Prevention of Complications of Diabetes

The complications of diabetes can be divided into acute and chronic complications.

Acute complications

• Diabetic Ketoacidosis (DKA)
• Hyperglycemic Hyperosmolar Non-Ketotic Syndrome (HHNS)

Acute complications of diabetes can occur at any time in the course of the disease.

Chronic complications

• Cardiovascular: Heart disease, peripheral vascular disease, stroke
• Eye: Diabetic retinopathy, cataracts, glaucoma
• Nerve Damage: Neuropathy
• Kidney Damage: Nephropathy

Chronic complications are responsible for the majority of illnesses and death associated with diabetes. Chronic complications usually appear after several years of elevated blood sugars (hyperglycemia). Since patients with type 2 diabetes may have elevated blood sugars for several years prior to diagnosis, these patients may have evidence of complications at the time of diagnosis.

Basic principles of prevention of complications of diabetes

• Take your medications (pills and/or insulin) as prescribed by your doctor
• Monitor your blood sugars closely
• Sensible diet. Do not skip meals.
• Exercise regularly
• See your doctor regularly to monitor for complications

Diabetic Ketoacidosis (DKA)

• Results from untreated hyperglycemia.
• Blood sugars typically range from 300 to 600.
• Occurs mostly in patients with type 1 diabetes (uncommon in type 2)
• Occurs due to a lack of insulin
• Body breaks down its own fat for energy and ketones appear in the urine and blood.
• Develops over several hours.
• Can cause coma and even death.
• Typically requires hospitalization.

Symptoms of DKA

• Nausea, vomiting
• Abdominal pain
• Drowsiness, lethargy
• Deep, rapid breathing
• Increased thirst
• Fruity-smelling breath
• Dehydration

Causes of DKA

• Inadequate insulin administration
• Infection
• Heart attack (myocardial infarction)

Prevention of DKA

• Take your medications as prescribed
• Monitor your blood sugar closely, especially when you are ill
• Maintain a balanced diet with regularly scheduled meals
• Keep yourself well-hydrated
• Exercise regularly
• Call or see your doctor if you or family members notice symptoms suggestive of DKA and/or your blood sugar is elevated (above 300).

Hyperglycemic Hyperosmolar Non-Ketotic Syndrome (HHNS)

• More gradual onset than DKA (days to even weeks)
• Occurs in patients with type 2 diabetes, especially the elderly
• Usually occurs when patients are ill or stressed
• Blood sugars typically are greater than 600
• Symptoms include frequent urination, drowsiness, lethargy, and decreased intake of fluids. HHNS is not typically associated with nausea, vomiting, or abdominal pain.
• Not associated with ketones in the blood.
• Can cause coma or death.
• Typically requires hospitalization.

Prevention of HHNS

• Similar to DKA
• Take your medications as prescribed by your doctor
• Monitor your blood sugars carefully, especially when ill
• Keep yourself well-hydrated
• Call or see your doctor if you or a family member suspect that you may have symptoms of HHNS and/or your blood sugars are elevated.

Cardiovascular complications in diabetes

• Cardiovascular disease is the most deadly complication of diabetes.
• 75 to 85% of patients with diabetes die from heart disease or stroke.
• Diabetes is one of the leading risk factors for cardiovascular disease.
• Patients with diabetes are considered to have the same risk for cardiovascular disease as patients without diabetes who have had a prior cardiovascular event.
• Men with diabetes are 2 to 3 times more likely to develop cardiovascular disease than are men without diabetes.
• Women without diabetes are 4 to 6 times more likely to develop cardiovascular disease than are women without diabetes.
• Patients with diabetes often do not have the classic symptoms of heart disease, such as chest pain.

