Good control on blood glucose levels will prevent micro vascular complications, but to a lesser extent the macro vascular complications. Microvascular complications include retinopathy and nephropathy. Macrovascular complications include coronary heart disease, stroke, and hyerlipidemia.

 

Complications of Diabetes mellitus

• Microvascular complications- retinopathy (deterioration in vision), nephropathy (kidney disease)
• Macrovascular complications- hypertension, Coronary heart disease, cerebrovascular disease (stroke), peripheral vascular disease, hyerlipidemia
• Diabetic neuropathy
• Diabetic foot
• Diabetic gastro paresis and other autonomic dysfunction
• Frequent infections- skin and soft tissue infection, oral infections, ear, nose and throat infections
• Balanitis- inflammation of glans penis, mainly by fungus
• Hypoglycemic unawareness
• Hyperosmolar hyperglycemic nonketotic coma
• Diabetic ketoacidosis
• Osteoporosis
• Depression

Macrovascular complications

Hypertension

• Hypertension, which itself is an individual risk factor for atherosclerosis; it’s twice as common in patients with type 2 diabetes.
• In patients with diabetes, hypertension must be treated aggressively to lower their risk of serious atherosclerosis.
• ACE inhibitors and angiotensin II–receptor blockers (ARBs) are the first line drugs - its controls hypertension, reduces the LDL cholesterol, and cardioprotective in action.
• Calcium channel blocker and diuretics are the second line drugs.

Coronary artery disease (CAD)

• CAD is the leading cause of death in patients with diabetes, causing 75% of deaths in this group but approximately 35% of deaths in people without diabetes.
• Diabetes increases the risk of myocardial infarction, triple vessel blocks and angina.
• Patients with diabetes may have an increased incidence of silent ischemia (silent heart attacks)
• Diastolic dysfunction is common in patients with diabetes
• ACE inhibitors and angiotensin II–receptor blockers (ARBs) reduces the risks of CAD
• Aggressive treatment of hypercholesterolemia is required with lipid lowering agents
• Prophylactic therapy with Aspirin is used in angina and MI patients

Dyslipidemia

• Dyslipidemia, particularly high triglycerides levels and low HDL- cholesterol, is more common in patients with type 2 diabetes mellitus.
• Fibrates may reduce coronary heart disease (CHD) events in patients with isolated low HDL-C.
• Primary prevention is statin (Atorvastatin or Simvastatin) therapy to reduce CHD events.

Microvascular complications

Diabetic retinopathy

• Diabetes affects the lens, vitreous, and retina, causing visual symptoms causing visual blurring and blindness.
• Patients with diabetes also tend to develop senile cataracts (snow-flake cataract) sooner than persons without diabetes
• Diabetic retinopathy depends on the duration of the diabetes and on the level of sugar control maintained
• Hard and soft exudates, flame shaped hemorrhages, and cotton wool spots are seen on fundoscopy
• Tractional retinal detachment and retinal hemorrhages are the complications of diabetic retinopathy.
• A good control on sugar levels can prevent diabetic retinopathy, microvascular complications are reduced by 25% when median HbA1c is 7% compared with 7.9%.
• Laser photocoagulation is the main treatment for retinal lesions.
• Extracapsular extraction is the treatment of choice in snowflake cataract.

Diabetic nephropathy

• Type 2 diabetes account for most patients with diabetes with end stage renal disease
• Persistnantly elevated blood pressure contributes to the decline in kidney function, hypertensive patients with diabetes must be referred for long-term management of the blood pressure
• Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blockers (ARB) are recommended because they decrease proteinuria and slow decline in kidney function independent of their effect on blood pressure.
• Potentially nephrotoxic drugs should be avoided whenever possible.

Diabetic neuropathy

• Neuropathy is typically distal, sensory-motor, polyneuropathy (glove and stocking in distribution)
• The most common cranial nerve affected is 3 rd (oculometer nerve), followed by fourth and sixth cranial nerve. Can present with diplopia and eye pain
• Treatment with methylcobalamin (vitamin B12) and GABA agonists (Gabapentin and Pregebalin) will reduce the numbness and tingling sensation.

Diabetic foot

• Insensitive and poorly perfused tissue, repeated skin stress; unnoticed minor trauma is the risk factors for diabetic foot.
• These can evolve into cellulitis, osteomyelitis, or nonclostridial gangrene and end in amputation.
• Local treatment for diabetic ulcers, appropriate use of good antibiotics, immobilization by bed rest, boots, wheelchair/crutches
• If gangrene has setup, vascular compromise is well recognized then amputation is required. Good control on blood glucose is very important.

Diabetic gastro paresis with autonomic neuropathy

• Presents with vomiting, severe diarrhea, bladder dysfunction and urinary retention, or symptomatic orthostatic hypotension
• Treatment of gastro paresis is symptomatic, patients with gastro paresis may benefit from metoclopramide or erythromycin.
• The degree of dehydration and metabolic imbalance must be assessed.
• Patients with disabling orthostatic hypotension may be treated with salt tablets, support stockings, or fludrocortisone.

Increased risk of infections

Infections, with as staphylococcal sepsis, occur more frequently and result in greater mortality.

Malignant or necrotizing otitis externa

• It principally occurs in patients with diabetes who are more than 35 years and is almost always due to Pseudomonas spp.
• Presents with earache, foul smelling greenish discharge, granulations in auditory tube spreading to ear pinna, mastoid with involvement of cranial nerves (7 th cranial nerve).
• CT scan is diagnostic
• Treatment -antipsuedomonal penicillin’s and surgical debridement

Mucormycosis

• Mucormycosis collectively refers to infections caused molds.
• Organisms colonize the nose and paranasal sinuses, spreading to adjacent tissues by invading blood vessels and causing soft tissue necrosis and bony erosion.
• Patient presents with periorbi.tal or paranasal pain, indurations, swelling, bloody discharge, black necrotic nasal turbinate.
• CT scan is diagnostic
• Treatment consists of controlling the predisposing hyperglycemia and acidemia, administering intravenous amphotericin B, and immediate surgical debridement

Urinary tract infections

• More than 70% of cases of emphysematous pyelonephritis occurred in patients with diabetes.
• Most common organism is E-coli and klebseilla.
• Ultrasound and CT scan KUB region is diagnostic
• Adequate hydration, metabolic derangement correction, and antibiotics is helpful

Diabetic ketoacidosis (DKA) - protocol

Fluid replacement

• 0.9% saline 500ml- 1lts in first 2 hrs
• Half normal saline 0.45% until the blood glucose levels are <250 mg/dl
• 5% dextrose in 0.45 normal saline until the resolution of DKA

Potassium replacement

• If serum potassium is >5.5 not to give K+, check the serum every 2 hrs
• K+ = 4.5- 5, add 20 mmol of KCL to intravenous fluids
• K+= 3-4, add 40 mmol of KCL to intravenous fluids

Insulin therapy

• Loading dose: 0.1-0.15 U/kg IV bolus
• Maintenance ED doses: 0.1 U/kg/h IV infusion
• When the blood glucose levels are <200 mg/dl change the 5%dextrose to 0.45% saline.