COMPLICATIONS OF DIABETES MELLITUS

Dr Shamila De Silva Department of Medicine - 2009

Introduction

life expectancy Major causes of death are, cardiovascular - 70% renal - 10% infections - 6% Depends on duration & degree of hyperglycaemia
Better diabetic control rate of progression of nephropathy & retinopathy

Classification
Macrovascular
Microvascular
Complications
atherosclerosis

Metabolic Other

Macrovasculer Complications
1) coronary artery disease (3-5X) 2) Strokes (2X) 3) peripheral vascular disease
intermittant claudication
dry gangrene (50X)

UKPDS & DCCT studies intensive treatment of DM has only a small effect on CVD risk

Hypertension
aggressive treatment marked in CVD most need 2 drugs

Smoking Lipid abnormalities

lowest achievable level almost all with Type 2 treated with a statin

Low-dose aspirin
- macrovascular risk
- but morbidity & mortality from bleeding

ACE inhibitors / angiotensin II receptor antagonists

with 1 major CVD risk factor 25-35% in risk of heart attack, stroke, nephropathy, CV death

Risk factors for Macrovascular Complications

Duration Increasing age Systolic hypertension Metabolic syndrome Hyperlipidaemia ( TG, HDL) Proteinuria
Other factors - same as for general population

Coronary Artery Disease

Angina stable, unstable Myocardial infarction may be silent

Stroke

Due to cerebral infaction TIA Stroke commonly face-arm-leg High morbidity cost

Peripheral Vascular Disease

Weak / absent peripheral pulses Intermittent claudication Digital gangrene amputation

Microvascular Complications
1) Retinopathy - retina 2) Neuropathy - nerve sheath 3) Nephropathy - glomerulus

Specific to DM Manifest 10-20 years after diagnosis in young patients Earlier in older patients - unrecognized diabetes for months to years before diagnosis Genetic factors siblings, race

Diabetic Eye Disease

Retinopathy Cataract
occur earlier

External ocular palsies

III, VI - painless - recover spontaneously

Retinopathy

Non-proliferative (background) Pre-proliferative Proliferative Advanced Retinopathy Maculopathy

Non-Proliferative

Dot haemorrhages
capillary microaneurysms usually appear first

Blot haemorrhages
leakage of blood into deeper retinal layers

Hard exudates
exudation of plasma rich in lipids and protein

Annual screening only

Pre-proliferative

Venous beading / loops Intraretinal microvascular abnormalities (IRMA) Multiple cotton wool spots

Non-urgent referral to an ophthalmologist

Proliferative

New blood vessel formation (neovascularization) Preretinal or subhyaloid haemorrhage Vitreous haemorrhage
Urgent referral to an ophthalmologist laser
therapy (pan-retinal photocoagulation)

Advanced Retinopathy

Retinal fibrosis Traction retinal detachment Urgent referral to an ophthalmologist - but much vision already lost

Maculopathy

Hard exudates within one disc-width of macula

Referral to an ophthalmologist soon

Nephropathy

Covered in detail Urinary Module (Systemic diseases affecting the kidney)

Microalbuminuria overt proteinuria ACEi / ARB

Neuropathy

symmetrical mainly sensory polyneuropathy acute painful neuropathy mononeuropathy and mononeuritis multiplex
(a) cranial nerve lesions (b) isolated peripheral nerve lesions

diabetic amyotrophy autonomic neuropathy

Symmetrical Mainly Sensory Polyneuropathy

Early loss of vibration, pain (deep > superficial) & temperature sensations in feet Late 'walking on cotton wool', impaired proprioception Hands less commonly involved
Unrecognized trauma (blistering ulceration) Interosseous wasting, high arch and clawing of toes callus perforating neuropathic ulceration Neuropathic arthropathy (Charcot's joints)

