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Year 2 Clinical > Microvascular Complications of Diabetes > Flashcards

Microvascular Complications of Diabetes Flashcards

1
Q

Macrovascular complications of diabetes?

A
  • Ischaemic heart disease

* Cerebrovascular disease, i.e: stroke

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2
Q

Microvascular complications of diabetes?

A

Neuropathy
Nephropathy
Retinopathy

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3
Q

Other chronic complications of diabetes?

A
  • Cognitive dysfunction/diabetes
  • Erectile dysfunction
  • Psychiatric
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4
Q

Types of neuropathy and symptoms of each?

A

Peripheral (sensory) neuropathy, e.g: pain/loss of sensation in hands and feet

Autonomic neuropathy, e.g: changes in bowel, bladder function, sexual response, sweating, heart rate and BP

Proximal neuropathy, e.g: pain in the thighs, hip or buttocks leading to weakness in the legs (AKA Diabetic Amyotrophy)

Focal neuropathy, e.g: sudden weakness in one nerve/group of nerves causing muscle weakness or pain, e.g: carpal tunnel, ulnar mono neuropathy, foot drop, Bell’s palsy, cranial nerve palsy

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5
Q

Risk factors for neuropathy?

A
  • Increased length of diabetes
  • Poor glycaemic control
  • T1DM (higher risk than T2DM)
  • High cholesterol/lipids
  • Smoking
  • Alcohol
  • Inherited traits, i.e: genes
  • Mechanical injury
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6
Q

Signs of peripheral neuropathy?

A
  • Numbness/insensitivity
  • Tingling/burning that is worse at night
  • Sharp pain or cramps
  • Sensitivity to touch
  • Loss of balance and coordination
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7
Q

Complications of peripheral neuropathy?

A
  • Charcot foot (progressive degeneration and destruction of a weight-bearing joint, e.g: tarsal/metatarsals, and could lead to amputation; signs include a hot, red foot that that mimics cellulitis but does not respond to antibiotics
  • Painless trauma
  • Foot ulcers (painless)
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8
Q

Treatment options for painful neuropathy?

A

Combinations are not recommended and the doses are titrated up as required:
• Amitriptyline
• Duloxetine
• Gabapentin
• Pregablin
Choose based on patient preference and co-morbidites, e.g: depression

If there is localised pain and patient wishes to avoid/cannot tolerate oral drugs:
• Topical Capsaicin cream

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9
Q

Signs of peripheral neuropathy in relation to the part of the nervous system affected?

A

Autonomic (supplies sweat glands) - dry feet that crack

Sensory - loss of sensation in a stocking distribution, i.e: spreads upwards, rather than in a dermatomal distribution

Motor - loss of lateral arch and development of clawed foot (dorsiflexors take over) changes pressure so painless foot ulcers develop

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10
Q

Signs of focal neuropathy?

A 
Occur suddenly and affect specific nerve, often the head, torso or leg:
• Inability to focus eye
• Double vision
• Aching behind the eye
• Bell's palsy
• Pain in thigh/chest/lower back/pelvis
• Pain on outside of the foot
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11
Q

What is entrapment neuropathy?

A

Weakness in one nerve/group of nerves causing muscle weakness or pain, e.g: carpal tunnel syndrome

These are not specific to diabetes but are more common

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12
Q

Other names for proximal neuropathy?

A
  • Lumbosacral plexus neuropathy
  • Femoral neuropathy
  • Diabetic amyotrophy
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13
Q

Development of proximal neuropathy?

A

Starts with pain in the thighs, hips, buttocks or legs, usually on ONE SIDE of the body

Atrophy of the proximal muscle may be seen

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14
Q

Occurrence of proximal neuropathy?

A

Tends to be in elderly people, often with marked assoc. weight loss

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15
Q

Effects of autonomic neuropathy?

A

Affects nerves that regulate HR and BP as well as control of internal organs, e.g: those inv. in gastric motility, respiratory function, urination, sexual function and vision

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16
Q

Effects of autonomic neuropathy on the digestive system?

