Diabetic Complications

One of the biggest problems is that there are several complications associated with these conditions:

 

Non-enzymatic glycosylation (NEG) of macrovessels

This leads to atherosclerosis

– Causes cardiovascular disease – MI is 4x more common in diabetes and stroke 2x common

– Causes peripheral vascular disease – leading cause of non-traumatic amputations.

– If foot pulses cannot be felt, use Doppler pressure measurements. Ensure regular chiropody to remove callus to reduce risk of ulcers

Non-enzymatic glycosylation (NEG) of microvessels

This leads to hyaline arteriosclerosis

– Causes Nephropathy – nephrotic syndrome characterized by Kimmelstiel-Wilson nodules in glomeruli

– Gives microalbuminuria (when the urine dipstick is negative for protein but the urine albumin:creatinine ratio is >4mg/mmol)

– Diabetic patients get annual screening to measuring morning albumin:creatinine ratio

Diabetic retinopathy

Glucose enters Schwann cells, the lens and retinal blood vessels damaging them

– Results in osmotic damage

– Leads to Cataracts + Rubeosis iridis (new vessels on iris leading to glaucoma)

– Diabetes is the leading cause of blindness in the developed world.

Diabetic peripheral neuropathy

This is loss of sensation which often occurs in the feet

– Patient shows loss of sensation in “stocking” distribution + numbness/tingling

– Also leads to neuropathic deformity e.g. claw toes, Charcot Joint

– Pain is felt, worse at night

– 1st line treatment is Duloxetine

Diabetic Autonomic Neuropathy

This causes decreased lower oesophageal sphincter pressure giving GORD

– Can lead to chronic diarrhoea worse at night

– Gastroparesis –> Bloating and vomiting, alleviated with prokinetic antimimetics 

Hyperosmolar Hyperglycaemic State 

This is where hyperglycaemia results in osmotic diuresis, severe dehydration and electrolyte deficiencies.

– High glucose leads to osmotic diuresis with loss of sodium and potassium

– Gives severe volume depletion giving raised serum osmolality (>320mosmol/kg), making blood viscous

 

Symptoms:

General malaise –> Fatigue, nausea + vomiting

Neurological –> Low consciousness, headaches, papilloedema

Haematological –> MI and peripheral thrombosis (due to hyperviscosity)

Cardiovascular –> Tachycardia + Hypotension (similar to hypovolaemic shock)

 

Diagnosis:

  1. Hypovolaemia
  2. Marked Hyperglycaemia (>30 mmol/L) without much ketones or acidosis
  3. Significantly raised serum osmolarity (> 320 mosmol/kg)

 

Management – manage in HDU.

– 1st fluid resuscitation – IV 0.9% sodium chloride solution

 

– 2nd normalise blood glucose – only give insulin if ketones are high, as fluids will naturally reduce glucose

– If no ketones avoid insulin, as it leads to a rapid decline in glucose and serum osmolality increasing risk of central pontine myelinosis or cardiovascular collapse

 

– 3rd replace potassium as required – prevents arrhythmias.

Hypoglycaemia:

This is the most common endocrine emergency characterized by plasma glucose <3mM.

 

Causes:

Diabetic – Insulin or sulphonylurea treatment e.g. increased activity missed meal, overdose.

Non-Diabetic – The causes of non-diabetic hypoglycaemia are remembered by acronym (EXPLAIN).

EX = Exogenous drugs

P=Pituitary insufficiency

L=Liver failure

A= Addison’s

I= Insulinoma

N=Non-pancreatic neoplasms

 

SymptomsAutonomic – sweating, anxiety, tremor, dizziness

Neurological – Confusion, drowsiness, can be confused with a stroke

 

Treatment – If conscious, 15-20g of fast carbohydrate snack (orange juice) and recheck glucose after 10 min

– If conscious but not cooperative –> put glucose gel between teeth and gums

– If unconscious –> start glucose IV (10% and 200mL/15min) or glucagon 1mg IM (not in malnourished)

– Once blood glucose >4mM, give long acting carbohydrate e.g. slice of toast.

Insulinoma

This is a benign pancreatic islet cell tumour which is sporadic or commonly seen with MEN-1

 

Symptoms – Characterised by fasting hypoglycaemia with mental status change that is relieved by administration of glucose

Whipple’s triad –> Symptoms associated with fasting/exercise

–> Recording hypoglycaemia with symptoms

–> Symptoms relieved by glucose

 

Diagnosis – Give insulin and measure C-peptide levels

– This is because exogenous insulin usually inhibits C-peptide production, but not in an insulinoma

– You will therefore find low serum glucose levels in the presence of high insulin and C-peptide

 

Treatment – Surgical excision

Sources

Image 1 Charcot Joint: https://cks.nice.org.uk/diabetes-type-2#!diagnosisSub