Diabetes – management of complications

• Aspirin is NOT routinely recommended for 1° prevention
• Smoking makes the largest contribution to the absolute risk of macrovascular complications for people w DM. QUIT website useful

Macrovascular Complications of Diabetes

1. Coronary Artery Disease (CAD)

• Pathophysiology: Atherosclerotic plaque buildup in coronary arteries.
• Signs/Symptoms: Chest pain, shortness of breath, myocardial infarction.

2. Peripheral Artery Disease (PAD)

• Pathophysiology: Atherosclerotic plaque buildup in peripheral arteries.
• Signs/Symptoms: Claudication, leg pain, ulcers, gangrene.

3. Cerebrovascular Disease

• Pathophysiology: Atherosclerosis leading to stroke or transient ischemic attack (TIA).

HYPERTENSION

• ACE/ARA are preferred initial agents
• Check UEC 1/52 after starting ACE/ARA

DYSLIPIDAEMIA

Microvascular Complications of Diabetes

1. Nephropathy

• Pathophysiology: Damage to kidney glomeruli, leading to albuminuria and decreased kidney function.
• Signs/Symptoms: Microalbuminuria progressing to macroalbuminuria, decreased glomerular filtration rate (GFR).
• Management
  • UEC + urine ACR done yearly
  • Proteinuria is the hallmark of diabetic nephropathy
  • Once dipstick +ve protein, progressive renal damage likely
  • If microalbuminuria is established ACE/ARA should be considered even in absence of HTN
  • ACEi
    • exert a renoprotective effect beyond their antihypertensive properties in some circumstances
    • ACE-I Absolute Contraindications
      • Angioneurotic edema: even if not due to ACE Inhibitor
      • Pregnancy (serious Teratogenicity – black box warning)
      • Renal Artery Stenosis ( azotemia/renal failure resulting from preferential efferent arteriolar vasodilation in the renal glomerulus due to inhibition of angiotensin II)
      • ACE Inhibitor related Allergic Reaction
    • Relative Contraindications
      • Aortic Stenosis
      • Hypertrophic Cardiomyopathy (hypotension)
      • Dry Cough (10% of people)
      • hyperkalemia (occurs because aldosterone formation is reduced) 
  • Angiotensin II receptor blockers
    • theoretical alternative to ACE inhibitors. 
  • A low-salt diet
    • evidence is not clear-cut

Definitions in diabetic renal disease

	Normal	Microalbuminuria (incipient nephropathy)	Clinical ‘overt’ nephropathy	Units
24 hour urinary albumin	<30	30-300	>300	mg/day
Urine albumin excretion rate	<20	20-200	>200	μg/min
Urine albumin/creatinine ratio	<2.5M	10-25	>25	mg/mmol

2. Retinopathy

• Pathophysiology: Damage to small blood vessels in the retina.
• Signs/Symptoms: Microaneurysms, retinal hemorrhages, exudates, cotton-wool spots, neovascularization, macular edema.
• Management:
  • At least every 2 year eye review
  • Refractive errors: occurs as lens shape alters w BSL, should correct w pinhole test. 
  • Cataracts: occurs prematurely if have DM. Present w blurred vision, glare intolerance & find night vision problem. Interpretation of colour becomes more difficult. Light reflex reduced. Rx is surgical.
  • Retinopathy: due to microvascular disease of retina, loss of acuity not corrected w pinhole test. Changes = dot + blot haemorrhages, soft + hard exudates, proliferative blood vessel formation. Laser photocoagulation may delay + prevent visual loss. 
  • Sudden loss of vision: due to central retinal artery occlusion, retinal detachment, vitreous haemorrhage. URGENT ophthalmologist required

Feature	Diabetic Retinopathy (DM Retinopathy)	Hypertensive Retinopathy (HTN Retinopathy)
Etiology	Hyperglycemia leading to microvascular damage	Elevated blood pressure causing arteriolar changes
Microaneurysms	Present (early sign)	Rarely present
Retinal Hemorrhages	Dot and blot hemorrhages	Flame-shaped hemorrhages
Exudates	Hard exudates often around the macula	Hard exudates along with cotton-wool spots
Cotton-Wool Spots	Present in moderate to severe stages	Present, often more numerous
Venous Changes	Beading and loops in severe cases	No specific changes
Neovascularization	Present in proliferative diabetic retinopathy	Not present
Macular Edema	Common, can be sight-threatening	Rare, unless associated with severe hypertensive crisis
Arteriolar Changes	Not specific	Arteriolar narrowing, arteriovenous nicking, copper/silver wiring
Optic Disc Edema	Rare, associated with advanced proliferative stage	Present in malignant hypertension
Severity Stages	Non-proliferative, proliferative stages	Graded I to IV (mild to severe)
Vision Loss	Due to macular edema and neovascular complications	Usually in severe cases, due to retinal ischemia or optic disc edema

3. Neuropathy

• Pathophysiology: Nerve damage due to prolonged hyperglycemia, affecting sensory, motor, and autonomic nerves.
• Signs/Symptoms:
• Most commonly affects sensory + motor nerves of limbs. Paraesthesia 🡪 decreased pain + touch sensation 🡪 impaired deep tendon reflexes 🡪 reduced proprioception
  • MX: pain of peripheral neuropathy can be mx w anti-depressants, anti-epileptics, NSAIDs. Local measures helpful, desensitization w capsaicin cream coverage w Opsite + avoidance of pressure from bedclothes at night
• Autonomic neuropathy can cause = orthostatic hypotension, impaired gastric emptying, diar, delayed/incomplete bladder emptying, ED + retrograde ejaculation,  vag lubrication, loss of cardiac pain, difficulties recognisin ‘hypo’

4. FOOT PROBLEMS

Ulcers

• Most common site: Plantar surface under the metatarsal heads.
• Superficial ulcers:
  • Keep moist.
  • Avoid pressure.
• Deep ulcers or cellulitis:
  • Hospitalization required.
  • Bed rest required.
• Investigations (IX)
  • Swab (include anaerobes).
  • X-ray to rule out osteomyelitis.
• Medications
  • Augmentin DF.

