Diabetes > Complications > Flashcards

Complications Flashcards

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1
Q

What are the causes of visual impairment in someone with diabetes?

A
  • Maculopathy
  • Glaucoma
  • Cataracts
  • Diabetic retinopathy
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2
Q

How would you manage somoene with signs of retinopathy?

A
  • Yearly screening
  • Good glycaemic control - HbA1c < 58 mmol/L
  • Blood pressure control - <130/80) - ACEi/amlodipine
  • Refer to opthalmology
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3
Q

What are pathophysiological consequences of diabetes?

A

Non-enzymatic glycosylation of a wide variety of proteins e.g. haemoglobin, collagen, LDL and tubulin in peripheral nerves -> leads to an accumulation of advanced glycosylated end-products causing injury and inflammation

Changes in vascular permeability, cell proliferation and capillary structure - due to metabolism of glucose

Abnormal microvascular blood flow

Haemodynamic changes - kidney

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4
Q

What macrovascular complications occur in diabetes?

A

Accelerated atheroma

  • Stroke
  • MI
  • Peripheral vascular disease
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5
Q

What microvascular complications occur in diabetes?

A
  • Eye disease
  • Renal disease
  • Neuropathy
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6
Q

What are the main complications seen in diabetes?

A
  • Microvascular - Eye disease, renal disease, neuropathy - peripheral, auonomic
  • Macrovascular - Stroke, MI
  • Diabetic foot
  • Infections
  • Gastroparesis
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7
Q

How would you attempt to manage the risk of macrovascular complications?

A
  • Target HbA1c 53 mmols/mol (7%)
  • Control BP to < 130/80
  • Smoking cessation
  • Statin therapy
  • Lifestyle choices
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8
Q

What are the main diabetic eye diseases?

A
  • Cataracts
  • Diabetic retinopathy
  • Glaucoma
  • External ocular nerve palsies
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9
Q

What is the main cause of diabetic eye disease?

A

Diabetic retinopathy

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10
Q

Why does cataracts occur in diabetes?

A

This can be due to reversible osmotic changes in patients with acute hyperglycaemia. It may also be due to senile cataracts.

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11
Q

What is the following?

A

Cataracts

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12
Q

How would you manage someone who had developed cataracts as a complication of diabetes?

A
  • Senile - consider surgery
  • Juvenile “snowflake” - better glycaemic control
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13
Q

What is juvenile “snowflake” cataracts?

A

Sustained very poor diabetes control with a degree of ketosis can cause an acute cataract (snowflake cataract), which comes on rapidly. Fluctuations in blood glucose concentration can cause refractive variability, as a result of osmotic changes within the lens (the absorption of water into the lens causes temporary hypermetropica). This presents as fluctuating difficulty in reading. It resolves with better metabolic control of the diabetes.

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14
Q

Why can glaucoma occur in diabetes?

A

New vessel formation can occur in the iris in late stage diabetes, which can lead to galucoma by blocking the natural drainage pathways of the eye.

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15
Q

What could be the following in the context of a diabetic patient?

A

Glaucoma

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16
Q

What is the pathophysiology of diabetic retinopathy?

A

The metabolic consequences of poorly-controlled diabetes cause intramural pericyte death, and thickening of the basement membrane in the small blood vessels of the retina. This leads initially to incompetence and increased permeability of the vascular walls, and later to occlusion of the vessels (capillary closure). This process has somewhat different consequences in the peripheral retina and in the macular area.

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17
Q

What are the effecs of diabetes on the peripheral retina?

A
  • Microaneurysms
  • Superficial (blot) haemorrhages
  • Hard exudates - protein and lipid deposits left after fluid is cleared into retinal veins
  • Cotton wool spots - Micro-infarcts within the retina due to occluded vessels. Spots themselves are caused by axoplasmic debris
  • Neovascularization
  • Retinal haemorrhage
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18
Q

What are the following?

A
  • Microaneurysm - small circles
  • Blot Haemorrhage - Large Circles
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19
Q

What are dot/blot haemorrhages?

A

Larger red dots with distinct (dot) or indistinct (blot) borders. Caused by burst blood vessel in the retina

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20
Q

What stage of retinopathy can be seen in this individuals eye (who has diabetes)?

A

Background retinopathy - Dot/bloot haemorrhages, microaneurysms

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21
Q

What are the stages of diabetic retinopathy?

A
  1. Background retinopathy
  2. Pre-proliferative retinopathy
  3. Proliferative retinopathy
  4. Advanced retinopathy

Maculopathy can also occur at any of these stages

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22
Q

What stage of retinopathy can be seen in this individuals eye (who has diabetes)?

