What are the chronic complications of Type 2 diabetes?
Macrovascular:
- IHD
- Stroke
Microvascular:
- Neuropathy
- Nephropathy
- Retinopathy
Cognitive dysfunction/ Dementia
Erectile Dysfunction
Psychiatric
What are the end stages of diabetic complications?
Blindness
Dialysis
Amputation
Why is reducing a patients HbA1c level so important with reference to complications in Type 1 Diabetes?
A reduction of 1% in a patient’s HbA1c level can dramatically decrease their risk of microvascular complications
What are the four main types of neuropathy experienced in diabetes
Peripheral
Autonomic
Proximal
Focal Neuropathy
What type of neuropathy is characterised by pain and loss of feeling in the feet and hands?
Peripheral
What can autonomic neuropathy cause?
changes in:
- bowel/bladder function
- sexual response
- sweating
- heart rate
- blood pressure
Where is proximal neuropathy usually felt?
pain in the thighs/ hips/ buttocks
leading to weakness in the legs (Amyotrophy)
Describe the concept of Focal neuropathy
- sudden weakness in one nerve or a group of nerves
- causes muscle weakness or pain
e.g. carpal tunnel, foot drop, cranial nerve palsy
What are the risk factors for the development of neuropathy in diabetes?
- Increased length of diabetes
- Poor glycaemic control
- Type 1 diabetes > Type 2 diabetes
- High Cholesterol/ Lipids
- Smoking and Alcohol
- Genetics
- Mechanical Injury
What are the complications of peripheral neuropathy
Charcot foot
Painless trauma (e.g. needle in foot)
Foot ulcer
How is a painful neuropathy usually treated?
amitriptyline
duloxetine
gabapentin
pregabalin
combinations not recommended
What treatment can be given for painful neuropathy if the condition is either localised or the patient cannot tolerate oral treatments?
Topical Capsaicin Cream
What GI symptoms can be created by autonomic neuropathy?
Gastric slowing/ frequency
=> Constipation/ Diarrhoea (sometimes both)
Can also cause Oesophagus nerve damage
=> swallowing difficult and can lead to weight loss
Gastroparesis
What is gastroparesis?
=> persistent nausea and vomiting, bloating, and loss of appetite.
=> blood glucose levels fluctuate widely, due to abnormal food digestion.
How is Gastroparesis treated?
- Improved glycaemic control
- Diet = smaller, more frequent food portions
(If severe may need liquid meals) - Promotility drugs
=> metoclopramide, domperidone, erythromycin - Anti-nausea medications
=> prochlorperazine, ondansetron. - For Abdominal pain :
=> NSAIDs
=> low dose tricyclic antidepressants,
=> gabapentin, tramadol and fentanyl - Botulinum Toxin
- Gastric Pacemaker
What is the name given to profuse sweating at night or while eating caused by nerve damage?
‘Gustatory Sweating’
How is excessive sweating in neuropathy usually treated?
Topical glycopyrrolate
clonidine
botulinum toxin
What symptoms involving heart rate and blood pressure can be seen in neuropathy?
Postural Hypotension:
Blood pressure may drop sharply after sitting or standing, causing a person to feel light-headed/ faint.
Tachycardia:
Heart rate may stay HIGH, instead of rising and falling in response to normal body functions and physical activity.
What investigations can be carried out in autonomic neuropathy?
Nerve conduction studies or electromyography
Heart rate variability
Ultrasound.
Gastric Emptying Studies
What is diabetic nephropathy?
- damage to the capillaries in the kidneys’ glomeruli
- characterized by nephrotic syndrome and diffuse scarring of the glomeruli
What test is often used to screen diabetic patients for kidney disease?
urinary Albumin Creatinine Ratio (ACR)
How should diabetic patients be screened regularly?
Screen all patients aged 12 or over
At diagnosis then annually
May use RANDOM rather than 1st pass urine sample as initial check
Dipstick test at point of care
Don’t forget UandE’s (Estimated Glomerular Filtration Rate = eGFR)
What are the risk factors for nephropathy progression?
Hypertension Cholesterol Smoking Glycaemic control Albuminuria
What us the SIGN guideline blood pressure target for all diabetic patients?
130/70
What type of drug should a patient be commenced on if they have positive microalbuminuria?
ACE inhibitor or ARB
What is the HbA1c target for good glycaemic control
53mmol/mol
What eye diseases are patients with diabetes more susceptible to?
Cataract - clouding of the lens (develops earlier)
Glaucoma- increase in fluid pressure in the eye leading to optic nerve damage. 2 x more common in diabetes
Acute hyperglycaemia- visual blurring (reversible)
What are the 4 stages of Retinopathy?
Mild non-proliferative (Background)
Moderate non-proliferative
Severe non-proliferative
Proliferative
What would you call a Dot/ Blot/ Flame which appeared on retinal screening?
Haemorrages
What do cotton wool spots on retinal screening indicate?
ischaemic areas in the eye
What are “hard exudates” seen on retinal screening composed of?
Lipid breakdown products
What name is given to abnormal or leaky blood vessels found on retinal screening?
Intra-retinal microvascular abnormalities
What are the different gradings of retinopathy and maculopathy?
Retinopathy = R0-R4 (R3 + R4 are referrable) Maculopathy = M1/M2 (M2 referrable to opthalmology)
What pathology can cause a sudden change in vision?
Vitreous haemorrhage
What are the secondary complications of retinopathy?
Secondary Glaucoma
Retinal detachment
What investigation is used to diagnose maculopathy?
Optical Coherence Tomography
What treatments can be used for retinopathy?
Laser
Vitrectomy
Anti-VEGF injections (VEGF=Vascular endothelial growth factor => stops formation of new abnormal blood vessels in eye)
What percentage of men with diabetes experience symptoms of erectile dysfunction?
50%
What other conditions can potentially cause erectile dysfunction?
Chronic renal failure
Hepatic failure
Multiple Sclerosis
Severe depression
What medications may be resposible for erectile dysfunction?
Anti-hypertensive drugs
- thiazides
- Beta blockers
CNS drugs
- Antidepressants, tricyclics, SSRIs
- Tranquilizers
- Sedatives
- Analgesics