Neuropathic Ulcer

Charcots Foot

Acute Painful Neuropathy

Less common burning pains in feet, shins, anterior thighs worse at night develop after sudden improvement in glycaemic control remits spontaneously after 3-12 months if good control is maintained
chronic form late, resistant to Rx

Tricyclics, gabapentin, pregabalin, valproate, carbamazepine

Trans-epidermal nerve stimulation (TENS) Topical capsaicin-containing creams

Mononeuritis & Mononeuritis Multiplex

Multiple mononeuropathy Any nerve Abrupt onset (sometimes painful) Radiculopathy (spinal root) Isolated nerve palsies III, VI (pupillary reflexes retained) Full spontaneous recovery in 3-6 months

Diabetic Amyotrophy

Older men Painful wasting, usually asymmetrical, of quadriceps Knee reflexes diminished or absent Tender to palpation Associated with poor glycaemic control Resolves with good control

Autonomic Neuropathy

CVS

tachycardia loss of sinus arrhythmia postural hypotension GIT gastroparesis nocturnal diarrhoea Bladder - loss of tone incomplete emptying & stasis infection Male erectile dysfunction common due to - anxiety, depression, alcohol, drugs (thiazides, beta-blockers), inadequate vascular supply counselling of both partners Phosphodiesterase type-5 inhibitors (sildenafil)

Diabetic Foot

Ischaemia, infection, neuropathy tissue necrosis Diffrentiating between ischaemic & neuropathic foot.READ
Principles of CareSeek early advice for any damage Check shoes for sharp areas before wearing Use lace-up shoes with plenty of room for toes Keep feet away from sources of heat

Infections

With poor DM control increased susceptibility to infections

Skin

GIT

staphylococcal infections (boils, abscesses, carbuncles) mucocutaneous candidiasis chronic periodontitis rectal and ischiorectal abscess formation urinary tract infections (in women) pyelonephritis perinephric abscess staphylococcal & pneumococcal pneumonia Gram-negative bacterial pneumonia tuberculosis

GUT

Lungs

Infections

Leads to loss of glycaemic control Can cause ketoacidosis Increase Insulin dose by up to 25% Non-insulin-treated may need insulin
Never omit insulin dose, even with nausea & LOA Test blood glucose Seek urgent medical advice

Metabolic Emergencies

Diabetic ketoacidosis Hyperosmolar hyperglycaemic state

Lactic acidosis

Diabetic Ketoacidosis

Hallmark of Type 1 DM Seen with previously undiagnosed diabetes interruption of insulin therapy stress of inter-current illness

DKA Management

Diagnosis -

Hyperglycaemia - blood glucose Ketonaemia - ketostix Acidosis - blood gas Blood glucose Urea and electrolytes Full blood count Blood gases Blood and urine culture Chest X-ray ECG Cardiac enzymes

Investigations -

Phase 1 Management

Admit to HDU Soluble insulin i.v. 6 units/h by infusion or 20 units im stat, followed by 6 units im hourly

0.9% sodium chloride with 20 mmol KCl/L

Adjust KCl conc depending on results of 2 hourly blood K+ measurement

Phase 2 Management

When blood glucose falls to 10-12 mmol/L change infusion fluid to 1 L 5% dextrose plus 20 mmol KCl 6hourly Continue insulin with dose adjusted according to hourly blood glucose test results

Phase 3 Management

Once stable and able to eat and drink normally, transfer patient to four times daily subcutaneous insulin regimen

Hyperosmolar Hyperglycaemic State

Severe hyperglycaemia without ketosis In uncontrolled Type 2 DM Middle or later life

Precipitation glucose-rich fluids concurrent medication - thiazides, steroids inter-current illness

Dehydration, stupor, coma Underlying illness pneumonia, pyelonephritis Predispose to stroke, myocardial infarction or arterial insufficiency in legs
Plasma osmolality & sodium high

Mx similar to DKA V sensitive to insulin

Prognosis - mortality high (20-30%) Not an absolute indication for insulin on discharge (unlike DKA)