A

Gastric slowing/frequency:
• Constipation
• Diarrhoea
• Or both sometimes

Gastroparesis (slow stomach emptying due to affected vagus nerve to the stomach)

Oesophagus nerve damage:
• Dysphagia can cause weight loss

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17
Q

Symptoms of gastroparesis?

A
  • Persistent nausea and vomiting
  • Bloating
  • Loss of appetite
  • Bad taste in mouth
  • BG levels can fluctuate, due to abnormal food digestion
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18
Q

Treatment of gastroparesis?

A
  • Improve glycaemic control
  • Diet alterations - smaller- more frequent food portions that are low in fat and low in fibre; if severe, may require liquid meals
  • Pro-motility drugs
  • Anti-emetic drugs
  • Treatment for abdominal pain
  • Botulimin toxin (to loosen the LOS)
  • Gastric pacemaker
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19
Q

Why is fat intake reduced in gastroparesis?

A

Fat slows digestion

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20
Q

Examples of pro-motility drugs?

A

Metoclopramide, domperidone and erythromycin

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21
Q

Examples of anti-emetic drugs?

A

Prochloperazine and serotonin antagonists, such as ondansetron

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22
Q

Drugs that can treat abdominal pain in gastroparesis?

A

NSAIDs, low-dose tricyclic antidepressants, gabapentin, tramadol and fentanyl

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23
Q

Effect of autonomic neuropathy on sweat glands?

A

Hyperhidrosis (excessive sweat) - profuse sweating at night or while eating, i.e: gustatory sweating

Anhidrosis (no sweat)

Body cannot regulate temperature

24
Q

Treatment of sweat gland problems in autonomic neuropathy?

A
  • Topical glycopyrollate
  • Clonidine
  • Botulinim toxin
25
Q

Cardiovascular effects of autonomic neuropathy?

A

Nerve damage interferes with the ability to control BP and HR, i.e:
• Postural hypotension
• HR may be high, instead of rising and falling in response to normal body functions and physical activity

26
Q

Effects of autonomic neuropathy on the eyes?

A

Pupils are less responsive to light changes, so patient may not see well when a light is turned on or may have trouble driving at night

27
Q

Tools to diagnosis neuropathy?

A

Nerve conduction studies or EMG (determine type and extent of nerve damage and how well muscles respond)

Heart rate variability (show how heart responds to deep breathing and changes in BP and posture)

Ultrasound of the bladder and other parts of the urinary tract (check if bladder empties completely after urination)

Gastric emptying studies (for gastroparesis)

28
Q

What is diabetic nephropathy?

A

Progressive kidney disease cause by damage to the capillaries of the glomeruli

Characterised by:
• Nephrotic syndrome
• Diffuse scarring of the glomeruli (AKA Kimmelsteil-Wilson Syndrome or nodular glomerulosclerosis)
• Microvascular changes in the capillaries

29
Q

Consequences of diabetic nephropathy?

A
  • Hypertension
  • Decline in renal function
  • Accelerated vascular disease means that most people with this die from CV events
30
Q

How to screen for nephropathy?

A

Urinalysis only detects macroalbuminaemia

Urinary Albumin : Creatinine ratio (ACR) screens for microalbuminaemia:
• Screen all patients 12 and over at diagnosis and annually
• Can use random rather than 1st pass urine sample as initial check
• Confirm abnormal result with EMU
• Also, do U&Es (eGFR)

31
Q

What are the approximate equivalents between urine ACR and other measures of protein excretion?

A

ADD PICTURE

32
Q

Steps after checking for microalbuminuria?

A

Monitor serum creatinine and Ix other causes of renal pathology

Screen for ischaemic heart disease, PVD and hypertension; assess fasting lipid profile

Tighten glycaemic control

Discourage smoking

33
Q

Risk factors for nephropathy progression?

A
  • Hypertension, cholesterol and glycaemic control
  • Smoking
  • Albuminuria
34
Q

Recommendations for treatment of hypertension in diabetic nephropathy?

