(PM3B) Diabetes Complications Flashcards
How is mortality increased with diabetes complications?
Increase in prevalence of cardiovascular disease and renal failure
How is morbidity increased with diabetes complications?
- Diabetic foot
- Retinopathy
- Peripheral neuropathy
- Peripheral vascular disease
What are the short-term complications of diabetes?
(1) Hypoglycaemia
(2) Diabetic ketoacidosis - DKA
(3) Hyperosmolar Hyperglycaemic State - HHS
What are the long-term complications of diabetes?
(1) Retinopathy
(2) Cardiovascular disease
(3) Neuropathy
(4) Peripheral vascular disease
(5) Nephropathy
When does hypoglycaemia occur?
When blood glucose falls below 4mmol/L
What can hypoglycaemia lead to if not treated?
- Convulsions
- Unconsciousness
- Coma
What are the potential causes of hypoglycaemia?
(1) Too much injected insulin
(2) Altered insulin ABSORPTION
(3) Altered insulin CLEARANCE
(4) Decreased insulin requirement
(5) Failure to recognise symptoms
How is hypoglycaemia treated?
If conscious: 10-20g of glucose
If unconscious: IM/ SC glucagon OR IV glucose (dextrose)
(1) When is dextrose administered to a diabetic patient?
(2) How is it administered?
(1) An unconscious patient having a hypoglycaemic episode
Intravenous (IV) injection
How and when is glucagon administered to a patient?
- IM/ SC injection
- Unconscious
- Hypoglycaemic
(1) What is nocturnal hypoglycaemia?
(2) How can it be recognised?
(1) Blood glucose <4mmol/L at night
(2) Waking up tired/ with a headache/ wet from sweating
What advice can be given to diabetic patients experiencing hypoglycaemia?
(1) Look for patterns - adjust insulin accordingly
(2) More regular blood glucose monitoring
(3) Avoid triggers - e.g. alcohol
(4) Carry glucose tablets/ sweets
(5) Diabetes Care Team
How does alcohol decrease blood sugar?
Inhibits glycogen breakdown + release in the liver
(1) What is diabetic ketoacidosis (DKA)?
(2) When is it most common?
(1) Use of fats + proteins as an energy alternative to glucose. Causes a build up of ketones, leading to acidosis.
(2) Type 1 diabetics
What is the treatment for diabetic ketoacidosis (DKA)?
- Emergency rehydration
- Emergency insulin
(Often requires hospital admission)
What most commonly causes DKA?
Infections - 40%
Diabetes diagnosis - 10-20%
What is DKA?
Diabetic Ketoacidosis
What is the effect of infection on insulin requirements for a diabetic patient?
Can increase insulin requirements
What are the most severe symptoms of DKA?
Diabetes symptoms with greater severity
- Thirst
- Polyuria
- Tiredness
- Blurry vision
What are the less frequent symptoms of DKA?
- Nausea
- Cramp
- Abdominal pain
- Laboured breathing
- Unconsciousness
- Postural hypotension
- Dehydration
What is the treatment for DKA?
(1) IV rehydration - 0.9% saline
(2) Insulin infusion - to correct hyperglycaemia
(3) Correction of electrolyte balance
In DKA, which electrolyte is most likely to be affected?
How is it affected?
Potassium
Decreases - hypokalaemia
What does HHS stand for?
Hyperosmolar Hyperglycaemic State
What is HHS?
Hyperosmolar Hyperglycaemic State
- Occurs in T2DM
- Medical emergency
- Very high blood glucose levels
- Severe dehydration
What causes HHS?
- Diuretics
- Acute illness
(1) When is ketone build-up observed in the urine?
(2) In which similar condition is it NOT present? Why?
- DKA
- HHS - because some insulin is produced in T2DM
What are the symptoms of HHS?
ø Polyuria ø Thirst ø Nausea + vomiting ø Dry skin ø General weakness ø Leg cramps ø Visual impairment ø Confusion ø Drowsiness + unconsciousness ø Can lead to coma
What are the diagnostic symptoms of HHS?
(1) Very high blood glucose (>30mmol/L)
(2) Low ketone levels in urine (<3mmol/L)
(3) No acidosis
(4) Hyperosmolality
What is more common, DKA or HHS?
