Long-term complications - micro and macro Flashcards
What are some risk factors for complications associated with diabetes?
- Duration of diabetes
- Metabolic control
- Smoking
- Hypertension
- Hyperlipidaemia
- Genetics
What are some risk factors for cardiovascular disease?
- Glucose control
- Blood pressure
- Smoking
- Lipids
- Proteinuria
- Family history
- Gender
What is the target HbA1c level in diabetics?
Target HbA1c - 53 mmols/mol (7%)
What is the target blood pressure in diabetics?
Control BP to ≤ 130/80
How can cardiovascular complication risk be decreased?
- Smoking cessation - support, nicotine replacement or drug therapy (Zyban, Champix)
- Statin therapy e.g. simvastatin for patients over 40 and in younger patients with significant complications
- Lifestyle choices – maintaining healthy weight, exercise
What drug therapy is used for smoking cessation?
Zyban (bupropion, also used as as antidepressant)
Champix (varenicline)
What 3 pathologies are caused by diabetic microvascular disease?
- Retinopathy
- Neuropathy
- Nephropathy
What is the most common cause of blindness in the working age population?
Diabetic retinopathy
What are some retinal abnormalities seen in diabetes?
- Microaneurysms (small red dots)
- White spots from lipid aggregates
- Blot haemorrhages
- Hard exudates
- Cotton wool spots
- New vessel formation
- Vitreous haemorrhage
How can proliferative retinopathy be treated?
Laser photocoagulation
Vitrectomy
What affects vision in maculopathy?
- Exudates and blot haemorrhages at macula
- Macular ischaemia
- Macular oedema deforms the macula, affecting visual acuity
What is used to treat diabetic maculopathy?
Grid laser therapy
BP and blood glucose control
How much does risk of cataracts increase in diabetic patients?
2X increase
What are the 3 subtypes of diabetic neuropathy?
o Peripheral neuropathy (diffuse nerve disease) – most common
o Mononeuritis (single nerve palsy) – less common
o Autonomic neuropathy
What are some symptoms of peripheral neuropathy?
Gloove and stocking distribution of:
- feet insensitive to trauma: risk of feet ulcers
- paraesthesia (abnormal sensation)
- burning pain
- numbness
- small muscle wasting
- can be asymptomatic!!
How can peripheral neuropathy be managed?
• Early detection – screening for diabetic foot disease
• Self care education
• Protection of feet
• Pain relief
– Capsaisin cream (local treatment)
– Amitriptyline, gabapentin, duloxetine (systemic treatment, pain)
What local treatment can be given for pain caused by peripheral neuropathy?
Capsaisin cream
What systemic treatment can be given for pain caused by peripheral neuropathy?
Amitriptyline
Gabapentin
Duloxetine
What techniques are used for foot screening and risk scoring for ulcer prevention?
Microfilament - record sensation
Peripheral pulses
How can foot ulcers be prevented?
Foot screening Education on foot care Regular podiatry for those at high risk Avoidance of trauma Avoid fitted footwear
What is Charcot foot/Charcot neuro-arthropathy, and why is prevention important?
- Progressive degeneration of a weight bearing joint, a process marked by bone destruction, bone resorption, and eventual deformity due to loss of sensation and an initial small trauma. Onset is usually insidious (gradual)
- If this pathological process continues unchecked, it can result in joint deformity, ulceration and/or superinfection, loss of function, and in the worst-case scenario, amputation or death. Early identification of joint changes is the best way to limit morbidity.
What factors indicate high risk of complications of the feet?
- Impaired circulation
- Impaired sensation
- Impaired vision
- Foot shape changes
- Abnormal pressures
What is acute sensorial peripheral neuropathy, and what causes it?
Rapid onset of neuropathic symptoms
Precipitating factors
– Rapid tightening of control e.g. trying to get pregnant
– Acute metabolic upset
What can happen after a rapid tightening of glycemic control or an acute metabolic upset?
Acute sensorial peripheral neuropathy
What is proximal motor neuropathy/diabetic amyotrophy?
A nerve disorder that results as a complication of diabetes mellitus. It can affect the thighs, hips, buttocks or lower legs. Proximal diabetic neuropathy is a peripheral nerve disease (diabetic neuropathy) characterized by muscle wasting or weakness, pain, or changes in sensation/numbness of the leg. Diabetic neuropathy is an uncommon complication of diabetes. It is a type of lumbosacral plexopathy, or adverse condition affecting the lumbosacral plexus.
Who is primarily affected with proximal motor neuropathy/diabetic amyotrophy?
Elderly men with type 2 DM
What are some symptoms and signs of proximal motor neuropathy/diabetic amyotrophy?
Leg muscle wasting Weakness in legs Pain Loss/changes in sensation/numbness Weight loss (due to muscle atrophy)
What does amyotrophy mean?
Muscle atrophy
What is mononeuritis?
Inflammation of a single nerve
What can be seen in patients with mononeuritis of the oculomotor nerve (CN III)?
Affected eye has downward and outer gaze
What can be seen in patients with mononeuritis of the trochlear nerve (CN IV)?
Affected eye has upward and slightly inwards gaze
What can be seen in patients with mononeuritis of the abducens nerve (CN VI)?
Affected eye cannot look to lateral side (cannot abduct)
What can be seen in patients with mononeuritis of the peroneal nerve?
Acute foot drop (inability to lift the front of your foot off the ground, tested by dangling legs over bed and ask to bring ball of feet up)
What are some signs of autonomic neuropathy?
Erectile dysfunction Postural hypotension Gastric stasis/recurrent vomiting Diarrhoea Abnormal sweating Peripheral oedema Urinary retention
How can erectile dysfunction be treated?
– Phosphodiasterase inhibitors e.g. Viagra, Cialis
– Prostaglandins, mechanical devices, implants
How is postural hypotension treated?
– NSAIDs
– Fludrocortisone
What is given to those with gastric stasis and recurrent vomiting?
Domperidone (dopamine D2 receptor antagonist, antiemetic)
What 2 drugs are given for diarrhoea?
Loperamide
Codeine phosphate
What % of patients will develop nephropathy after 30 years of diabetes?
25%
How do we screen for early kidney disease?
Microalbuminuria - test using first pee in the morning
Is any stage of kidney disease reversible?
Microalbuminuria, before it progresses to proteinuria
What is the definitive test for microalbuminuria?
Definitive test- timed over night urine collection for albumin excretion rate (AER)
o Normal < 20μg/min
o Microalbuminuria 20-200μg/min
How can we manage early kidney disease to try and prevent its progression?
- Optimise glycaemic control
- Tight BP control - aim for <125/75 in type 1 diabetes
- ACE inhibitor therapy slows progression
- Cardiovascular risk factor management