A

BP should be maintained <130/80 mmHg in all diabetics (SIGN target 130/70 mmHg)

Patients with microalbuminuria or proteinuria should commence on an ACEI or ARB

35
Q

Recommendation for glycaemic control to reduce risk of diabetic nephropathy?

A

Good glycaemic control (HbA1c 53 mmol/mol) should be maintained

36
Q

Drugs used in diabetic nephropathy?

A

Have to alter doses or stop drugs altogether, to prevent drug toxicity

ADD TABLE

37
Q

Eye problems in diabetics?

A

Diabetic retinopathy

Cataract (clouding of the lens - develops earlier in diabetics)

Glaucoma (increase in fluid pressure in the eye causes optic nerve damage - 2x more common in diabetes)

Acute hyperglycaemia can cause reversible visual blurring (osmotic effect on the eye)

38
Q

Normal retina image?

A

ADD IMAGE

39
Q

Stages of retinopathy?

A
  1. Mild non-proliferative (background)
  2. Moderate non-proliferative
  3. Severe non-proliferative
  4. Proliferative
40
Q

Gross abnormalities that can be seen on the retina with retinopathy?

A

Haemorrhage:
• Dot
• Blot
• Flame

Cotton wool spots - ischaemic areas

Hard exudates - white spots that are lipid break down products

IRMA (Intra-retinal microvascular abnormalities) - abnormalities of blood vessels/precursor to neovascularisation but blood vessels are patents (do not leak)

41
Q

Difference between retinopathy and maculopathy?

A

Maculopathy is damage to the macula, not to the retina

They are both graded separately

42
Q

Signs of mild background retinopathy?

A

Haemorrhages and microaneurysms only

ADD PICTURE

43
Q

Signs of pre-proliferative retinopathy?

A

Microaneurysms, hard exudates and haemorrhages

ADD PICTURE

44
Q

Signs of severe non-proliferative retinopathy?

A

IRMA, venous bleeding and haemorrhages

ADD PICTURE

45
Q

Signs of severe proliferative retinopathy?

A

New vessel formation - look life tangled branches

ADD PICTURE

46
Q

Other eye problems in diabetics?

A

Pre-retinal fibrosis +/e tranction retinal detachment

ADD PICTURE

47
Q

Signs of retinal bleeding (from fragile new vessels)?

A

Sudden change in vision and floaters; looks boat-like and requires urgent referral

48
Q

Other complications of retinopathy?

A

Secondary glaucoma

Retinal detachment

49
Q

Ix for maculopathy?

A

Optical coherence tomography

50
Q

Treatment of retinopathy?

A

Laser
Vitrectomy
Anti-VEGF injections

51
Q

Occurrence of erectile dysfunction in diabetes?

A

At least 50% of all diabetic men

52
Q

Causes of erectile dysfunction in diabetes?

A

Vascular disease and neuropathy

53
Q

Other causes of ED?

A

Chronic renal failure, hepatic failure

MS

Severe depression

Others, e.g: vascular disease, low HDL, high cholesterol and hormonal deficiency

Spinal cord injuries

Pelvic and urogenital surgery and radiation

Substance abuse, alcohol (>600 ml/week) and smoking (amplifies other risk factors)

Medications

Bicycle riding

54
Q

Medications that can cause erectile dysfunction?

A

Anti-hypertensive drugs (all are capable but common causes are thiazides and beta-blockers; uncommon is CCBs, ACEIs)

CNS drugs, e.g: antidepressants, tricyclics, SSRIs, tranquilisers, sedatives and analgesics

55
Q

Mx of erectile dysfunction in diabetes?

A

ADD PICTURE

56
Q

Annual screening in diabetes?

A

For all diabetic patients, i.e: eyes, feet and kidneys (ACR and U&Es)

57
Q

How to substantially reduce risk of complications in diabetes?

A

Good blood glycaemic control, BP control and blood lipid control

Year 2 Clinical (119 decks)

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