Diabetic complications

Question 1

What are the short-term complications

Answer 1

1. Hypoglycaemia

2. Hyperglycaemia

Question 2

What are the common symptoms of hypoglycaemia?

Answer 2

Adrenergic symptoms:

• Tremor
• Sweating
• Irritability
• Dizziness
• Pallor

Question 3

What are the serious symptoms of hypoglycaemia?

Answer 3

Neuroglycopenic:

• Reduced consciousness
• Coma
• Death
• Paraesthesia
• Blurred vision
• Seizures

Question 4

What are the causes of hypoglycaemia?

Answer 4

EXPLAIN
•	E - exogenous drugs
      Insulin, sulphonylurea, Alcohol, ACE-I, Beta-blockers, pentamidine, quinine sulfate, aminoglutethimide, insulin-like GF
•	P - pituitary insufficiency
•	L - liver failure
•	A - addison’s disease
•	I - islet cell tumours
•	N - non-pancreatic neoplasms

Question 5

How would you treat hypoglycaemia?

Answer 5

Able to cooperate
- 30ml Lucozade or equivalent

Unable to cooperate but conscious
- Glucose gel (glucogel) - buccal

Comatose, fitting

• Glucagon – SC, IM, IV
• IV glucose 50%; try to avoid

Question 6

What are the long-term effects of poorly controlled diabetes?

Answer 6

• Chronic exposure to hyperglycaemia causes damage to endothelial cells.
• This causes leaky malfunctioning vessels that are unable to regenerate
• Hyperglycaemia suppresses immune system and provides an ideal environment for bacteria

Question 7

What are the macrovascular consequences of diabetes?

Answer 7

• CAD
• Peripheral ischemia
• Stroke
• HTN

Question 8

What are the microvascular consequences of diabetes?

Answer 8

• Peripheral neuropathy
• Retinopathy
• Nephropathy

Question 9

What are the infective consequences of diabetes?

Answer 9

• UTIs
• Pneumonia
• Skin and soft tissue infections
• Fungal infections

Question 10

What is retinopathy associated with?

Answer 10

• Prolonged hyperglycaemia

- Other conditions linked to DM such at HTN

Question 11

How does retinopathy cause loss of vision?

Answer 11

• Capillary leakage

- Capillary occlusion

Question 12

What is a cataract?

Answer 12

Degenerative opacity of the lens

Question 13

What is rubeosis iridis?

Answer 13

• New vessels in the iris

- Can cause glaucoma

Question 14

What are the primary preventions for nephropathy?

Answer 14

Control BP and blood glucose

Question 15

What does diabetes most commonly cause regarding the kidneys?

Answer 15

End stage renal disease

Question 16

What is the pathophysiology of nephropathy?

Answer 16

Changes to haemodynamics of glomerulus which leads to increased glomerular capillary pressure

Question 17

What are the primary preventions for nephropathy?

Answer 17

Control BP and blood glucose

Question 18

What T2DM drugs should be avoided in nephropathy?

Answer 18

eGFR <30
o Metformin
o 1st gen sulfonylureas (not glipizide and glicazide)
o GLP-1 agonists

eGFR <60
o SGLT2 inhibitors

Question 19

Why does diabetic foot disease occur?

Answer 19

o Neuropathy: loss of protective sensation, Charcot’s arthropathy, dry skin
o Peripheral arterial disease: macro- and micro-vascular ischaemia

Question 20

How does diabetic foot disease present?

Answer 20

o Neuropathy: loss of sensation
o Ischemia: loss of foot pulses, reduced ankle-brachial pressure index, intermittent claudication
o Complications: calluses, ulceration, Charcot’s arthopathy, cellulitis, osteomyelitis, gangrene

Question 21

What is the primary prevention for diabetic foot disease?

Answer 21

o	Control blood glucose
o	Lifestyle (smoking, exercise and alcohol)

Question 22

What is Cherioarthropathy?

Answer 22

Limited joint mobility in the hands

Question 23

How would you treat HTN in DM?

Answer 23

1st line: Ace-i

2nd line: ARB

Question 24

What is the primary prevention for CV disease?

Answer 24

o Lifestyle (diet, weight, exercise, smoking, alcohol
o Metabolic control (glucose, BP, lipids)
o ACE-I, A2RB, aspirin, statins/fibrates

Question 25

What can DM cause in pregnancy?

