Diabetes mellitus: complications

Question 1

What are 3 microvascular complications of diabetes mellitus

Answer 1

• peripheral neuropathy
• retinopathy
• nephropathy

Question 2

What is the typical presentation of diabetic peripheral neuropathy?

Answer 2

• typically causes sensory loss, often in a “glove and stocking” distribution, with the lower legs affected first due to the length of the sensory neurons
• it is commonly painful

Question 3

How is diabetic neuropathy managed?

Answer 3

• first-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin
• tramadol may be used as ‘rescue therapy’ for exacerbations of neuropathic pain
• topical capsaicin may be used for localised neuropathic pain
• resistant diabetic neuropathy: pain management clinics

Question 4

What is gastroparesis

Answer 4

condition caused by autonomic neuropathy that leads to delayed gastric emptying

Question 5

Symptoms of gastroparesis

Answer 5

erratic blood glucose control, bloating, and vomiting

Question 6

How is gastroparesis managed

Answer 6

prokinetic agents like metoclopramide, domperidone, or erythromycin

Question 7

How often should patients with diabetes be screened for diabetic nephropathy?

Answer 7

All patients should be screened annually for diabetic nephropathy using a urinary albumin:creatinine ratio (ACR).

Question 8

What is the ideal specimen for testing urinary albumin:creatinine ratio (ACR) in screening for diabetic nephropathy?

Answer 8

An early morning urine specimen

Question 9

What albumin:creatinine ratio value is indicative of microalbuminuria?

Answer 9

greater than 2.5

Question 10

What is the management approach for diabetic nephropathy?

Answer 10

• Dietary protein restriction
• Tight glycaemic control
• Blood pressure control: Aim for a target of less than 130/80 mmHg
• ACE inhibitor or angiotensin-II receptor antagonist: Should be started if urinary ACR is 3 mg/mmol or more.

Question 11

What is the most common cause of blindness in adults aged 35-65 years old?

Answer 11

Diabetic retinopathy

Question 12

Explain the pathophysiology of diabetic retinopathy?

Answer 12

• Hyperglycaemia causes increased retinal blood flow and abnormal metabolism in retinal vessel walls, leading to endothelial dysfunction, increased vascular permeability, and pericyte dysfunction
• This results in microaneurysms, exudates, and neovascularization due to retinal ischemia.

Question 13

What are the classifications of diabetic retinopathy?

Answer 13

• Non-proliferative diabetic retinopathy (NPDR)
• Proliferative diabetic retinopathy (PDR)
• Maculopathy

Question 14

What are the characteristics of mild Non-Proliferative Diabetic Retinopathy?

Answer 14

one or more microaneurysms

Question 15

What are the characteristics of moderate Non-Proliferative Diabetic Retinopathy?

Answer 15

• Microaneurysms
• Blot haemorrhages
• Hard exudates
• Cotton wool spots (soft exudates)
• Venous beading/looping
• Intraretinal microvascular abnormalities (IRMA)

Question 16

What are the characteristics of severe Non-Proliferative Diabetic Retinopathy?

Answer 16

• blot haemorrhages and microaneurysms in 4 quadrants
• venous beading in at least 2 quadrants
• Intraretinal microvascular abnormalities in at least 1 quadrant

Question 17

What are key features of Proliferative Diabetic Retinopathy?

Answer 17

• Retinal neovascularisation (can lead to vitreous haemorrhage)
• Fibrous tissue formation anterior to the retinal disc
• mc in Type 1 diabetes, with 50% blindness within 5 years.

Question 18

What are the key features of Maculopathy in diabetic retinopathy?

Answer 18

• Hard exudates and other background changes in the macula
• It is based on location rather than severity
• Changes in visual acuity can occur
• mc in Type 2 diabetes.

Question 19

What is the management approach for all diabetic retinopathy patients?

Answer 19

• Optimising glycaemic control, blood pressure, and hyperlipidaemia
• Regular ophthalmology reviews.

Question 20

What treatment should be given for maculopathy with changes in visual acuity?

Answer 20

Intravitreal vascular endothelial growth factor

Question 21

How is severe Non-Proliferative Diabetic Retinopathy (NPDR) managed?

Answer 21

may require regular observation and, if necessary, panretinal laser photocoagulation.

Question 22

What is the treatment for Proliferative Diabetic Retinopathy?

Answer 22

• Panretinal laser photocoagulation
• Intravitreal VEGF inhibitors (e.g., ranibizumab), often used in combination with laser therapy
• Vitreoretinal surgery if there is severe vitreous haemorrhage.

Question 23

What are some potential complications following panretinal laser photocoagulation?

Answer 23

• Reduced visual fields
• Decreased night vision
• Generalised decrease in visual acuity
• Macular oedema.

Question 24

What are the two main factors that contribute to diabetic foot disease?

Answer 24

• Neuropathy: resulting in loss of protective sensation.
• Peripheral arterial disease: leading to macro and microvascular ischaemia.

Question 25

What are some common presentations of diabetic foot disease?

Answer 25

* Neuropathy: Loss of sensation. * Ischaemia: Absent foot pulses, reduced ankle-brachial pressure index (ABPI), intermittent claudication. * Complications: Calluses, ulceration, Charcot's arthropathy, cellulitis, osteomyelitis, gangrene

Question 26

How often should patients with diabetes be screened for diabetic foot disease?

Answer 26

at least annually

Question 27

How is screening for ischaemia performed in diabetic foot disease?

Answer 27

Screening for ischaemia is done by palpating for both the dorsalis pedis pulse and posterior tibial artery pulse, and measuring the ankle-brachial pressure index

Question 28

How is screening for neuropathy performed in diabetic foot disease?

Answer 28

Screening for neuropathy is done using a 10g monofilament on various parts of the sole of the foot to assess protective sensation.

Question 29

What is the NICE recommendation for risk stratification in diabetic foot disease?

Answer 29

* Low risk: No risk factors except callus alone. * Moderate risk: Deformity, neuropathy, or non-critical limb ischaemia. * High risk: Previous ulceration, previous amputation, on renal replacement therapy, or a combination of neuropathy, callus, deformity, and/or non-critical limb ischaemia.