Diabetic Complications

Question 1

What are common criteria to screen for diabetes or prediabetes in asymptotic adults

Answer 1

Overweight > 25 BMI or >23 in Asian Americans

1st degree relative with diabetes

High risk ethnicity (African American, Latino, native, Pacific Islander, Asian American)

History of CVD

HTN

HDL <35 mL/dL or TAG level >250

Women with polycystic ovary syndrome

Patient is very sedentary

Patients with impaired OGTT or elevated A1c

Any one over age 45 yrs

Question 2

Diabetes control and complications trial

Answer 2

Study that showed:

• tighter glycemic control for treatment of diabetes leads to decreased complications
• intensive glycemic control is beneficial in. All forms of DM
• duration and degree of hyperglycemia correlates directly with complication risk
• not all diabetes develop complications

Mean A1C and the rates of retinopathy

• 11% = 24% retinopathy in 5years
• 10% = 12% retinopathy in 5 years
• 9% = 6% retinopathy in 5 years
• 8% = 4% retinopathy in 5 years
• 7% = 1.5% retinopathy in 5 years

Question 3

What are common physical exam findings of DM?

Answer 3

Acanthosis nigricans

Obesity

Charcot arthropathies (swollen foot with bones articulations)

MSK exam shows foot/wrist drop

HTN

Decreased peripheral pulses

Reflex abnormalities

Hypoglycemia complications

Loss of sensation on feet and hands

Gastroparesis or infection symptoms

Signs or retinopathy on ophthalmology exam

Diabetic dermopathy
- spots of edema and skin changes along the tibia usually

Question 4

Possible Hypoglycemia symptoms

Answer 4

Tachycardia

Fatigue

Tremors

Sweating

Irritability

Pallor

Anxiety

AMS/confusion

Loss of consciousness

Visual disturbances (blurred vision)

Hunger

Question 5

What condition of hypoglycemia can you NOT give glucagon?

Answer 5

Sulfonylurea induced hypoglycemia
- induces paradoxical insulin releases

Instead give octerotide first and then glucagon

Question 6

Ophthalmology complications

Answer 6

Blindness

Glaucoma

Retinopathy
- shows wool spots and retinal hemorrhages on eye exams

Treatment = laser photocoagulation and anti-VEGF-intraoccular injections (Ranibizumab, pegatanib)
- also always preventative measures first line and refer to ophthalmology

Question 7

Diabetic nephropathy

Answer 7

Always begins as renal tubular necrosis

Need to screen for albuminuria at least annually
- presence implies declining GFR that gets progressively worse

If not treated = ESRD and dialysis

Treatment = improve glycemic control, use of ACE/ARB to stop HTN and renin production
- refer out to nephrology if GFR is <30 and has albuminuria

Question 8

Cardiovascular complications

Answer 8

The Framingham heart study has shown DM cardiovascular complication

• DM increases risks for CAD/PAD/MI/CHF
• also 3x risk for CVA/stroke
• MI chance increases 2s in men and 4x in women with T2DM

Treatments:

• for CAD = ACE-I and statins. Can also add aspirin in >50 aged patients with CAD risk factors. Also can add GLP-1 analog and SGLT2 inhibitors to diabetes therapy
• dyslipidemia = LDL <100 mg/dL and use statin

Question 9

Neurological complications in diabetes

Answer 9

Peripheral Neuropathy in a distal “Stocking and glove” appearance is #1

Can also show increased risk for dementia and stroke

Chronic = autonomic neuropathy which leads to GI paralysis and erratic heart rates

Treatments
- peripheral neuropathy = prevention and supplementation with B12/folate vitamins. Can also consider duloxetine, pregabalin for use also (especially if painful).

Off target use = Gabapentin, TCAs, venlafaxine

Question 10

GI/GU complications

Answer 10

Only chronic DM

• gastroparesis
• treatment = metoclopramide or erythromycin*
• diabetic cystopathy
• treatment = self-catheterization*
• sexual dysfunction
• treatment = phosphodiesterase inhibitors (sildenafil, tadalafil, etc)

Question 11

MSK complications

Answer 11

Gangrene/ osteomyelitis/ gas gangrene and amputation

Non-healing wounds

Ulcer/infections

Hammer/claw toes

Charcot joints

Frozen shoulder

Duputren contracture

Question 12

Questions to ask for 1 minutes diabetes screen

Answer 12

History of:

• leg/foot ulcers or lower leg amputations?
• prior angioplasty, stent or bypass?
• foot wound requiring more than 3 weeks to heal
• smoking
• diabetes (family also)

Do you currently have:

• burning or tingling in the legs or feet
• leg or foot pain with activity or rest
• changes in skin color
• presence of new skin lesions
• loss of lower extremity sensation