Long-term complications - micro and macro

Question 1

What are some risk factors for complications associated with diabetes?

Answer 1

• Duration of diabetes
• Metabolic control
• Smoking
• Hypertension
• Hyperlipidaemia
• Genetics

Question 2

What are some risk factors for cardiovascular disease?

Answer 2

• Glucose control
• Blood pressure
• Smoking
• Lipids
• Proteinuria
• Family history
• Gender

Question 3

What is the target HbA1c level in diabetics?

Answer 3

Target HbA1c - 53 mmols/mol (7%)

Question 4

What is the target blood pressure in diabetics?

Answer 4

Control BP to ≤ 130/80

Question 5

How can cardiovascular complication risk be decreased?

Answer 5

• Smoking cessation - support, nicotine replacement or drug therapy (Zyban, Champix)
• Statin therapy e.g. simvastatin for patients over 40 and in younger patients with significant complications
• Lifestyle choices – maintaining healthy weight, exercise

Question 6

What drug therapy is used for smoking cessation?

Answer 6

Zyban (bupropion, also used as as antidepressant)

Champix (varenicline)

Question 7

What 3 pathologies are caused by diabetic microvascular disease?

Answer 7

• Retinopathy
• Neuropathy
• Nephropathy

Question 8

What is the most common cause of blindness in the working age population?

Answer 8

Diabetic retinopathy

Question 9

What are some retinal abnormalities seen in diabetes?

Answer 9

• Microaneurysms (small red dots)
• White spots from lipid aggregates
• Blot haemorrhages
• Hard exudates
• Cotton wool spots
• New vessel formation
• Vitreous haemorrhage

Question 10

How can proliferative retinopathy be treated?

Answer 10

Laser photocoagulation

Vitrectomy

Question 11

What affects vision in maculopathy?

Answer 11

• Exudates and blot haemorrhages at macula
• Macular ischaemia
• Macular oedema deforms the macula, affecting visual acuity

Question 12

What is used to treat diabetic maculopathy?

Answer 12

Grid laser therapy

BP and blood glucose control

Question 13

How much does risk of cataracts increase in diabetic patients?

Answer 13

2X increase

Question 14

What are the 3 subtypes of diabetic neuropathy?

Answer 14

o Peripheral neuropathy (diffuse nerve disease) – most common
o Mononeuritis (single nerve palsy) – less common
o Autonomic neuropathy

Question 15

What are some symptoms of peripheral neuropathy?

Answer 15

Gloove and stocking distribution of:

• feet insensitive to trauma: risk of feet ulcers
• paraesthesia (abnormal sensation)
• burning pain
• numbness
• small muscle wasting
• can be asymptomatic!!

Question 16

How can peripheral neuropathy be managed?

Answer 16

• Early detection – screening for diabetic foot disease
• Self care education
• Protection of feet
• Pain relief
– Capsaisin cream (local treatment)
– Amitriptyline, gabapentin, duloxetine (systemic treatment, pain)

Question 17

What local treatment can be given for pain caused by peripheral neuropathy?

Answer 17

Capsaisin cream

Question 18

What systemic treatment can be given for pain caused by peripheral neuropathy?

Answer 18

Amitriptyline
Gabapentin
Duloxetine

Question 19

What techniques are used for foot screening and risk scoring for ulcer prevention?

Answer 19

Microfilament - record sensation

Peripheral pulses

Question 20

How can foot ulcers be prevented?

Answer 20

Foot screening
Education on foot care
Regular podiatry for those at high risk
Avoidance of trauma
Avoid fitted footwear

Question 21

What is Charcot foot/Charcot neuro-arthropathy, and why is prevention important?

Answer 21

• Progressive degeneration of a weight bearing joint, a process marked by bone destruction, bone resorption, and eventual deformity due to loss of sensation and an initial small trauma. Onset is usually insidious (gradual)
• If this pathological process continues unchecked, it can result in joint deformity, ulceration and/or superinfection, loss of function, and in the worst-case scenario, amputation or death. Early identification of joint changes is the best way to limit morbidity.