Risk factors for heart disease

• Age
• Diabetes
• High blood pressure
• High cholesterol
• Tobacco use
• Family history

General principles for prevention of heart disease in patients with diabetes

• Aggressive control of blood sugar
• Aggressively treat other modifiable risk factors for heart disease (high blood pressure, high cholesterol, and smoking)
• Aspirin has been shown to be protective in patients with known cardiovascular disease. Although it has not definitively been shown to prevent heart disease, it should be considered in patients with diabetes, especially those with other risks for heart disease (high blood pressure, high cholesterol). Ask your doctor if aspirin is appropriate for you.
• There are no specific recommendations regarding routine stress testing to look for heart disease in patients with diabetes. Ask your physician if he or she thinks you need a stress test.

Peripheral vascular disease

• Decreased blood flow in the legs and feet
• Symptoms: Pain in the calf, thigh, and buttocks with walking. Symptoms are relieved with rest.
• These symptoms are known as intermittent claudication.
• Claudication is associated with an increased risk of heart disease, leg ulcers/ infections, and lower extremity amputation.
• If you think you have symptoms suspicious for claudication, please tell your physician.

Cholesterol and diabetes
A fasting cholesterol profile should be checked at least every year in patients with diabetes.

Component	Goal for Patients with Diabetes
Total Cholesterol	Less than 200
LDL Cholesterol (Bad Cholesterol)	Less than 100
HDL Cholesterol (Good Cholesterol)	Men: Above 45; Women: Above 55
Triglycerides (Fats in the Blood)	Less than 150

The typical cholesterol profile in patients with diabetes includes low HDL cholesterol and high triglycerides.

The initial focus of treatment of high cholesterol in patients with diabetes is to lower the LDL cholesterol. Studies have suggested that the risk for cardiovascular disease in patients with diabetes may increase with LDL cholesterol above 80.

Treatment of high cholesterol in diabetes

• Control blood sugars, blood pressure
• Low-fat diet
• Quit smoking
• Exercise and weight loss help raise the HDL cholesterol
• Medications

Medications

Statin drugs (HMG CoA reductase inhibitors): Lipitor, Zocor, Pravachol, Mevacor, Lescol. These medications are especially effective at lowering LDL and total cholesterol. They also help lower triglycerides and raise HDL cholesterol. Statin drugs are the most powerful drugs that we have to lower the LDL cholesterol. Two potential side effects of statins that all patients on these medications need to be aware of are liver inflammation and muscle damage. While these side effects are very rare, patients need to know what to look for. Symptoms suggestive of liver inflammation include nausea, vomiting, right-sided abdominal pain, decreased appetite, dark-colored urine, and light-colored stools. Symptoms suggestive of muscle damage include any new muscle soreness or weakness. If you think you have developed any of these symptoms while on statin drugs, please notify your doctor immediately.

Fibrates: Tricor, Lopid. The main effect of these medications is to lower triglycerides. These medications also can lower LDL cholesterol and raise HDL cholesterol. These medications can also cause liver inflammation.

Niacin lowers triglycerides and LDL cholesterol while raising HDL cholesterol. Niacin can make diabetes more difficult to control, but does not necessarily mean that you cannot be started on this medication. Niacin can also cause liver inflammation.

ACE inhibitors: One study showed that the ACE inhibitor Ramipril (a blood pressure medication) decrease the rate of heart attack, stroke, and death from cardiovascular causes in patients with diabetes and cholesterol above 200 or a low HDL cholesterol. Not all patients are suitable for these medications, so please consult with your doctor.

Eye complications with diabetes

• Diabetes is the leading cause of new blindness in adults ages 20 to 74.
• Patients with diabetes are 25 times more likely to become legally blind than are patients without diabetes.
• 3 Major Complications: Retinopathy, Cataracts, Glaucoma
• Blurred vision can occur as a result of high blood sugars. However, it can also be a result of more serious eye problems. Contact your doctor if your vision is blurred.

