Diabetic complications

Question 1

What is diabetic amyotrophy?

Answer 1

it’s a well controlled DM or new onset diabetics who may not have other end organ damage but see ischemic injury from non systemic microvasculitis

Question 2

What is the presentation of diabetic amyotrophy?

Answer 2

acute symmetric focal onset of pain followed by weakness in proximal leg and see autonomic failure and weight loss of >10%

Question 3

Prognosis of diabetic amyotrophy?

Answer 3

condition progresses to involve contralateral limb and distal legs. Majority of pts will need ambulatory assistance device at some point progress is followed by partial to full recovery in most pts some may have lingering foot drop or neuropathic pain for years

Question 4

Who gets diabetic amyotrophy?

Answer 4

>50 yrs DM2 or reasonably controlled A1c about 7.5%. They have acute or asymmetric focal proximal lower extremity pain associated with weakness

Question 5

what must we keep on differential for someone with DM amyotrophy?

Answer 5

cauda equina syndrome, guillain barre syndrome, myositis, myopathy, structural plexus lesion, infections, autoimmune or inflammatory conditions and an EMG or NCS can confirm the diagnosis.

Question 6

best way to prevent diabetic foot ulcers?

Answer 6

wearing well fitting diabetic footwear, good foot hygiene, and avoiding injury.

Question 7

treatment options for diabetic peripheral neuropathy?

Answer 7

antidepressants (amitriptyline, duloxetine)

anticonvulsants (pregabalin or valproic acid)

tropical capsaicin cream alpha lipoic acid transcutaneous

electrical nerve stimulation TENS

lidocaine patch

Question 8

symmetrical sensory neuropathy that affects both distal lower extremities with loss of vibraotry sensation and proprioception and pain in extremities and decreased or absent ankle reflexes

Answer 8

diabetic peripheral neuropathy

Question 9

what helps with diabetic peripheral neuropathy

Answer 9

tighter glycemic control may help prevent it

Question 10

side effects of pregabalin

Answer 10

dizziness, somnolence, and confusion seen at higher doses of drug

Question 11

what is diabetic nephropathy?

Answer 11

albuminuria >300 mg/day or >300 mg/g creatinine on random urine sample.

Question 12

how to treat diabetic nephropathy?

Answer 12

strict glycemic control and good blood pressure control (goal BP <140/90) and need to RAS inhibition via ACEi or ARB

Question 13

what does ACE i commonly do after starting to GFR?

Answer 13

can reduce renal capillary pressure (due to greater relaxation of the efferent arteriole) see possible rise in serum K from reduced levels of aldosterone. Can cause an initial decrease in GFR

Question 14

what is our acceptable change in GFR and Cr change after starting a ACEi with someone who has diabetic nephropathy?

Answer 14

rise of serum Cr of 30-35% from baseline is acceptable and should not cause discontinuation therapy.

Question 15

what is our acceptable change in K after starting an ACEi or ARB?

Answer 15

Moderate elevations of serum K (5.1-5.5) above normal should lead to dose reductions. Severe elevations that cannot be managed by diuretics mean ACEi should be discontinued.

Question 16

when to recheck BMP after starting a ACEi or arb

Answer 16

check in 2 weeks and if slight elevation but within our 30-35% change and no hyperkalemia recheck in another 2-3 weeks.

Question 17

in treatment of DKA what is core therapies of treatment

Answer 17

focus on fluid and electrolyte management with IV insulin and correction of precipitating causes

Question 18

What are the deficits in pts who present in DKA : IVF K

Answer 18

3-6 L fluid down so tx: NS IVF for 1-2 to expand intravascular volume and improve tissue perfusion. After fluid repletion depends on pt hemodynamic status and sodium level NS is recommended for low Na levels and 1/2 NS given to pts with normal or high Na at presentation. Serum K is high or normal at presentation but they have a total body deficit. So 20-30 mEq of K is added to each liter of IVF to maintain serum K of 4-5 Only hold Na when K >5.2

Question 19

After pt who presents with DKA has been on IVFs and insulin and their glucose is <200-250 what to do?

Answer 19

give D5 1/2 NS because you want to give dextrose to keep them from getting hypoglycemic as you continue the insulin gtt to help see the resolution of ketosis.

Question 20

Management of DKA

Answer 20

Question 21

Resolution of DKA is defined by:

Answer 21

Glucose <200

no anion gap

bicarb is >15

and patient is able to reliably eat and corrected the precipitating factor

Question 22

intense diabetic control (A1c) provides what benefit?

What does it not do?

Answer 22

A1c decrases risk for microvascular complications (retinopathy, nephropathy) but doesn’t reduce risk of ASCVD esp in those with longstanding DM2.

Some meds can reduce cardiovascular risk: emphagliflozin, canagliflozin, liraglutide, and semaglutide).

Question 23

Diabetic food ulcers >2 cm are likely to

Answer 23

extend to bone and cause osteomyelitis

Question 24

acute osteomyelitis presentation

Answer 24

see tenderness, warmth, erythema and swelling and systemic symptoms esp if >2 weeks

see elevated ESR or CRP.

Plain radiographs don’t show acute osteomyeltiis (cortical erions or periosteal elevation or sclerosis for 10-14 days)

Thus MRI is preferred for osteomyelitis but if there’s fracture of Charcot joint it may pick that up too. It can also be negative in pts who have PAD due to lack of blood flow.

Question 25

Charcot joint is

Answer 25

acute diabetic neuropathy arthropathy- see progressive bony, soft tissue destruction leading to joint dislocation and incpacitating defmorities and instability

Seen in DM2, but can occur with syphilis and chronic alcoholism.

Need to rule out septic arthritis because presents with erythema, warmth and edema of foot and ankle. Needs a joint aspiration and synovial fluid aspiration

Question 26

Acute treatment of charcot joint

Answer 26

avoid weight bearing until clinical findings resolve and XR findings improve

cast changed after 1-2 weeks to allow for resovling edema.

See after 8 weeks of acute treatment and can progress to partial weight bearing and then full weight bearing by 4-5 th month.

some ppl recommend bisphosphonates

Well fitting shoes and podiatry referral are needed to prevent chronic defmorities, skin ulceration or infections.

Avoid surgery due to 27% failure rate.

Question 27

Preferred SSRI to help treat diabetic neuropathy (esp if has concurrent depression)

Answer 27

duloxetine

TCAs can also help but has other side effects

Question 28

DM1 diabetic with delayed gastric emptying and gastroparesis can cause

Answer 28

hypoglycemia after meals followed by hyperglycemia

• due to delayed gastric emptying and see hypoglycemia as food is not yet absorbed and see hyperglycemia afterwards as carbohydrates are digested