Diabetes complication Flashcards
what are the short term complications of diabetes?
hypoglycaemia, diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS).
what are the longterm complications of diabetes?
retinopathy, cardiovascular disease (CVD), nephropathy and neuropathy.
what is hypoglyceamia?
what are the causes
what are the treatment
what are the advices given
what?
- Occurs when blood glucose levels fall below 4mmol/L.
- Can become a medical emergency if not treated, leading to convulsions, unconsciousness, coma.
causes
-Too much insulin (patient/doctor/pharmacist error), or due to use of oral hypoglycaemic agents, e.g. sulfonylureas (Insulin secretagogues).
-Altered insulin absorption (insulin is absorbed more rapidly from abdomen; lipohypertrophy at injection site).
-Altered clearance of insulin (i.e. reduced clearance in renal failure).
-Decreased insulin requirement (missed, small, delayed meals, exercise increases insulin absorption; alcohol inhibits hepatic glucose output).
-Failure to recognise symptoms.
treatment
Key is to recognise signs and symptoms early and to treat immediately.
Treatment involves:
- Oral glucose (10-20g) if conscious and able to swallow (i.e. glucose rich foods and drinks, sugar cubes, glucose gel or tablet).
-intramuscular or sub-cutaneous glucagon or intravenous glucose (dextrose) if unconscious or unable to swallow:
Glucagon mobilises the liver’s glycogen stores; once episode is over, must replenished (them) by administration of longer-acting carbohydrates.
advices given
Look for patterns in when hypos occur (i.e. just before lunch, after sport) and adjust routine, or insulin if necessary.
Consider more regular blood glucose monitoring until glucose levels stabilise (i.e. after illness or stress).
Avoid triggers (i.e. alcohol can increase incidence of nocturnal hypo).
Ask your family, friends and colleagues to help you recognise signs and tell them what to do if you need help.
Be prepared (i.e. carry glucose tablets or sweets).
See Diabetes Care Team to review or alter treatment regime.
what is nocturnal hypoglycemia?
Night-time hypoglycaemic episodes are relatively common in diabetics (especially in insulin users).
Caused by skipping meals, accidental overdose, alcohol or exercising in the evening
Signs of nocturnal hypo might include waking up tired or with a headache, wet from sweating.
Can be dangerous so worrying for patients and carers
what is diabetic ketoacidosis
what is it commonly caused by
symptoms
treatment
Chronically, uncontrolled hyperglycaemia can lead to diabetic ketoacidosis (DKA). Most common among Type I diabetics.
Lack of insulin means that the body is unable to use glucose as an energy source, so the body seeks an alternative energy source: breakdown of fats (triglycerides), release of free fatty acids (FFA).
Ketones can build up (as a by-product) and cause the body to become acidic (acidosis
Severe diabetic emergency requiring emergency rehydration and insulin to prevent death (often hospital admission).
Occurs more commonly in younger patients, but risk of death is higher in older patients (overall mortality rates for DKA are <1%).
Most commonly caused by infections (up to 40% of cases), but newly diagnosed diabetes (10-20% of cases) and insulin errors, omissions and non-compliance (15-30% of cases) can also contribute:
Common mistake made by diabetics is that they stop taking insulin if they are feeling unwell and lose their appetite, so as to prevent hypoglycaemia, BUT infections can increase insulin requirements!
symptoms:
More severe version of the presenting symptoms of diabetes (thirst, frequent urination, tiredness, blurry vision); may also include nausea, cramps, abdominal pain (latter in children), laboured breathing, unconsciousness and postural hypotension and dehydration (patients may be hypotensive and tachycardic due to dehydration and acidosis).
Treatment involves:
Intravenous rehydration (IV 0.9% saline).
Insulin infusion (to correct hyperglycaemia).
Careful correction of electrolyte balance (potassium may be low: hypokalemia).
what is. Hyperglycaemic hyperosmolar state (HHS)
causes
difference between dka
symptoms
treatment
Previously: hyperglycaemic hyperosmolar non-ketotic coma (HONK).
Medical emergency that occurs in Type II diabetics with very high blood glucose levels, often as a result of both illness and severe dehydration.
Precipitating factors: acute illness, drugs that increase fluid loss (diuretics). Patient may have stopped medication as a result of their illness (i.e. nausea or swallowing difficulties), or usual anti-diabetic medication has reduced effects due to the body’s response to illness.
Unlike in DKA, ketone build up in urine is not seen in HHS, possibly because some insulin is produced in Type II diabetes (enough to suppress ketogenesis).
causes
Excessive urination.
Thirst.
Nausea and vomiting.
Dry skin.
General weakness.
Leg cramps.
Visual impairment.
Confusion.
Drowsiness.
Unconsciousness.
Can lead to coma.
Very high blood glucose levels (>30mmol/L).
Low ketone levels in urine (<3mmol/L).
No acidosis (arterial pH >7.3, bicarbonate >15mmol/L), or mild acidosis due to lactate accumulation.
Hyperosmolality (>320 mOsm/kg; normal range 275-295 mOsm/kg).
treatment
HHS is less common than diabetic ketoacidosis (DKA), but it is associated with increased mortality (15-20%; gradual onset of symptoms, over days, leads to patients presenting with severe dehydration and metabolic disturbances):
Rehydration and replacement of electrolytes (intravenous [IV] fluids).
Normalise water-electrolyte balance (osmolality; IV fluids).
Normalise blood glucose levels (low dose insulin, IV).
Anti-coagulant prophylaxis with low molecular weight heparins (HHS is associated with arterial or venous thrombosis i.e. MI, stroke).