Prevention of eye complications

• At least yearly comprehensive eye examinations by an eye doctor (ophthalmologist) to screen for retinopathy, cataracts, and glaucoma.
• Intensive control of blood sugars
• Control blood pressure

Diabetic retinopathy

• Damage to the retina (the lining of the interior of the eye)
• Patients with type 2 diabetes may have evidence of retinopathy when they are diagnosed with diabetes.
• Non-proliferative and proliferative types
• Non-proliferative: Typically occurs after several years of diabetes. The non-proliferative form is common and usually mild. Patients do not typically have symptoms with this form of retinopathy.
• Proliferative: Some patients with the non-proliferative form progress to the proliferative form of retinopathy. New blood vessels grow in and around the retina.
• Symptoms with proliferative retinopathy: Blurred vision, black spots or holes in the vision, blindness.
• Treatments include laser treatment and surgery

Cataracts

• Clouding or fogging of the lens
• Symptoms: Blurred or cloudy vision
• Treatment: Surgery, lens implants

Glaucoma

• Increased pressure in the eyes
• Symptoms: Headache, nausea, vomiting, eye pain, decreased vision, blurred vision, watering of the eyes
• Treatment: Eye drops, laser therapy, surgery

Nerve damage (Neuropathy) and diabetes

• 2 Forms: Peripheral and Autonomic
• 50 to 70% of patients with diabetes develop neuropathy.
• Neuropathy most likely develops due to long-term high blood sugars.
• Diabetes is the leading cause of non-traumatic lower limb amputation.

Peripheral Neuropathy

• Affects sensation, especially in legs and feet
• Can be permanent
• Symptoms: Burning, pain, tingling, or numbness in the extremities, especially in the feet and legs
• Can have no symptoms
• Usually notice symptoms at rest; symptoms are often worse at night.
• Medications to help relieve symptoms of peripheral neuropathy: Tricyclic antidepressants (Elavil) and Neurontin

The development of peripheral neuropathy is potentially serious. Since patients with diabetes have a decreased ability to perceive pain, minor and even major injuries or trauma can go unnoticed. Similarly, because of difficulty perceiving changes in position, patients with diabetes may have difficulty bearing weight properly and are at risk for developing calluses and ulcers on their feet.

Prevention of complications involving the feet and legs

• Control blood sugars.
• Keep your feet clean and moist.
• Wear properly fitting shoes and clean socks. Do not walk barefoot.
• Take warm (not hot) showers.
• Examine your feet every day for evidence of skin breakdown, sores, or ulcers.
• See your doctor for any foot injury or ulcer. Do not try to treat them yourself.
• Many patients with diabetes see a podiatrist (foot doctor) for foot and nail care.

Autonomic Neuropathy

• Cardiovascular
  - Symptoms: Low blood pressure, fast pulse, dizziness, passing out
  - Treatment: Avoid standing up too quickly, medications, stockings
• Gastrointestinal
  - Symptoms: Nausea, vomiting, decreased appetite, feeling full more quickly, bloating, diarrhea, constipation.
  - Treatment: Control blood sugar, smaller meals, medications
• Genitourinary
  - Symptoms: Impotence, female sexual dysfunction, unable to empty bladder fully
  - Treatment: Viagra, vaginal lubricants, self-catheterization
• Skin: Dry, cracked skin; impaired wound healing

Kidney damage (Nephropathy) and diabetes

• Diabetes is the leading cause of end-stage kidney disease in the US
• End-stage kidney disease requires dialysis and/or a kidney transplant.
• An early sign of kidney damage with diabetes is the presence of small amounts of protein (albumin) in the urine.
• If protein in the urine goes undiagnosed or untreated, it can lead to end-stage kidney disease.

Prevention of kidney damage in patients with diabetes

• At least yearly blood tests (BUN and creatinine) to assess kidney function
• Your doctor should check your urine once a year for protein in the urine.
• Strict control of blood sugars and blood pressure
• ACE inhibitors (blood pressure medication) have been shown to slow the rate of progression of kidney disease in diabetes. Commonly prescribed ACE inhibitors include Altace, Accupril, Zestril, and Vasotec.
• Monitor protein intake closely. Patients with evidence of protein in the urine should modestly restrict the protein intake. You may want to consult with a nutritionist or diabetic educator to determine the appropriate degree of protein in your diet.

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