nephropathy treated?
- 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
why are CHD symptoms in diabetics an unrelated guide to CHD severity and total ischaemic burden?
autonomic neuropathy, altered pain perception, possibly increased positive arterial remodelling
what is the 1st presentation of CHD in DM in 50%?
angina
sudden death more common in DM
target SBP?
130
what is the most common and feared adverse effect of insulin therapy?
hypoglycaemia
what does hypoglycaemia result from in diabetics?
absolute or relative hyperinsulinaemia and / or defective glucose counter regulation
what are the key defences against hypoglycaemia?
adrenaline and symptoms
what is lost when glucose levels drop in t1d?
inhibition of insulin, glucagon secretion, adrenaline, symptoms
what can severe hypoglycaemia cause?
coma, seizures, strokes, arrhythmias and even death
what are acute implications of hypoglycaemia?
- 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
what are the long term effects of hypoglycaemia?
- 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)
how does t1d pose a big burden on the individual?
- 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
what factors affect blood glucose?
what factors contribute to high HvA1c sub-optimal diabetes (T1DM)?
- 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)
what are common analogue insulins used in T1D?
- 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
what is an analogue insulin?
laboratory grown genetically modified sequence
what is the current technology in type 1 diabetes?
what is the target range for type 1 and 2 diabetes?
70-180 mg/dl = 3.9-10.0 mmol/L
what is the HbA1c target for most adults?
<7% (<53mmol/mol)
target SBP?
130mmHg for most adults, <130mmHg if tolerated, but not <120
