Chronic Care

Plan
Programme

1 Long-term complications

2 Co-morbid conditions
Long-term complications
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Complications

Eyes (retinopathy) blindness

Also cataracts
Kidneys (nephropathy) kidney failure
Nerves (neuropathy) decreased pain perception
Blood vessels
Limbs peripheral vascular disease
Amputations
Heart heart attacks
Brain strokes
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Long-term complications

Take years to develop

May occur in childhood
Glucose control (HbA1c) related to risk of complications
Early control in childhood important (metabolic
memory)
Complications due to injury to blood vessels
Cause of mortality
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Screening programmes

Limited joint mobility

(LJM)
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Neuropathy

Peripheral neuropathy
Painful neuritis
Glove and sticking distribution
Loss of sensation
Reduced reflexes
Autonomic neuropathy
Alteration in gastric function (gastroparesis)
Bloating, decreased appetite, constipation, diarrhoea
Palpitations
Urinary retention
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Neuropathy screening

Symptoms

Neurological examination
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Nephropathy

Increase protein excretion

Small increase early microalbuminuria
Treatment can slow progression
Large amount of protein excretion macroalbuminuria
or proteinuria
Can cause increased blood pressure
Kidney failure
Treatment is dialysis or transplant
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Nephropathy screening

Annual microalbumin tests

Start 5 years after diagnosis or at start of puberty
Monitor blood pressure
Treat microalbuminuria proteinuria and/or high blood
pressure with medication
Improve control (i.e. decrease HbA1c)
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Retinopathy

Bleeding and new blood vessels in the eye

5-10% chance of blindness
Rapid improvement of poor control can cause
retinopathy to get worse
Screen from 5 years after diagnosis or at start of
puberty
Eye examination
Retinoscopy
Fundus photography is better if available
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Cataract / Retinal hemorrhage

Cataract Retinal hemorrhage

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Retinal Microvascular
Complications

Normal retina Proliferative retinopathy

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Nonproliferative diabetic
retinopathy (NPDR)
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Proliferative diabetic
retinopathy (PDR)
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Post Laser/Severe PDR

Treatments
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Co-morbid conditions
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Co-morbid conditions (1)

Not caused by diabetes

More common in children & adolescents with diabetes
Common genetic predisposition
Auto-immune disease
Often no clinical symptoms
Need laboratory screening
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Co-morbid conditions (2)

Thyroid dysfunction
Goitre, hypothyroidism, hyperthyroidism
Thyroid function tests, thyroid antibodies
Coeliac disease
Sensitivity to gluten bowel dysfunction
Often asymptomatic positive transglutaminase or
endomysial or gliadin antibodies
Addisons disease
Unexplained decrease in insulin doses, hypoglycaemia,
slow growth, fatigue, increased skin pigmentation
Refer for management
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Other issues

Osteopenia
Necrobiosis lipoidica diabeticorum
Itchy/painful hardened skin patches
Lipohypertrophy (if injection sites are not rotated
correctly)
Lipoatrophy
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Necrobiosis lipoidica
diabeticorum
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Skin complications
of insulin injections

Lipohypertrophy Lipoatrophy
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Questions
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