Diabetes Mellitus -3

Question 1

How to diagnose peripheral neuropathy in diabetic patients

Answer 1

Diagnosis is made after excluding all causes of peripheral neuropathy

It has gradual onset and progressive course with predominant sensory manifestations.

Diagnosis depends on loss of perception of pain, touch, vibration and pressures in glove and stocking pattern.

Question 2

Manifestation of peripheral neuropathy- Onset, spread

Answer 2

Usually insidious onset with numbness or paresthesia, often found on screening rather than as a presenting problem

Starts in the toes and on the soles of the feet, and then spreads up to mid-shin level, mostly in a symmetrical fashion. Less often, it also involves the fingers and hands.

Question 3

Manifestations of peripheral neuropathy - Sensory modalities, sensations affected, risk factor for ulceration

Answer 3

• Affects all sensory modalities and results in reduced vibration perception thresholds, pinprick, fine touch, and temperature sensations.
• Vibration sensation and absent ankle reflexes are often the first features found.
• Another risk factor for ulceration is the inability to feel a 10 g monofilament.

Question 4

Other less ccommon signs of peripheral neuropathy

Answer 4

• Less often, the skin is tender or sensitive to touch (hyperesthesia).
• Painful neuropathy affects up to 5% of a general clinic population.
• This pain may be sharp, stabbing, or burning in nature and at times very severe.
• There may also be some wasting of the intrinsic muscles of the foot with clawing of the toes.

Question 5

Management of peripheral neuropathy

Answer 5

• Tight glycemic control.
• Alpha Lipoic acid and Benfotiamine can help to improve nerve functions - contained in some multivitamins or alone
  Drugs that reduce pain
  e.g. tricyclic antidepressants - amitryptilin, profanel
• gabapentin, pregabalin (anti-convulsants)
• serotonin noradrenaline reuptake inhibitors (duloxetine) - also used for depression

Question 6

Diabetic eye disease

Answer 6

Diabetic retinopathy
_ Cataract which develops earlier in diabetes than in the general population.
- Error of refraction due to fluctuations in blood sugar leading to osmotic changes within the lens.
- Ocular Nerve palsies: Cranial nerves VI and III are the most commonly affected. These nerve palsies usually recover spontaneously within a period of 3–6 months

Question 7

Diabetic retinopathy

Answer 7

• is the commonest cause of blindness worldwide.
• it increases with the duration of diabetes.
• Progression of retinopathy is often accelerated with poor control of diabetes and blood pressure.
• Diabetic retinopathy is asymptomatic until it becomes advanced,
  fundus examination should be routinely done at least annually.
• It can be either background - macular lesions (Non proliferative) or Proliferative - new vessels are formed.

Question 8

Diabetic maculopathy

Answer 8

If the oedema extends into the macula then the retina becomes thickened, visual function deteriorates and there is loss of central vision.

Question 9

Renal affection in Diabetes leads to increased risk of:

Answer 9

• Renal atherosclerosis
• Urinary tract infections, papillary necrosis
  -Glomerular lesions, e.g. from basement membrane thickening and glomerulosclerosis (Diabetic nephropathy).

Question 10

How common is diabetic neuropathy in type 1 & 2

Answer 10

Approximately 40% of patients with type 1 and 20% with type 2 diabetes develop nephropathy.

Some centers have reported a falling incidence rate of diabetic nephropathy in type 1 diabetes - because type 1 need insulin, which is given freely, glucometer, glucose strips and eye checks are all free. So it’s a reflection of good quality local care for diabetes.

Question 11

What does Diabetic nephropathy commonly cause?

Answer 11

Diabetic nephropathy is the most common cause of chronic kidney disease and end-stage kidney disease worldwide.

Question 12

Describe the pathogenesis of Diabetic nephropathy, beginning from the earlies functioning abnormality

Answer 12

The earliest functional abnormality in the diabetic kidney is renal hypertrophy associated with a raised glomerular filtration rate.
As the kidney becomes damaged by diabetes, the afferent arteriole becomes vasodilated to a greater extent than the efferent glomerular arteriole. This increases the intraglomerular filtration pressure.

Question 13

Pathogenesis from increased intraglomerular pressure.

Answer 13

This increased intraglomerular pressure leads to increased shearing forces locally which are thought to contribute to mesangial cell hypertrophy and increased secretion of extracellular mesangial matrix material.

• This process eventually leads to glomerular sclerosis. The initial structural lesion in the glomerulus is thickening of the basement membrane.
  Associated changes result in disruption of the protein cross-linkages which normally make the membrane an effective filter.
• Consequencely, there is a progressive leak of large molecules (particularly protein) into the urine - Massive proteinuria.