Question 22

What factors indicate high risk of complications of the feet?

Answer 22

• Impaired circulation
• Impaired sensation
• Impaired vision
• Foot shape changes
• Abnormal pressures

Question 23

What is acute sensorial peripheral neuropathy, and what causes it?

Answer 23

Rapid onset of neuropathic symptoms
Precipitating factors
– Rapid tightening of control e.g. trying to get pregnant
– Acute metabolic upset

Question 24

What can happen after a rapid tightening of glycemic control or an acute metabolic upset?

Answer 24

Acute sensorial peripheral neuropathy

Question 25

What is proximal motor neuropathy/diabetic amyotrophy?

Answer 25

A nerve disorder that results as a complication of diabetes mellitus. It can affect the thighs, hips, buttocks or lower legs. Proximal diabetic neuropathy is a peripheral nerve disease (diabetic neuropathy) characterized by muscle wasting or weakness, pain, or changes in sensation/numbness of the leg. Diabetic neuropathy is an uncommon complication of diabetes. It is a type of lumbosacral plexopathy, or adverse condition affecting the lumbosacral plexus.

Question 26

Who is primarily affected with proximal motor neuropathy/diabetic amyotrophy?

Answer 26

Elderly men with type 2 DM

Question 27

What are some symptoms and signs of proximal motor neuropathy/diabetic amyotrophy?

Answer 27

``` Leg muscle wasting Weakness in legs Pain Loss/changes in sensation/numbness Weight loss (due to muscle atrophy) ```

Question 28

What does amyotrophy mean?

Answer 28

Muscle atrophy

Question 29

What is mononeuritis?

Answer 29

Inflammation of a single nerve

Question 30

What can be seen in patients with mononeuritis of the oculomotor nerve (CN III)?

Answer 30

Affected eye has downward and outer gaze

Question 31

What can be seen in patients with mononeuritis of the trochlear nerve (CN IV)?

Answer 31

Affected eye has upward and slightly inwards gaze

Question 32

What can be seen in patients with mononeuritis of the abducens nerve (CN VI)?

Answer 32

Affected eye cannot look to lateral side (cannot abduct)

Question 33

What can be seen in patients with mononeuritis of the peroneal nerve?

Answer 33

Acute foot drop (inability to lift the front of your foot off the ground, tested by dangling legs over bed and ask to bring ball of feet up)

Question 34

What are some signs of autonomic neuropathy?

Answer 34

``` Erectile dysfunction Postural hypotension Gastric stasis/recurrent vomiting Diarrhoea Abnormal sweating Peripheral oedema Urinary retention ```

Question 35

How can erectile dysfunction be treated?

Answer 35

– Phosphodiasterase inhibitors e.g. Viagra, Cialis | – Prostaglandins, mechanical devices, implants

Question 36

How is postural hypotension treated?

Answer 36

– NSAIDs | – Fludrocortisone

Question 37

What is given to those with gastric stasis and recurrent vomiting?

Answer 37

Domperidone (dopamine D2 receptor antagonist, antiemetic)

Question 38

What 2 drugs are given for diarrhoea?

Answer 38

Loperamide | Codeine phosphate

Question 39

What % of patients will develop nephropathy after 30 years of diabetes?

Answer 39

25%

Question 40

How do we screen for early kidney disease?

Answer 40

Microalbuminuria - test using first pee in the morning

Question 41

Is any stage of kidney disease reversible?

Answer 41

Microalbuminuria, before it progresses to proteinuria

Question 42

What is the definitive test for microalbuminuria?

Answer 42

Definitive test- timed over night urine collection for albumin excretion rate (AER) o Normal < 20μg/min o Microalbuminuria 20-200μg/min

Question 43

How can we manage early kidney disease to try and prevent its progression?

Answer 43

* Optimise glycaemic control * Tight BP control - aim for <125/75 in type 1 diabetes * ACE inhibitor therapy slows progression * Cardiovascular risk factor management