Complications Of Diabetes Mellitus

Chronic hyperglycaemia (high blood sugar levels) causes irreversible damage over time to several tissues, particularly the small blood vessels of the retina (retinopathy), the glomerulus of the kidney (nephropathy), and peripheral nerves (peripheral neuropathy). These so-called microvascular complications are amongst the commonest causes of visual loss, end-stage renal failure (dialysis), and foot ulceration (amputation) in most global populations and have a major adverse impact on quality of life. They are strongly linked to
hyperglycaemia and increased duration of diabetes.

There are also macrovascular complications including coronary heart disease and stroke due to dyslipidemia, hypertension which is more common in people with type 2 diabetes and insulin resistance. In type 2 diabetes, insulin resistance is present years before diagnosis and is associated with obesity and ectopic accumulation of lipids in muscle and liver. Additionally, insulin fails to appropriately suppress lipolysis from adipose tissue, which results in increased delivery of fatty acids to the liver, muscle, endothelial cells, and cardiac tissues, leading to tissue accumulation of triglycerides, diacylglycerol.

HOW TO MANAGE  CARDIOVASCULAR RISK FACTORS?

All individuals with diabetes should be advised about lifestyle modification, including diet, weight loss, stopping smoking, increasing physical activity, treatment of hypertension, and Dyslipidemia. Hypertension can accelerate other complications of diabetes mellitus, particularly cardiovascular diseases(CVD), nephropathy, and retinopathy. Blood pressure should be measured at every clinic visit. In targeting a goal of blood pressure of <140/90 mmHg, the blood pressure goal should be individualized. In some younger individuals or those with increased cardiovascular risk, the provider may target a blood pressure of <130/80 mmHg. The ADA recommends that all patients with diabetes and hypertension be treated with an ACE or an ARB initially.
Lipid abnormalities should be assessed aggressively and treated as part of comprehensive diabetes care. The most common pattern of dyslipidemia is hypertriglyceridemia and reduced HDL cholesterol levels. The ADA recommended management for diabetics with dyslipidemia:

• All patients with diabetes and atherosclerotic cardiovascular disease should receive high-intensity statin therapy
• In patients aged 40–75 years without cardiovascular disease, consider moderate-intensity statin therapy to target LDL cholesterol <100 mg/dL (without additional risk factors) or high-intensity statin therapy to target LDL cholesterol <70 mg/dL (with additional risk factors)
• In patients aged 20–39 years with additional risk factors, consider moderate-intensity statin therapy

Diabetes related eye diseases

Diabetes mellitus is the leading cause of blindness among people between the ages of 20 and 74. Severe vision loss is primarily the result of progressive diabetic retinopathy, which leads to significant macular edema and new blood vessel formation. Diabetic retinopathy is classified into two stages: nonproliferative and proliferative. Nonproliferative diabetic retinopathy usually appears late in the first decade or early in the second decade of hyperglycemia and is marked by retinal vascular microaneurysms, blot hemorrhages, and cotton-wool spots.

Whereas proliferative diabetic retinopathy is new blood vessels due to retinal hypoxemia that appear near the optic nerve and/or macula and rupture easily, leading to vitreous hemorrhage, fibrosis, and ultimately retinal detachment.

HOW TO MANAGE DIABETIC RETINOPATHY?

Intensive glycemic and blood pressure control will delay the development and slow the progression of retinopathy. In the long term, improved glycemic control is associated with less diabetic retinopathy. Regular annual, comprehensive eye examinations are essential for all individuals with diabetes mellitus. Most diabetic eye disease can be successfully treated if detected early. Routine, nondilated eye examinations by the primary care provider or diabetes specialist are inadequate to detect diabetic eye disease, which requires a dilated eye exam performed by an optometrist or ophthalmologist, and subsequent management by a retinal
specialist. Treatment of severe nonproliferative or proliferative retinopathy or macular Edema with laser photocoagulation and/or anti-VEGF therapy (intravitreous injection) is usually successful in preserving vision.

Diabetes related kidney diseases

Diabetic nephropathy is the leading cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD) requiring renal replacement therapy. CKD in individuals with diabetes mellitus associated with an increased risk of cardiovascular disease, and the prognosis of individuals with diabetes on dialysis is poor. Individuals with diabetic nephropathy commonly have diabetic retinopathy. The presence of CKD in individuals with diabetes mellitus and no
retinopathy should prompt investigation for alternative causes of kidney disease.

how to mange diabetic nephropathy?

The optimal therapy for diabetic nephropathy is prevention by:

• Improved glycemic control reduces the rate at which albuminuria appears and progresses in type 1 and type 2 diabetes mellitus.
• Strict blood pressure control, blood pressure should be maintained at <140/90mmHg for individuals with diabetes administration of an ACE inhibitor or ARB to reduce the albuminuria and the associated decline in GFR in individuals with type 1 or type 2 diabetes mellitus.
• In individuals with type 2 diabetes mellitus administration of an SGLT-2 inhibitor can reduce albuminuria and, after an initial decline (∼3 mL/min per 1.73 m2) in GFR, may slow further decline in kidney function.
• Treatment of dyslipidemia.
• Urine should be tested for microalbuminuria and a blood test sent for estimated glomerular filtration rate (eGFR) on an annual basis in all adults with diabetes.