Prevention of foot ulceration (HHS increases susceptibility to pressure sores).
what are examples of long term complications
Cardiovascular disease.
Neuropathy.
Retinopathy.
Renal disease (nephropathy).
Skin.
Extremities (i.e. feet).
Macrovascular complications:
CVD and stroke.
Extremities.
Microvascular complications:
Eye (retinopathy).
Kidney (nephropathy).
Nerves (neuropathy).
Skin (healing, etc.).
what is metabolic syndrome
Type II diabetes common in those with other risk factors for CVD (i.e. obesity, hypertension, dyslipidaemia): known as the metabolic syndrome.
how to Avoid complicationsaffecting cardiovascular system:risk reduction
Maintain a healthy weight.
Exercise.
Achieve and maintain recommended levels of low-density lipoproteins (LDL) and high-density lipoproteins (HDL):
Statins recommended for diabetic patients from 40 years of age.
Maintain blood pressure in normal range (<130/85 mm Hg).
Stop smoking.
what is diabetic neuropathy
Diabetes and poor glycaemic control eventually affects the blood vessels supplying the nerves, leading to neuropathy (nerve damage).
Signs and symptoms of neuropathy depend on the nerves affected (location in the body e.g. distal feet, hands etc.).
what is the types of neuropathy?
Sensory neuropathy: i.e. lack of feeling ‘numbness’ in extremities (pain, loss of temperature sensation, etc.).
Autonomic neuropathy: i.e. incontinence, erectile dysfunction, irregular heart rate (resting tachycardia), abnormal sweating (too much/not enough), gastroparesis (delayed gastric emptying).
Motor neuropathy: i.e. muscle weakness, muscle wasting, muscle twitching and cramp.
how can diabetic effect feets
how to avoid
Poorly controlled diabetes can lead to nerve damage and poor circulation.
Neuropathy can leads to loss of feeling/sensation in feet; may not notice injury (i.e. cuts or blisters and so on).
Skin of diabetics is often dry, cracked and lacking elasticity; more prone to injury (minor cuts can lead to ulcers) and infection.
Poor circulation means that any wounds are slow to heal; may require amputation.
avoid
Regularly monitor sensitivity of feet to touch: i.e. Ipswich Touch Test or ‘Touch the Toes’ test: https://www.diabetes.org.uk/guide-to-diabetes/complications/feet/touch-the-toes
Look after your feet:
wash with soap and dry.
keep nails trimmed (consider podiatrist).
Keep skin healthy (consider podiatrist).
Wear well fitting shoes.
Attend annual clinical foot examination.
what is the treatment for diabetic neuropathy: nerve pain
Offer One of these:
Tricyclic antidepressants (TCA): amitriptyline
Serotonin-noradrenaline reuptake inhibitors (SNRI): duloxetine
Voltage-gated calcium channel (VGCC) alpha2-delta subunit ligand(s): pregabalin, gabapentin
if not effective
Offer one of the remaining 3 drugs; consider switching again
Consider tramadol (related to morphine) only if acute rescue therapy is needed.
Consider capsaicin cream for people painful diabetic peripheral polyneuropathy who wish to avoid/cannot tolerate oral treatments (only if pain is localised).
other :
Analgesia (pain relief; sensory neuropathy)
Physiotherapy to combat muscle weakness (motor neuropathy).
Sildenafil (phosphodiesterase 5 Inhibitor, PDE5) for erectile dysfunction (autonomic neuropathy).
Antiemetics for nausea and vomiting (related to gastroparesis; autonomic neuropathy). Note: there is not strong evidence that any available antiemetic therapy is effective in Type II diabetics (
diabetic complicationsaffecting the eyes
how to avoid
treatment
Diabetes is associated with retinopathy (damage to the retina).
Retinopathy is the leading cause of blindness in the UK.
Blood vessels supplying the retina become blocked and/or leaky, leading to damage and reduced function.
AVOID
Annual eye screening to monitor retina.
Keep blood glucose within normal limits.
Maintain blood pressure in normal range (<130/85 mm Hg).
Achieve and maintain recommended LDL and HDL levels.
Seek medical advice if notice changes affecting vision (focal ‘blurring’, partial/total loss of vision, etc.).
TREATMENT
Laser surgery to improve circulation to retina and stop leaky, or inappropriate vessel growth.
Anti-vascular endothelial growth factor (VEGF) intra-ocular injection to prevent inappropriate growth of blood vessels.
Intra-ocular corticosteroid implant (i.e. fluocinolone acetonide) to inhibit inflammation and VEGF.
diabetic complicationsaffecting the kidneys
causes
avoiding?
treatment
Diabetes is associated with nephropathy (damage to the kidney).
Between 25-50% diabetics will develop nephropathy.
Hyperglycaemia damages the small blood vessels supplying the kidneys, which affects kidney function (filtration; GFR), leading to nephropathy.
AVOID
Annual kidney function test:
Protein present can indicate damage.
Keep blood glucose within normal limits.
Maintain blood pressure in normal range (<130/85 mm Hg).
Stop smoking .
TREATMENT
Managing blood pressure, and glucose levels, are both important.
1st line: ACE inhibitors and angiotensin II (AII) receptor antagonists can be used to prevent further kidney damage and control blood pressure (BP):
May be used even if BP is normal, as effects are independent of hypotensive actions (ACE inhibitors only).
Diet modification (i.e. low salt, limited proteins, etc.) to ensure that kidney function is not overloaded (i.e. prevent waste build-up).
Dialysis (or kidney transplant) may be necessary if kidney function is poor.