Neuropathic Joint Pain

• Painful, red, hot, swollen foot is not always infected; can be Charcot’s arthropathy (due to minor trauma).
• Usually affects the metatarsal joint but can also involve the ankle.
• Investigations (IX)
  • X-ray can be normal.
  • Bone scan is best.
  • Normal WCC and no fever to rule out osteomyelitis and septic arthritis.
• Management (Mx)
  • Non-weight bearing with crutches.
  • Appliances fitted by a podiatrist.
  • +/- Below knee cast until inflammation subsides.

Ischaemic Foot

• Claudication, rest pain, ulceration, gangrene.
• Usually requires surgical intervention (e.g., arterial reconstruction or amputation).

Charcot Arthropathy

Condition of the foot and ankle caused by an inability to sense injuries

• Neuropathy (nerve damage) is essential for development.
• Injuries can occur from:
  • Obvious traumatic events (e.g., falls, ankle sprains).
  • Microtrauma due to altered weight distribution.
• Without normal pain sensation, patients continue walking on injured foot, worsening the injury.
• Only 25-50% of patients recall a specific injury.
• Other risk factors: Obesity., Increased age in diabetic patients.
• Consequences
  • Deformities can lead to:
    • Difficulty in normal shoe wear.
    • Instability in foot and ankle, affecting normal walking.
    • Prominent bone under skin, leading to ulcers and high risk of infection.
• Symptoms
  • Early signs:
    • Swelling of the foot.
    • Redness and warmth.
  • Symptoms can be confused with infection.
  • In Charcot, symptoms improve with foot elevation; in infection, they do not.
• Assessment of:
  • Injury history.
  • Diabetes management (e.g., hemoglobin A1C).
  • Foot warmth, redness, and swelling.
  • Ulcers or bony prominences.
  • Deformities (flexible vs. rigid).
  • Blood flow and sensation in foot.
• Imaging Tests
  • X-rays: Early stages may appear normal . Advanced stages show fractures, bone fragments, deformities, dislocations.
  • CT Scan
  • MRI and Ultrasound: Better images of soft tissues. Useful for suspected infections.
  • Bone Scan: Determine bone infection.
• Treatment Goals
• Create an ulcer-free, plantigrade foot for safe walking with diabetic shoes.
  • Ensure foot is:
    • Stable.
    • Plantigrade.
    • Braceable.
    • Ulcer-free.
• Nonsurgical Treatment
  • Casting:
    • Early stages treated with cast or special boot.
    • Prevent further deformities, reduce swelling.
    • Total contact cast used.
    • Non-weight bearing with crutches, knee scooter, or wheelchair.
    • Healing may take 3+ months.
    • Transition to specialized boot after swelling reduces.
  • Custom Shoes, Braces, and Orthotics:
    • For those unable to wear regular shoes.
    • Custom shoe inserts or braces to support foot and ankle.
• Surgical Treatment – Recommended when nonsurgical methods fail or for severe deformities.
  • Procedures:
    • Debridement of ulcers.
    • Lengthening calf muscle or Achilles tendon.
    • Removal of bony prominences (exostectomy).
    • Charcot deformity correction with plates, screws, rods.
    • Arthrodesis (joint fusion).
    • Amputation in severe cases.

Patient advice for DM foot management

• Inspect your feet daily. Check for cuts, blisters, redness, swelling or nail problems. Use a magnifying hand mirror to look at the bottom of your feet. Call your doctor if you notice anything.
• Bathe feet in lukewarm, never hot, water. Keep your feet clean by washing them daily. Use only lukewarm water—the temperature you would use on a newborn baby.
• Moisturize your feet but not between your toes. Use a moisturizer daily to keep dry skin from itching or cracking. But don’t moisturize between the toes—that could encourage a fungal infection.
• Cut nails carefully. Cut them straight across and file the edges. Don’t cut nails too short, as this could lead to ingrown toenails. If you have concerns about your nails, consult your doctor.
• Never treat corns or calluses yourself. No “bathroom surgery” or medicated pads. Visit your doctor for appropriate treatment.
• Wear clean, dry socks. Change them daily.
• Consider socks made specifically for patients living with diabetes. These socks have extra cushioning, do not have elastic tops, are higher than the ankle and are made from fibers that wick moisture away from the skin.
• Wear socks to bed. If your feet get cold at night, wear socks. Never use a heating pad or a hot water bottle.
• Keep your feet warm and dry. Don’t let your feet get wet in snow or rain. Wear warm socks and shoes in winter.
• Never walk barefoot. Not even at home! Always wear shoes or slippers. You could step on something and get a scratch or cut.
• Get periodic foot exams. Seeing your foot and ankle surgeon on a regular basis can help prevent the foot complications of diabetes.

DRIVING

www.austroads.com.au/assessing-fitness-to-drive/

TRAVEL

• Special insurance may be necessary
• All diabetic supplies should be carried on hand luggage
• Advisable to carry legible prescriptions + letter from medical practitioner
• NDSS card is accepted as primary proof that person w IDDM needs to carry diabetic equipment w them