Answer 25

- Accelerated growth - IUGR - Congenital abnormalities

Question 26

What is the primary prevention in a woman who is pregnant and has diabetes?

Answer 26

o Pre-pregnancy blood glucose control / folate (5mg/day high dose) o Intensive pregnancy blood glucose control and monitoring (low HbA1c) o Within 1 week of confirmation of pregnancy -> seen by joint diabetes and antenatal care team

Question 27

What are classed as diabetic emergencies?

Answer 27

* Diabetic ketoacidosis (DKA) * Hyperglycaemic hyperosmolar state (HHS) * Severe hypoglycaemia

Question 28

What is DKA?

Answer 28

Hyperglycaemia + Hyperketonaemia + Acidosis

Question 29

What is the normal physiology of ketogenesis?

Answer 29

1. Ketogenesis occurs when there is insufficient glucose supply and glycogen stores are exhausted 2. Liver takes fatty acids and converts them into ketones -> water-soluble fatty acids that can be used as fuel 3. Normally ketones are buffered by HCO3 released by the kidneys to prevent metabolic acidosis

Question 30

What is the pathophysiology of DKA?

Answer 30

1. Severe insulin deficiency + increased catabolic hormones (glucagon, catecholamines, cortisol, HG) 2. This gives rise to excess glucose, through glycogenolysis and gluconeogenesis, and ketones through lipolysis 3. Hyperglycaemia and hyperketonaemia are enhanced as the tissues that normally absorb glucose and ketones become saturated, so they stop up taking them 4. Over time, the high ketone levels use up the HCO3 released by the kidneys, causing metabolic acidosis

Question 31

What are the clinical features of DKA?

Answer 31

- Hyperventilation - Nausea and vomiting - Dehydration - Hypotension and warm peripheries - Decreased conscious level - Acetone smelling breath - Tachycardia

Question 32

Why is dehydration and polyuria a clinical feature in DKA?

Answer 32

o Hyperglycaemia overwhelms the kidneys and glucose starts to be filtered into urine. o The glucose draws water into the urine through osmotic diuresis causing polyuria and dehydration

Question 33

Why is hyperventilation a clinical feature in DKA?

Answer 33

Metabolic acidosis

Question 34

What are the metabolic characteristics of DKA?

Answer 34

1. Water deficiency ~ 5l 2. Na+ deficiency ~ 500mmol 3. K+ deficiency ~ 300-1000mmol 4. Hyperglycaemia > 25mmol/l 5. Metabolic acidosis – low pH, low HCO3

Question 35

Why does potassium decrease in DKA?

Answer 35

- Sodium-potassium ATPase is dependent on insulin, so potassium leaks out of cells when you have insufficient insulin - Loss of K+ through urine

Question 36

What are the typical test results in DKA?

Answer 36

• Hyperglycaemia, glycosuria • Ketonaemia, ketonuria • Na+ = 125-160mmol/l Can be low or high Low - glucose in blood is diluting Na+ High - osmotic diuresis means more water than Na+ is being lost from kidneys • K+ = 3-7 mmol/l • Urea, creatinine raised (muscle breakdown as well as hypotensive AKI) • Lipids raised • Leucocytosis (neutrophils)

Question 37

How do you diagnose DKA?

Answer 37

``` - Hyperglycaemia o Blood glucose ≥11mmol/L - Ketosis o Blood ketones ≥3mmol/L - Acidosis o pH <7.35 ```

Question 38

What tests would you order for DKA?

Answer 38

- venous blood: U+Es, glucose, ABG or VBG - Urine and blood analysis: ketones - ECG - Infection screen

Question 39

How do you treat DKA?

Answer 39

FIG-PICK ``` - F - Fluids Normal saline Be careful due to cerebral oedema - G - Glucose Add dextrose infusion if <14mmol/L - P - Potassium Give if serum K+ <5.5mmol/L - I - Infection - C - Chart - K - Ketones Monitor ```

Question 40

What is Hyperglycaemic Hyperosmolar State?

Answer 40

Same as DKA, but without the metabolic acidosis: 1. Water deficiency ~ 5l 2. Na+ deficiency ~ 500mmol 3. K+ deficiency ~ 300-1000mmol 4. Hyperglycaemia > 25mmol/l