Diabetes Lecture 4: Diabetes and its complications

Question 1

What causes increased mortality in diabetic patients

Answer 1

Increased incidence of cardiovascular disease and renal failure

Question 2

What causes increase morbidity in diabetic patients

Answer 2

Increased incidence of blindness and amputation

Question 3

What are the short term complications of diabetes

Answer 3

Hypoglycaemia

Diabetic Ketoacidosis (DKA)

Hyperosmolar hyperglycaemic state (HHS)

Question 4

What are the long term complications of diabetes

Answer 4

Retinopathy

Cardiovascular Disease

Neuropathy

Nephropathy

Macrovascular: CVD, stroke, extremities (feet)

Microvascular: Eye, kidney, nerves and skin

Question 5

When does hypoglycaemia occur and what are the symptoms

Answer 5

Blood glucose falls below 4mmol/L

Symptoms: 
Shaking
Sweating
Anxious
Impaired vision
Hunger
Fatigue
Headache
Irritable

Question 6

What are the causes of hypoglycaemia

Answer 6

Too much insulin or sulfonylureas- patient, doctor or pharmacist error

Altered insulin absorption- absorbed more rapidly from abdomen

Altered insulin clearance- reduced clearance in renal failure

Decreased insulin requirements:
Missed, small, delayed meals
Exercise: increases insulin absorption
Alcohol: inhibits hepatic glucose output

Question 7

How do you treat symptoms of hypoglycaemia

Answer 7

Recognise signs and symptoms as soon as possible

Use oral glucose if conscious and able to swallow- tablets, sugary drinks, sweets

Use intramuscular or subcutaneous glucagon, intravenous glucose if patient is unconciousess

Question 8

How does glucagon work in the body

Answer 8

Metabolises liver glycogen storage

Once over, can replenish them by administration of longer acting carbohydrates

Question 9

What are signs of nocturnal hypoglycaemia and how do you prevent it

Answer 9

Waking up tired with headache
Wet from sweating

Avoid triggers like alcohol and more regular blood glucose monitoring
Carry glucose tablets and sweets

Question 10

How does diabetic ketoacidosis occur

Answer 10

Chronic, uncontrolled hyperglycaemia

Lack of insulin- body is unable to use glucose as energy source, body must use alternative to break down fatty acids

Build up of ketones becomes acidic

Question 11

What are the common causes of diabetic ketoacidosis

Answer 11

Infections- people stop taking insulin after feeling unwell and lose appetite- people can increase insulin requirement

Newly diagnosed diabetes

Insulin errors

Omissions

Non-compliance

Question 12

What are the common symptoms and manage of DKA

Answer 12

Thirstiness
Frequent urination
tiredness
Blurry vision
Cramp
Laboured breathing
Unconsciousness 
Postural hypotension and dehydration

Question 13

How do you treat diabetic ketoacidosis

Answer 13

Intravenous Rehydration
Insulin infusion
Careful correction of electrolyte balance (K+)

Question 14

How does hyperglycaemic hyperosmolar state (HHS) occur and reasons behind it

Answer 14

Type 2 diabetic with high blood glucose level- due to both illness and dehydration

Patient may have stopped medication due to illness (nausea or swallowing difficulties)

Usual anti diabetic medication has reduced effects due to body’s response to illness

Question 15

What are the signs and symptoms of hyperosmolar state (HHS)

Answer 15

Excess urination
Nausea and vomiting
Thirst
Dry skin
General weakness

Leg cramps
visual impairment
Confusion
Drowsiness
Unconsciousness

Question 16

What counts as very high blood glucose, low ketone levels in urine, mild acidosis or hyperosmolality

Answer 16

High blood glucose (>30mmol/L)

Low ketone levels (<3mmol/L)

Mild acidosis (pH > 7.3)

Hyperosmolality (>320 milliosmoles/kg)

Question 17

How do you treat hyperglycaemic hyperosmolar state (HHS)

Answer 17

Rehydration and replacement of electrolytes (IV fluids)

Normalise water electrolyte balance (osmolarity with IV fluids)

Normalise blood glucose levels (low dose insulin IV)

Anti-coagulant prophylaxis (low molecular weight heparins)

Prevention of foot ulceration

Question 18

How do diabetic foot complications arise

Answer 18

Poorly controlled diabetes from nerve damage and poor circulation

Neuropathy: loss of feeling in feet- may notice cut or injury on food

Skin: dry, cracked or no elasticity- more prone to injury or infection

Poor circulation- wounds are slow to heal and may require amputation

Question 19

How do you avoid complications affecting feet

Answer 19

Monitor regular sensitivity of food to touch

Look after feet with
soap and dry
nails trimmed
Wear well fitting shoes

Attend annual clinical foot examination

Question 20

how do diabetic retinopathy occur

Answer 20

Blood vessels supplying the retain become blocked and/or leaky and leads to damage and reduced friction

Question 21

How do you avoid complications affecting the eye

Answer 21

Annual eye screening

Keep blood glucose to normal limits

Achieve recommended HDL/LDL levels

Maintain blood pressure in normally range

Question 22

How do you treat diabetic retinopathy

Answer 22

Laser surgery- improves circulation in retina and stops leaky or inappropriate retina growth

Corticosteroid implant- fluocinolone

Question 23

How does hyperglycaemia cause kidney complcations

Answer 23

Damages the small blood vessels that supply the kidneys

Affects the kidney function (filtration) and leads to neuropathy

Question 24

What is the treatment for diabetic nephropathy

Answer 24

Managing blood pressure

ACE inhibitors and angiotensin II receptor antagonists- both used to prevent further kidney damage and to control BP

Possible to use ACE inhibitors even if BP is normal as effects are independent of hypotensive action

Diet modification- low salt and limited protein

Question 25

What are the three types of diabetic neuropathy and describe what they involve

Answer 25

1. Sensory Neuropathy:
   Lack of feeling in extremities (pain,temperature)

2. Autonomic Neuropathy:
Incontinence, erectile dysfunction, irregular heart beat
Abnormal sweating (lots or little) 
Gastroparesis (delayed gastric emptying)

3. Motor Neuropathy
   Muscle weakness, washing, twitching and cramp

Question 26

How do you avoid diabetic neuropathy

Answer 26

Annual foot examination

Blood glucose within normal limits

Sensory Neuropathy- avoid situations that lead to injury (bare foot, friction from shoes)

Noticing signs of tingling, numbness, shooting or burning pain, insensitivity to temperature or pain, co-ordination loss

Question 27

What is the treatment for diabetic neuropathy

Answer 27

Analgesia: Sensory Neuropathy

Slidenafil- erectile dysfunction (autonomic neuropathy)

Antiemetics- nausea and vomiting (gastroperesis)