Long Term Complications of Diabetes Flashcards
What vessels are affected in macrovascular complications?
Large vessels making up the CV system
What vessels are affected in microvascular complications?
Smaller vessels in the eyes (retinopathy), kidneys (nephropathy) and nerves (neuropathy)
Risk factors for these complications?
Duration of diabetes Metabolic control Smoking Hypertension Hyperlipidaemia
Genetics
What sort of complication is the main cause of death in diabetes?
Macrovascular/Cardiovascular
MI (2-5x), Stroke (3x) and peripheral arterial disease (5x) risks all rise
Explain peripheral arterial disease and the risk that is carries.
It is a diffuse and more distal disease
x40 fold increased risk of amputation
CV risk factors?
Glucose control
BP
Smoking
Lipids
Proteinuria
FHx
Gender
Primary prevention of CV risk ?
Target HbA1x to 53mmols/mol (7%)
Control BP to less than 130/80
Smoking cessation
Statin therapy
Lifestyle choices
How to support smoking cessation?
Nicotine replacement
Drug therapy - Zyban or Champix
What statin is used mainly and in what type of patients?
Simvastatin
Aged 40 or older or in younger patients with significant complications
What sort of vessels specifically does microvascular disease affect?
Arterioles and capillaries
What is the commonest cause of blindness in the working age pop.?
Diabetic retinopathy
How to prevent diabetic retinopathy?
Good glucose control
Tight BP control
Early detection and intervention
Types of retinoptahy?
Background retinopathy (mild, moderate, severe)
Proliferative retinopathy
Maculopathy
Is visual acuity a good guide for detecting retinopathy?
No - regular screening is essential
What retinal abnormalities can be spotted in diabetic complications?
Microaneurysms (dots)
Blot haemorrhages
Hard exudates
Cotton wool spots
New vessel formation
Vitreous haemorrhage
Advanced eye disease
What exactly is proliferative retinopathy?
in proliferative retinopathy ‘new blood vessels’ grow on the surface of the retina and can bleed
Treatment for proliferative retinopathy?
Laser photocoagulation -
Destruction of peripheral ischaemic retina = reduction of endothelial growth factors and regression of new vessels
Vitrectomy
What exactly is diabetic maculopathy?
Exudates and blot hemorrhages at the macula
A macular oedema deforms the macula
Macular ischaemia
Reduced visual acuity - common in type 2
Treatment of maculopathys?
Grid laser therapy
Tight control of glucose and BP
Who is cataracts common in?
Elderly
2x fold increase in diabetes
Poor diabetic control increases risk
Is treatment for cataract successful?
Yes surgery is highly successful - visual acuity after dictates the timing
List some diabetic neuropathies.`
Peripheral neuropathy - diffuse nerve disease
Mononeuritis - single nerve palsy
Autonomic neuropathy
Where does peripheral neuropathy mainly affect? What are the effects? What problems does this raise?
Feet mainly but also hands
Unpleasent chronic symptoms like paraesthiae (pins and needles), burning pain and numbness, but may also be asymptomatic
Small muscle wasting
Feet become insensitive to trauma and can become infected
Management of PERIPHERAL NEUROPATHY
Early detection
Self care education
Protection of feet
Pain relief - capsaisin cream, amitriptyline, gabapentin, duloxetine
How are ulcers prevented?
Foot screening and risk scores
Patient education on foot care
Regular podiatry for high risk patients
Trauma avoidance/fitted footwear
What is charcot foot?
Where the arch caves in due to weakening of the bones in the foot due to significant neuropathy.
The bones are weakened enough to fracture, and with continued walking, the foot eventually changes shape
What is acute sensory peripheral neuropathy?
A rapid onset of neuropathic symptoms - may be very severe with gradual recovery
Precipitating factors of acute sensory peripheral neuropathy?
Rapid tightening of control
Acute metabolic upset
What is proximal motor neuropathy - diabetic amyotrophy ?
Wasting of legs/thigh muscles
Weight loss
Can be painful
Affects elderly men with Type 2 DM
Has a good prognosis
Where does mononeuritits mainly occur?
Cr. N’s 3, 4 and 6
What nerve causes acute foot drop when affected?
Peroneal nerve
What problem is common in autonomic neuropathy? What treatments are effective?
Erectile dysfunction
Phosphodiasterase inhibitors - Viagra
Prostaglandins, mechanical devices, implants
Other problems you get with autonomic neuropathy? Treatment?
Postural hypotension Gastric stasis and recurrent Vomiting Diarrhoea Abnormal sweating Peipheral odema Urinary retention
Treatment for postural hypotension?
NSAIDs
Fludrocortisone
Treatment for gastric stasis and recurrent vomiting
Domperidone
Treatment for Diarrhoea
Loperamide
Codeine phosphate
How is autonomic neuropathy diagnosed?
Based on symptom pattern and exclusion of differentials
Abnormal ECG rhythm responses - no variation to rate on deep breathing
What is diabetic nephropathy?
Damage to the structure and function of the meshwork of capillaries which make up the glomerulus
What does this damage in nephropathy cause?
Glomeruli become leaky to larger molecules and eventual reduction in ability to filtrate blood
How do we detect early kidney disease? Screening tests and definitive test?
Microalbuminuria
Screening - 1st morning urine sample showing a normal albumin/creatinine ratio (male <2.5 mg/mmol and female less than 3.5)
Definitive - timed over night urine collection for albumin excretion rate - normal = <20μg/min and microalbuminuria = 20-200 μg/min
Management of early kidney disease?
Optimise glycaemic control
Tight BP control - aim for <125/75 in type 1
ACE inhibitors slows progession
CV risk factor management
