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Flashcards in ENDO - Complications of diabetes Deck (24):

describe the clinical features of complications that can affect a person with diabetes

•Macrovascular disease
–Cardiovascular disease
–Peripheral vascular disease
–Cerebrovascular disease

•Microvascular disease

–Peripheral sensory, autonomic, other


outline the time course for the development of diabetes complications (especially nephropathy)

1. Microalbuminuria - 30-300mg albumin/day

If untreated, natural history is:
•Type 1 DM – Albuminuria can increase at 10-20%/yr to overt nephropathy over 10 – 15 yrs
•Type 2 DM – 20-40% progress to overt nephropathy

2. Macroproteinuria - Albumin excretion rate > 300mg/24 hrs

If untreated, natural history is:
•Type 1 DM – GFR decease by 2-20ml/min/yr. ESRF 50% at 10yrs, >75% 20yrs
•Type 2 – 20% ESRF at 20yrs


What are the appropriate tests to confirm and quantify the extent of diabetes complications?

- ECG, echocardiogram
- fundoscopy
- albumin creatinine ratio, GFR


Describe the general principles for the prevention of diabetes complications

- Strict blood glucose control
- strict blood pressure control
- lipid control with statins
- regular check ups with specialists
- reduce other CV risk factors; lipids, smoking
- take care of feet every day


What dose the chronic complications of diabetes risk relate to?

–Degree of glucose control; HbA1C (especially microvascular complications)
–Duration of diabetes: in Type 2, Complications present in 50% at time of diagnosis
–Degree of BP control
–Control of other CV risk factors: Lipids, Smoking
–Individual (genetic) susceptibility


Describe diabetic eye disease. What are the 3 classifications?

•Classified as:-
–Non proliferative
–Pre- Proliferative

•Imperative that life threatening retinopathy is detected early
–Proliferative; vitreous hemorrhage from neovascularisation can be prevented by laser treatment

•Cataracts and glaucoma also more common in diabetes


Describe diabetic nephropathy. Is microalbuminuria detected on dipstick?

1. Microalbuminuria- Albumin excretion rate 30-300mg/24 hrs

•NOT detected on standard dipstick
•The most common screening test is ALBUMIN CREATININE RATIO. (Normal 300mg/24 hrs

If untreated, natural history is:
•Type 1 DM – GFR decease by 2-20ml/min/yr. ESRF 50% at 10yrs, >75% 20yrs
•Type 2 – 20% ESRF at 20yrs


What are the types of neuropathy in diabetes?

1. Distal Symmetric polyneuropathy: “glove and stocking” affects up to 50%. Often painful and distressing. 70% of amputations in diabetes relate to sensory neuropathy

2. Autonomic neuropathy (very common if sensitive tests are used)

3. Other types (much rarer)
- Individual peripheral and cranial nerve involvement (esp median, 3rd nerve)
- Polyradiculopathies- thoracic and lumbar nerve roots
- Mononeuritis multiplex - Assymetrical involving multiple peripheral nerves


What is diabetes an independent risk factor for?

Macrovascular disease

Other major risk factors are also more likely :
- Hypertension. 2x prevalence. Even more common in renal failure
- Dyslipidaemia: Worse with poor metabolic control (Type 1 and 2 DM) but often present in Type 2 even when glycaemic control is good. High TG, low HDL, small dense LDL


Describe macrovascular complications of diabetes

1. Myocardial ischaemia often “silent”
- Dyspnoea on exertion is a common symptom. Need high degree of clinical suspicion

2. Cerebrovascular diasease is common – TIA, stroke + high rate multi infarct dementia

3. Peripheral vascular disease accounts for up to 25% hospital admissions amongst diabetic patients
- Ischemic prone areas great toe, medial surface 1st metatarsal head, lateral surface 5th metatarsal, secondary infection common


What are the ischaemic prone areas in diabetes?

great toe, medial surface 1st metatarsal head, lateral surface 5th metatarsal, secondary infection common


How do you prevent & Rx diabetic eye disease?

•Early detection through regular examination: retinopathy is asymptomatic until visual loss occurs
•Laser treatment – significantly reduces risk of severe visual loss from PDR and can improve macular oedema
•Meticulous blood glucose control
•Stop smoking
•Some evidence for renin-angiotensin system blockade


How do you manage diabetic nephropathy?

•Meticulous BP control – Ideal 120 -130 / 70-75
–Systolic and diastolic H/T accelerate progression
–ACE, AT2 blockers
–Appropriate anti hypertensive therapy in type 1 diabetes can reduce the need for dialysis and transplantation from 73% -> 31% over 16 yrs

•Meticulous glucose control – Ideally HbA1C


How do you manage diabetic neuropathy?

•Meticulous glucose control – Can result in some restoration of nerve function but long standing changes are usually permanent.
•Tricyclic antidepressants: amitriptyline, desipramine, imipramine
•SNRI antidepressants: venlafaxine, duloxitine
•Anti epileptics: carbamazepine, gabapentin, pregabalin
•Opioid analgesics: tramadol
•Capsaicin cream: depletes substance p from nerve endings


How do you prevent foot ulcers in high risk feet?

•Good education in foot care
•Daily inspection
•Regular podiatry review
•Early treatment of skin injury
•Appropriate footwear
•Callus detection and treatment
•Urea cream for dry feet
•Early referral for ulcers


What is the best management that reduced CHD in diabetic patients?

STATINS (control of LDL cholesterol)

•Statins 30 - 40%
•Fibrates 10 - 20%
•ACE inhibition 20 - 25 %
•Aspirin 20%
•Glucose control 15%


What do patients with atherogenic dyslipidaemia benefit the most from?

Fenofibrate treatment


What are the effects of ACE inhibition with ramipril 10mg daily on events in diabetic patients at high risk of CV disease?

Significant relative risk reduction in all: MI, stroke, CV death, onset of nephropathy


Chronic changes in diabetic foot

- callus (pre-ulcer)
- Charcot's foot
- ulcers
- curling of toes


Signs of diabetic nephropathy

- ACR (albumin creatinine ratio)
- moderate proteinuria
- glycosuria
- raised specific gravity


(4) Signs of non proliferative diabetic retinopathy on fundoscopy

- hard exudates
- microaneurysms (dots)
- retinal haemorrhages (blots)
- soft exudates (cotton wool spots)


Where do you get diabetic ulcers? Pathogenesis?

- on pressure areas
- due to a combination of ischaemia + peripheral neuropathy + trauma


Describe Necrobiosis lipoidica diabeticorum

- rare 1% of diabetes
- over shins, central yellow scarred area, surrounding red margin
- can ulcerate


Describe proliferative diabetic retinopathy

- proliferation of new blood vssels
- secondary to chronic ischaemia
- vitreal haemorrhage if they bleed

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