Nephrology consultation should be considered when the estimated GFR is <30mL/min 1.743 m2 or with atypical features such as hematuria, rapidly declining renal function, or proteinuria >3 g/day. Referral for transplant evaluation should be made when the GFR approaches 20 mL/min per 1.73 m2.

Diabetes related neuropathy

Diabetic neuropathy, which occurs in ∼50% of individuals with longstanding type 1 and type 2 diabetes mellitus , the development of neuropathy associated with the duration of diabetes and glycemic control. Additional risk factors are obesity (the greater the body mass index, the greater the risk of neuropathy) and smoking. The presence of cardiovascular disease(CVD), elevated triglycerides, and hypertension is also associated with diabetic peripheral neuropathy.
Symptoms of diabetic neuropathy include a sensation of numbness, tingling, sharpness, or burning that begins in the hands and feet (glove and stocking distribution) and spreads proximally. Pain typically involves the lower limbs, is usually present at rest, and worsens at night. Diabetic neuropathy is a major risk factors for foot ulceration and falls due to small and large nerve fiber dysfunction and predisposes to lower extremity amputation.

Diabetes related autonomic dysfunction

Diabetes mellitus-related autonomic neuropathy can affect multiple organ systems, including the cardiovascular, gastrointestinal (GI), genitourinary, and metabolic systems. Common symptoms include dizziness, nausea and vomiting, post-gustatory sweating, difficulty with micturition, and diarrhoea/faecal incontinence. A postural drop may be detected on lying and standing blood pressure (orthostatic hypotension) measurement with a resting tachycardia. Diabetic autonomic neuropathy also leads to sexual dysfunction, in men
causes erectile dysfunction and in women can cause vaginal dryness, dyspareunia (pain during sexual intercourse), and increased susceptibility to urinary tract infections.

how to mange diabetic neuropathy

Prevention of diabetic neuropathy is critical through improved glycemic control. Lifestyle modifications (exercise, diet), hypertension, and hypertriglyceridemia should be treated. Patients should avoid neurotoxins (including alcohol) and smoking, and consider supplementation with vitamins for possible deficiencies (B12, folate). Metformin may reduce intestinal absorption of vitamin B12 in type 2 diabetes mellitus, and pernicious anemia is more common in type 1 diabetes mellitus where it is associated with anti–parietal cell autoantibodies and may require sublingual or parenteral B12 replacement. Two oral agents approved by the Food and Drug Admininistration(FDA) duloxetine and pregabalin, or gabapentin are usually initially used for pain associated with diabetic neuropathy. Diabetic neuropathy may respond to tricyclic antidepressants, venlafaxine, carbamazepine, tramadol, or topical capsaicin products.

Treatment of orthostatic hypotension secondary to autonomic neuropathy includes nonpharmacologic manoeuvres (adequate salt intake, avoidance of dehydration and diuretics, lower extremity support hose, and physical activity) may offer some benefit. Patients with resting tachycardia may be considered for beta blocker therapy with caution exercised if there is hypoglycemia unawareness.

Foot ulceration IN DIABETICS

People with a foot ulcer require urgent assessment by a multidisciplinary foot team, involving a diabetes specialist, a podiatrist, a vascular surgeon, and an orthotist.
Management involves:

• Débridement of necrotic tissue
• Antibiotic therapy (may be prolonged as infection can accelerate tissue necrosis and lead to gangrene)
• Pressure relief (depending on site, severity, and stage of healing): customised insoles, specialised orthotic footwear, total contact plaster cast, irremovable aircast boot.

How to care for the feet of the patient with diabetes?

Systematic annual screening to estimate and record the risk of foot ulceration to ensure appropriate access to podiatry has been shown to reduce rates of ulceration and amputation. Assessment sensation at five points on each foot and foot pulses should be palpated (dorsalis pedis and/or posterior tibial), in addition to that People with diabetes and their relatives or carers can easily learn to use the Ipswich Touch Test to screen for neuropathy: this involves lightly and briefly (for 1–2 seconds) touching the tips of the first, third and fifth toes of both feet with the index finger, an abnormal result is when touch cannot be felt on two or more toes.

Advice for patients with diabetes to prevent food ulcers:

• Wash your feet every day
• Inspect your feet every day
• Avoid walking barefoot
• Cut or file toenails regularly
• Change socks or stockings every day
• Cover minor cuts with sterile dressings
• Treat fungal skin and nail infections promptly
• Do not burst blisters
• Wear well-fitting shoes (e.g. trainers)
• Avoid over-the-counter corn/callus remedies
• Do not attempt corn removal Check footwear for foreign bodies
• Avoid high and low temperatures