Diabetic Complications

Question 1

How does diabetic neuropathy present?

Answer 1

Symmetric sensory polyneuropathy (glove and stocking numbness, tingling and pain)

Decreased sensation
Absent ankle jerks 
Charcot joint 
Rocker bottom sole 
Swelling, instability, deformity 

If foot pulses cannot be felt, do Doppler pressure measurements

Question 2

How does foot ulceration present and what is the management?

Answer 2

Painless, punched out ulcer in an area of thick callus. Causes cellulitis, abscess and osteomyelitis

Assess degree of neuropathy, ischaemia (clinically, doppler, angiogram), bony deformity (Charcot joint), infection

Question 3

What is the management of a Charcot joint?

Answer 3

Bed rest/crutches/total contact cast until oedema reduces and bony repair is complete (>8 weeks)

Bisphosphonates may help

Metatarsal head surgery may be needed

If there is cellulitis, give benpen, flucloxacillin, and metronidazole

Question 4

What is the management of diabetic neuropathy?

Answer 4

1) Paracetamol
2) TCA (amitriptyline)
3) Duloxetine, gabapentin or pregabalin
4) Opiates

Question 5

If diabetic neuropathy presents suddenly or severely, what may help?

Answer 5

Immunosuppression may help (corticosteroids, IV immunoglobulin, ciclosporin)

Question 6

What types of autonomic neuropathy can diabetics get?

Answer 6

Postural BP drop
Urine retention
Gastroparesis
Diarrhoea
Erectile dysfunction

Question 7

What is the treatment and symptoms of gastroparesis in diabetics?

Answer 7

Early satiety, post prandial bloating, nausea/vomiting

Diagnose gastroparesis using gastric scintigraphy with a technetium labelled meal

Anti emetics, erythromycin or gastric pacing

Question 8

How would you treat postural hypotension as a complication of diabetes?

Answer 8

Fludracortisone may help or midodrine

Question 9

What is the chief cause of death in diabetes?

Answer 9

Vascular disease (MI)

Question 10

How do you prevent vascular disease in diabetics?

Answer 10

Atorvastatin 20mg for all, and aspirin 75mg reduces vascular events

Question 11

How would you manage/prevent diabetic nephropathy?

Answer 11

If microalbuminuria is found (urine dipstick is negative for protein but UA:CR >3), start an ACEi even if BP is normal
Spironolactone may also be used instead

Question 12

What occurs in background retinopathy?

Answer 12

Microaneurysms, haemorrhages and hard exudates

Question 13

What can be seen in pre-proliferative retinopathy?

Answer 13

Cotton wool spots
Haemorrhages
Venous bleeding
These are signs of retinal ischaemia

Refer to a specialist

Question 14

What can be seen in proliferative retinopathy?

Answer 14

Formation of new vessels

Refer urgently

Question 15

What is the pathogenesis of maculopathy in diabetics?

Answer 15

Hyperglycaemia causes high retinal blood flow
Capillary pericyte damage occurs
Capillary occlusion occurs (cotton wool spots) leading to local hypoxia and ischaemia
New vessels form

Question 16

What is the management of hypoglycaemia?

Answer 16

If mild, give 15-20g glucose tablets, sugary drinks
Severe: IM glucagon

A blood test should be taken 15-20mins after to look for recovery

Question 17

What are the non diabetic causes of hypoglycaemia?

Answer 17

“EXPLAIN”

Exogenous drugs 
Pituitary insuffiency
Liver failure 
Addisons disease
Islet cell tumours 
Non pancreatic neoplasms

Question 18

When would you investigate hypoglycaemia?

Answer 18

Whipple’s triad; if there are symptoms or signs of hypoglycaemia, decreased plasma glucose, and resolution of symptoms post glucose rise

Take a drug history, exclude liver failure

72h fasting may be needed, take bloods, glucose, insulin, C peptide, and plasma ketones if symptomatic

Question 19

What are the causes of hypoglycaemic hyperinsulinaemia?

Answer 19

Insulinoma, sulfonylureas, insulin injection

Question 20

What are the causes of hypoglycaemia if insulin is low and there are no excess ketones?

Answer 20

Non pancreatic neoplasm

Anti insulin receptor antibodies

Question 21

What are the causes of hypoglycaemia if there is low insulin and high ketones?

Answer 21

Alcohol
Pituitary insufficiency
Addisons disease