Complications of Diabetes Mellitus
- Macrovascular complications
- Stroke/TIA
- Myocardial Infarction
- Angina
- Peripheral Vascular disease
- Microvascular complications
- Diabetic retinopathy
- Nephropathy (albuminuria)
- Erectile dysfunction
- Osteomyelitis
- Infection
- Neuropathic complications
- Autonomic neuropathy (eg. gastroparesis)
- Peripheral neuropathy (30-40% of patients. Common complication)
| Complication | When to tx | Tx | Recheck |
|---|---|---|---|
| Hypertension | >140/90 x 2 | ACEi/ARB +/- HCTZ | q 6 months |
| Nephropathy | + proteinuria | ACEi/ARB | q1y |
| Hyperlipidemia | LDL > 100 (2.6) | Statin | q1y |
| Retinopathy | Proliferative retinopathy; Non-proliferative retinopathy | Symptoms; Tighter glucose control | q1y |
| Foot health | Injury present | Depends on injury | q1y |
| Peripheral neuropathy | Symptoms present: | Gabapentin, Pregabalin, AEDs | PRN |
| Gastroparesis | Symptoms present: nausea, vomiting, abdominal discomfort, and early satiety. | metoclopromide or erythromycin | – |
| Infection | – | Annual influenza, One-time Pneumococcal vaccine | – |
| Obesity | When present | Diet/Exercise; Refer to bariatric surgeon if morbid | – |
| Smoking cessation | – | Stop smoking… | – |
Hypertension
Screening is done as normal (140/90 on two occasions). ACEi (Lisinopril, Captopril) or ARB (Valsartan, losartan) is preferable. Adjunctive therapy with thiazide (hydrocholorthiazide) can be considered. BP goal is <130/80 (140/90 works as well)
- Blood pressure goals
- < 140/80 mmHg
- < 130/80 mmHg if there is end-organ damage e.g. renal disease, retinopathy
Nephropathy
Screening for proteinuria is MANDATORY. ACEis or ARBs slows progression to ESRD
Lipids
Lipids are taken after diagnosis. LDL goal is <130 (3.4). Preferably start a patient with LDL >100 (2.6) on a statin (atorvastatin, lovastatin). Recommend exercise (exercise will lower blood glucose and raise HDL)
Retinopathy
Screening for retinopathy is done at diagnosis and q1y thereafter. Done by ophthalmologists. Symptoms of retinopathy include loss of visual acuity, floaters, and blurred vision. Proliferative retinopathy is the most problematic complication
- Treatment of proliferative retinopathy
- Surgery (Ophthalmology)
- Treatment of non-proliferative retinopathy
- Tight glucose control
Infection prophylaxis
Leaves patients in a semi-immunocompromised state leaving them at risk of infection. Annual influenza vaccine AND one-time pneumococcal vaccine
Obesity
Obesity has a causal linkage with T2DM. Weight loss (low carb and low-calorie diet with appropriate exercise) is always recommended with diabetes. Can refer to a bariatric surgeon if BMI > 35.
Smoking cessation
Reduces the risk of macrovascular and microvascular complications, as well as has other obvious health benefits.
Erectile dysfunction
Microvascular complication. May treat with sildenafil, and tadafil (Contraindicated if the patient is on nitrates). Ensure the patient is healthy enough for sex (NYHA class, Rule out unstable angina).
Gastroparesis
Neuropathic complication. Suspect in uncontrolled diabetes, if the patient presents with dyspepsia, nausea, vomiting, or diarrhea. The best test for diagnosis is Barium swallow (gastric emptying time). Treat with metoclopramide OR erythromycin
Peripheral neuropathy
Microvascular complication. Pins and needle sensation, particularly in the feet and legs. Treat with gabapentin, pregabalin OR AEDs (carbamazepine, phenytoin)