Question 14

Stages of Diabetic Nephropathy

Answer 14

• Elevated glomerular filtration rate with enlarged kidneys
• Intermittent Microalbuminuria
• Microalbuminuria (persistent(
• Proteinuria and Nephrotic syndrome.
• ESRD

Question 15

Clinical Features of Diabetic Nephropathy and what this leads us to do.

Answer 15

• Clinical features are usually absent until advanced chronic kidney disease develops.
• Therefore, we should evaluate urinary albumin excretion (microalbuminuria) annually in all subjects with diabetes.

Question 16

Management of Diabetic Nephropathies

Answer 16

• Optimal control of blood glucose and blood pressure.
• Avoid high protein intake.
• ACE inhibitors should be started and titrated to full dose in all patients with confirmed nephropathy (including those with microalbuminuria alone).
• If ACE inhibitors are not tolerated, angiotensin ll receptor antagonists should be substituted.
• Avoid taking Contrast agents containing Iodine and NSAIDs.

Question 17

What is Diabetic Foot

Answer 17

The term diabetic foot indicates any foot pathology that results directly from diabetes or its long-term complications.

In the past, the term diabetic foot was used to indicate gangrene and amputations.

Then, it was realized that Diabetic gangrene do not occur suddenly but is preceded by several stages.

Question 18

What is Diabetic Gangrene preceded by?

Answer 18

Usually preceded by advanced foot pathology e.g.
- Diabetic Foot ulcers, diabetic foot Infections
- critical limb ischemia and Charcot foot.
* Also, advanced foot pathology didn’t occur suddenly but is preceded by risk factors for the more severe foot pathology.

Question 19

What is a high risk foot

Answer 19

The foot that has developed one or more of the following risk factors:
- Peripheral Neuropathy
- Peripheral arterial disease
- Foot Deformity
- Trauma
- Callus
- Skin and Nail pathology

Question 20

For Prevention of Foot Problems, the diabetic patients should

Answer 20

• Achieve tight control of blood glucose levels
• Annual foot screening - by patient or family member or chiropractic nurse
• Report any changes immediately to healthcare professional.
• Engage in a simple daily foot care
  by washing and drying between toes, moisturizing and checking for abnormalities.

Question 21

GastroIntestinal Complications of Diabetes - Mouth and Esophagus

Answer 21

Mouth:
- periodontal disease with looseness of the teeth and gum inflammation.
Esophagus:
- gastroesophageal reflux disease (GERD) caused by autonomic neuropathy with decreased lower esophageal sphincter (LES) pressure or delayed gastric emptying.

Question 22

Clinical symptoms of Gastroparesis

Answer 22

include early satiety, nausea, vomiting, bloating, and postprandial abdominal fullness in addition to unexplained poor glycemic control despite strong therapeutic efforts.

Question 23

What supports the diagnosis of Gastroparesis and what’s the Gold standard for diagnosis

Answer 23

• The presence of residual food in the stomach after an overnight fast during upper gastrointestinal endoscopy supports the diagnosis.
• The traditional “gold standard” to establish the diagnosis of gastroparesis is scintigraphic measurement of gastric emptying.

Question 24

Treatment of Gastroparesis

Answer 24

Take small meals, avoid fatty meals, use of prokinetics eg metoclopramide and avoid use of GLP-1 based therapies in treatment of diabetes.

Question 25

Signs and symptoms of Diabetic enteropathy

Answer 25

• Present with diarrhea which is watery and painless, occurs at night, and may be associated with fecal incontinence.
• Bouts of diarrhea can be episodic with intermittent normal bowel habits or even alternating with periods of constipation.
• Steatorrhea can occur due to bacterial overgrowth.

Question 26

Management and symptomatic therapy of Diabetic enteropathy

Answer 26

• Exclude other causes of diarrhea especially infectious ones.
• Correction of water and electrolyte imbalances
• Tight control of blood glucose
• And restoration of possible nutritional deficiencies.

Symptomatic therapy
- antidiarrheal agents such as loperamide.

Question 27

Diabetic enteropathy - Liver and Gall Bladder findings

Answer 27

Liver:
Non alcoholic fatty liver including non alcoholic steato- hepatitis.

Gall bladder:
cholecystitis including emphysematous cholecystitis.

Question 28

Skin & Diabetes (Acanthosis, Necrobiosis, Dermopathy)

Answer 28

• Acanthosis negricans:
  Velvety hyperpigmented plaques in neck, back and body folds
• Necrobiosis lipoidica diabeticorum
  Painful violaceous plaque with central yellowish area surrounded by brownish border usually on shin of the leg. Central ulceration may occur.
• Diabetic dermopathy:
  Painless reddish papules usually on the shin of the tibia heal leaving atrophic scarred hyperpigmented macules.

Question 29

Skin changes and diabetes (Bullosis and Granuloma)

Answer 29

• Bullosis diabeticorum:
  Non-inflamed bullae with sterile fluid heal within 2-3 weeks without residual scarring.
• Granuloma annulare:
  Ring shaped papules with depressed centers usually on dorsum of the hand and arm.