A

Background retinopathy - Hard exudates

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23
Q

What are cotton wool spots?

A

Ischaemic swelling of the optic nerve layer causes a white, round or patchy appearance (circled)

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24
Q

What are features of background retinopathy in diabetes?

A
  • Microaneurysms
  • Dot/Blot haemorrhages
  • Hard exudates
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25
What are features of pre-proliferative retinopathy?
* **Cotton wool spots** * **Haemorrhages** * **Venous bleeding** * **Retinal ischaemia signs** * **Intra-retinal microvascular abnormalities**
26
What stage of diabetic eye disease is the following?
**Pre-proliferative disease** - A Small dot haemorrhages, microaneurysms, hard (lipid) exudates, circinate retinopathy, an intraretinal microvascular abnormality and macular oedema
27
What are the following?
Intra-retinal microvascular abnormalities (IRMAs)
28
What are features of proliferative retinopathy in someone with diabetes?
New vessel formation arising from optic disk or vessels
29
What is the following, and what is it indicative of?
DIFFICULT TO SEE!!! **Venous loop** - a type of Intra-retinal microvasulcar abnormality indicitave of pre-proliferative disease
30
What stage of diabetic eye disease is the following?
**Proliferative** - fronds of new vessels formed
31
What stage of diabetic eye disease is the following?
**Severe proliferative disease** - with cotton wool spots, intraretinal microvascular abnormalities and venous bleeding
32
What is maculopathy?
Thickening and oedema involving the macula
33
What stage can maculopathy occur at in the progression of diabetic retinopathy?
May occur at any stage of proliferative or non-proliferative diabetic retinopathy
34
What stage of diabetic retinopathy is the following?
**Proliferative** - with large pre-retinal haemorrhage
35
What can be seen in the following in someone with diabetes?
**Maculopathy** - hard exudates and oedema within 1 disc width of the macula
36
What is rubeosis iridis?
New vessel formation arounld the iris, which can lead to glaucoma
37
What clinical features in someone with diabetes might make you suspect they have maculopathy?
If acuity decreases
38
What are features of maculopathy on fundoscopy?
* **Hard exudates** - within disc width of macula * **Microaneurysms/retinal haemorrhages** - within 1 disc width of macula
39
What are features of advanced diabetic retinopathy?
* **Retinal fibrosis** * **Traction retinal detachment**
40
When would you consider referring someone with signs of diabetic retinopathy to an opthalmologist?
Signs of pre-proliferative stage
41
How would you manage diabetic retinopathy?
**Annual review** **Referal at pre-proliferative/maculopathy staging** **Proliferative retinopathy** * **Photocoagulation therapy** * **Vitreoretinal surgery**
42
How would you manage diabetic maculopathy?
* **Grid laser therapy** * **Tight glucose control** * **BP control**
43
What can happen to the kidneys in diabetes?
**Diabetic nephropathy**
44
What is the consequence of damage to the kidneys caused by diabetes?
There is a progressive leak of large molecules (particularly protein) into the urine.
45
How would you monitor for diabetic nephropathy?
Look for signs of microalbuminurea * **Urine dipstick** * **Urine Albumin:creatinine ratio** - \>3mg/mmol require treatment
46
How would you manage someone who had a urine albumin:creatinine ratio of \> 3mg/mmol?
* **Optimise glycaemic control** * **Tight BP control** - aim for \<125/75 in type 1 diabetes * **ACEi therapy slows progression** - reduces efferent back pressure into glomerulus * **Cardiovascular risk factor management**
47
What is thought to be the cause of peripheral neuropathy in diabetic patients?
## Footnote Diabetes can damage peripheral nervous tissue - vascular hypothesis postulates occlusion of the vasa nervorum as the prime cause. This seems likely in isolated mononeuropathies, but the diffuse symmetrical nature of the common forms of neuropathy implies a metabolic cause. Since hyperglycaemia leads to increased formation of sorbitol and fructose in Schwann cells, accumulation of these sugars may disrupt function and structure.
48
What are the types of neuropathy that occur in diabetes?
* **Symmetrical mainly sensory polyneuropathy (distal)** * **Acute painful neuropathy** * **Mononeuropathy and mononeuritis multiplex** * **Diabetic amyotrophy** * **Autonomic neuropathy.**
49
What are the symptoms of peripheral neuropathy?
* **Loss of sensation** * **Pain** - shooting * **Tingling/Paraesthesiae** * **"Feels like walking on cotton wool"**
50
Where does peripheral neuropathy most commonly occur?
Feet
51