DKA is more common
What is the treatment for HHS?
- IV fluids
- IV low-dose insulin
- Anticoagulant - HHS is associated with vascular thrombosis
- Prevention of foot ulceration
Which comorbidities does HHS increase risk of?
(1) Vascular (arterial/ venous) thrombosis
(2) Foot ulceration - increases susceptibility to pressure sores
When does the incidence of microvascular complications overtake the incidence of microvascular complications?
As the average blood glucose increases
Incidence of macrovascular complications increases linearly
Incidence of microvascular complications increases exponentially
What does ‘metabolic syndrome’ refer to?
Type 2 diabetes mellitus due to a cardiovascular disease risk factor
How can the complication of cardiovascular disease be minimised in diabetic patients?
- Reduce weight
- Exercise
- Statins (>40yrs old)
- Maintain BP in normal range (<130/85mmHg)
- Smoking cessation
How is diabetic neuropathy caused?
Diabetes + poor glycaemic control affects the blood vessels supplying the nerves
Leads to nerve damage - neuropathy
What are the types of neuropathy associated with diabetes?
(1) SENSORY - numbness in extremities
(2) AUTONOMIC - Incontinence, erectile dysfunction, resting tachycardia, gastroparesis (delayed gastric emptying)
(3) MOTOR - Muscle weakness, muscle degradation, muscle twitching, cramp
How is diabetic foot ulceration caused?
Poorly managed diabetes leads to poor circulation and nerve damage
How can the skin of a diabetic patient often present?
- Dry
- Cracked
- Lacking elasticity
- More prone to injury
- Infected
Why are people with diabetic foot at increased risk of amputation?
(1) Ulceration of foot can lead to infection
(2) Often not felt due to nerve damage (neuropathy)
(3) Slow to heal due to poor circulation
What preventative management options are there for a diabetic patient attempting to avoid foot ulceration?
(1) Wash with soap
(2) Dry thoroughly
(3) Keep nails trimmed - podiatrist/ chiropodist
(4) Keep skin healthy - podiatrist/ chiropodist
(5) Wear fitting shoes
(6) Annual clinical foot examination
What are the treatment options for each type of neuropathy, relating to diabetes?
(1) Sensory - analgesia
(2) Motor - Physiotherapist - Prevent muscle degradation
(3) Autonomic
- Sildenafil - specifically indicated for erectile dysfunction
- Antiemetics - specifically indicated for nausea + vomiting (gastroparesis)
Are antiemetics useful in Type 2 diabetic patients?
Can be beneficial for treating nausea + vomiting or gastroparesis (delayed gastric emptying)
Limited evidence to suggest effectiveness of antiemetics in T2DM
What is retinopathy?
Damage to the retina
How is retinopathy caused?
Weak blood vessels bleed onto the retina
Blind spots form due to leakage
What preventative management options are there for diabetic patients protecting against retinopathy?
(1) Annual eye screening
(2) Maintenance of normal blood glucose
(3) Maintenance of normal BP (<130/85mmHg)
(4) Maintenance of normal LDL + HDL levels
(5) Seek medical help if vision changes
What is the treatment for diabetic retinopathy?
(1) Laser surgery - improves circulation
(2) Anti-VEGF intra-ocular injection - prevents inappropriate blood vessel growth
(3) Intra-ocular corticosteroid implant - inhibit inflammation
What is VEGF?
Vascular endothelial growth factor
How common is nephropathy in diabetic patients?
25-50% of all diabetics
How is nephropathy caused in diabetic patients?
- Hyperglycaemia damages small blood vessels supplying the kidney
- Poor blood supply affects kidney function
- Leads to nephropathy
How can the complication of nephropathy be reduced in diabetic patients?
- Annual kidney function test (protein presence indicates damage)
- Maintenance of normal blood glucose
- Maintenance of normal BP (<130/85mmHg)
- Smoking cessation
What is the treatment for diabetic nephropathy?
(1) Management of BP and blood glucose
(2) 1st Line: ACEi and ARBs
(3) Diet modification - low salt, limited proteins
(4) Dialysis
(5) Kidney transplant - if kidney function is poor
What is the first line treatment for nephropathy in diabetic patients?
ACE inhibitors and Angiotensin II Receptor blockers