Question 30

Hyperlipidemia and Diabetes (Xanthelasma, xanthoma, Fungal)

Answer 30

Eruptive xanthoma:
yellow papules or nodules usually on extensor surfaces.

Xanthelasma:
yellow plaques that usually appear on the medial aspects of the eyelids.

Skin infections:
Fungal:
Candidal intertrigo and paronychia, dermatophytes causing powdery white lesions especially between fingers.

Question 31

Hyperlipidemia and skin infections

Answer 31

Skin infections:
Fungal:
Candidal intertrigo and paronychia, dermatophytes causing powdery white lesions especially between fingers.

Bacterial:
Carbuncles, furuncles, abscesses, cellulitis, erysipelas.

Question 32

Skin and Anti-diabetic medications

Answer 32

• Insulin:
  Lipoatrophy and lipohypertrophy.
• Sulphonylurea:
  Drug eruptions.

Question 33

Management of DM - Lifestyle, Oral anti-diabetic agents, insulin

Answer 33

Life style modification (including medically assisted weight loss)

Weight loss (for overweight and obese patients): Reduce by 5% to 10%
Physical activity: 150 min/week of moderate-intensity exercise (eg, brisk walking) plus flexibility and strength training.

Oral anti-diabetic agents
Insulin

Question 34

Diet and Diabetes Management

Answer 34

• Eat regular meals and snacks; avoid fasting to lose weight
• Consume plant-based diet (high in fiber, low calories/glycemic index, and high in phytochemicals/antioxidants)
• Incorporate beliefs and culture into discussions
• Keep physician-patient discussions informal.

Question 35

Healthy Eating Recommendation and Diabetes - Carbohydrate and Fat

Answer 35

*Carbohydrate:
- Specify healthful carbohydrates (fresh fruits and vegetables, legumes, whole grains); target 7-10 servings per day
- Preferentially consume lower-glycemic index foods (glycemic index score <55 out of 100: multigrain bread, pumpernickel bread, whole oats, legumes, apple, lentils, chickpeas, mango, yams, brown rice)
*Fat
- Specify healthful fats; containing poly-unsaturated fatty acids (nuts, avocado, certain plant oils, fish)
- Limit saturated fats (butter, fatty red meats, tropical plant oils, fast foods) and trans fat; choose fat-free or low-fat dairy products.

Question 36

Healthy Eating Recommendation and Diabetes - Protein, Micronutrients, Vitamin Supplements

Answer 36

• Protein:
  Consume protein in foods with low saturated fats (fish, egg whites, beans); there is no need to avoid animal protein
  Avoid or limit processed meats
• Micronutrients
  Routine supplementation is not necessary; a healthful eating meal plan can generally provide sufficient micronutrients
  Chromium; vanadium; magnesium; vitamins A, C, and E; and CoQ10 are not recommended for glycemic control
• Vitamin supplements should be recommended to patients at risk of insufficiency or deficiency.

Question 37

Why Insulin therapy?

Answer 37

Insulin therapy is appropriate for patients with type (1) and type (2) diabetes.
The absolute insulin deficiency of established type (1) diabetes can only be treated effectively with multiple daily insulin injections

Question 38

Indications of insulin therapy in type (2) diabetes:

Answer 38

• Patients unable to adequately control their blood glucose levels with maximum dose combinations of oral glucose lowering medications.
• Patients undergoing surgery
• Patients with renal or hepatic disease or allergies.
• Women who are planning pregnancy or who are already pregnant.
• Critically ill hospitalized patients.

Question 39

Insulin therapy is often instituted early for type (2) diabetes patients who:

Answer 39

• Can not control their diabetes with diet and exercise
• Are highly symptomatic with marked catabolic state.
• Are newly diagnosed with very high glucose level or high HbA1C

Question 40

The first step in choosing an insulin regimen is to establish glycemic goals for your patients; this means that one half of SHBG results of all within the following ranges:

Answer 40

Preprandial 5 - 7.2 mmol/l
Bedtime 5.5 – 7.8 mmol/l
Postprandial <10 mmol/l

Question 41

Why is it important to individualize the patient’s age, health states, and history of significant hypoglycemia, life styles and personal goals - an example?

Answer 41

For example, it would be reasonable to modify pre-prandial goal to 5.5- 7.8 mmol/l or higher for a type (1) diabetes patients with severe or hypoglycemia unawareness.

Question 42

Insulin Regimen for treating diabetes

Answer 42

2 injections /day

Disadvantages: NPH (Neutral Protamine Hagedorn) intermediate acting given at supper peaks during the night
And often not last overnight until breakfast Leading to nocturnal hypoglycemia and/or
And high breakfast glucose levels.
1) Inflexibility in dealing with midday glucose levels.