What is the usual sensory distribution in someone with peripheral neuropathy in their feet?
Stocking distribution
52
What are clinical signs of peripheral neuropathy (early and late)?
**Early** * **Loss of vibration, pain and temperature sensation** **Later** * **Decreased proprioception** * **Absent reflexes** - ankle jerks * **Interosseous wasting** * **Neuropathy deformity** - pes cavus, claw toes, rocker bottom sole
53
What a complications that can occur from peripheral neuropathy?
* **Unrecognized trauma** * **Interosseous wasting** * **Neuropathic arthropathy**
54
How does neuropathic arthropathy occur?
Unbalanced traction by the long flexor muscles leads to a characteristic shape of the foot, with a high arch and clawing of the toes, which in turn leads to abnormal distribution of pressure on walking, resulting in callus formation under the first metatarsal head or on the tips of the toes and perforating neuropathic ulceration. Neuropathic arthropathy (Charcot’s joints) may sometimes develop in the ankle.
55
What do you have to distinguish peripheral neuropathy from when you see signs of muscle wasting in the hands in someone who is diabetic??
**Carpal tunnel syndrome** - increased risk in diabetics
56
What are features of an acute sensory peripheral neuropathy?
**Burning or crawling pains** - feet, shins and anterior thighs * Typically worse at night, and pressure from bedclothes may be intolerable. * May present at diagnosis or develop after sudden improvement in glycaemic control No muscle wasting
57
What medications could you use to manage neuropathic pain in diabetes?
* **Duloxetine** * **Tricyclics** * **Gabapentin** * **Pregabalin**
58
What is mononeuritis mutliplex?
**Multiple mononeuropathies** - e.g. multiple cranial nerves
59
What are the most common mononeurites seen in diabetes?
* **Cranial nerves III + VI** * **Common sites for external pressure palsies or nerve entrapment** - median nerve in the carpal tunnel
60
How long does it normally take for an episode of mononeuritis to recover in diabetes?
3-6 months
61
What is diabetic amyotrophy?
Usually seen in older men with diabetes, which is usually associated with periods of poor glycaemic control **Presentation**: * Painful asymmetrical wasting of the quadriceps muscles or occasionally in the shoulders * Diminished/absent knee reflexes
62
What are cardiovascular features of autonomic neuropathy in someone with diabetes?
* **Tachycardia at rest** * **Loss of respiratory sinus arrythmia** * **Impaired cardiac reflexes** - e.g. Valsalva manoeuvre are impaired * **Postural hypotension** - loss of sympathetic tone to peripheral arterioles. * **Warm foot with a bounding pulse** - due to vasodilation
63
What are gastrointestinal features of autonomic neuropathy in someone with diabetes?
* **Gastroparesis** * **Autonomic diarrhoea** * **Bacterial overgrowth**
64
What are features of gastroparesis?
* **Post-prandial bloating** * **Early satiety** * **Nausea/vomiting**
65
How would you investigate for suspected gastroparesis in someone with diabetes?
Gastric scintigraphy with technitium meal
66
How would you manage gastroparesis in someone with diabetes?
* **Gastric pacemaker** - stimulates gastric emptying, * **Botulinum toxin** - partly paralyse the pylorus * **Anti-emetics**
67
What a genitourinary features of autonomic neuropathy in someone with diabetes?
* **Loss of tone** * **Incomplete emptying** * **Stasis** * **Atonic, painless, distended bladder** * **Erectile dynsfunction**
68
If someone has an MI with diabetes, what aspects of their long term management would you address?
* **Lifestyle** * **Medications** * ACEi * B-Blockers * Dual antiplatelet * Statin * Aggressive treatment of hypertension * Adequate glycaemic control - start hyperglycaemic meds again e.g. metformin, gliclazide
69
How would you manage someones diabetes when they are having an MI?
DIGAMI protocol - venous BG \> 11mmol/L * Stop oral hypoglycaemias during acute episodes * Give IV dextrose to provide myocardium with extra substrate * 24 hour insulin sliding scale * Tight glucose control
70
How long after an MI in someone with diabetes should they return to work?
Approx 2 Months
71
How long after an MI in someone with diabetes should they start driving?
**After 4 weeks** - must inform DVLA
72
What feature in peripheral pulses can indicate peripheral autonomic neuropathy?
**Bounding pulse**
73
What symptoms would be present at pre-prolifertive stage of diabetic retinopathy?
None
74
What symptoms might be present at the proliferative stage of diabetic retinopathy?
* **Floaters** * **Sudden visual loss**
75
What are symptoms of advanced retinopathy?
* **Floaters** * **Central loss of vision**
Diabetes
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