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Treatment of Long-Term Complications Associated with Diabetes Mellitus!

 

TREATMENT OF CONCOMINANT CONDITIONS RELATED TO DIABETES MELLITUS

  1. Coronary Heart Disease
  2. Dyslipidemia
  3. Hypertension
  4. HIV and AIDS
  5. Antipsychotic Therapy
  6. Hypoglycemia
  7. Diabetic Ketoacidosis (DKA)
  8. Hyperosmolar Hyperglycemic state
  9. Retinopathy
  10. Neuropathy
  11. Foot Ulcers 
TREATMENT OF LONG-TERM COMPLICATIONS
1. Retinopathy
2. Neuropathy
3.Microablumiuria
4. Foot Ulcers

9.RETINOPATHY

  • Diabetic retinopathy is the leading cause of blindness in adults 20-74 years of age in the United States.

Pathophysiology:

  • Diabetic retinopathy occurs when the microvasculature that supplies blood to the retina becomes damaged. This damage permits leakage of blood components through the vessel walls.

Etiology:

  • The risk of retinopathy is increased in patients with longstanding DM, chronic hyperglycemia, hypertension and nephropathy. Glaucoma, cataracts and eye disorders are more frequent in pt. with DM.

Treatment:

  • The AD recommends that patients with DM receive a dilated eye examination annually by an ophthalmologist or optometrist.
  • Examinations should begin within 5 years of diagnosis of T1 DM and shortly after the diagnosis of T2 DM.

Prevention:

  • Glycemic control is the best prevention for slowing the progression of retinopathy along with optimal blood pressure control.
  • Early retinopathy may be reversed with improved glucose control.

10.NEUROPATHY

  • Peripheral neuropathy is a common complication reported in T2 DM.

Clinical Presentation:

  • Gastroparesis, resting tachycardia, orthostatic hypotension, Impotence, Constipation and Hypoglycemic autonomic failure.

Symptoms:

  1. Pain
  2. numbness in the extremities
  3. The feet are affected more often than the hands and fingers.

Complication:

    • Autonomic neuropathy is a common complication as DM progresses.

    Treatment:

    • Current options include Pregabalin, Low-dose tricyclic antidepressants, Duloxetine, Venlafaxine, Topiramate, NSAIDs and Topical Capsaicin.

    Therapy:

    • Therapy for each individual is addressed separately.

    11.MICROALBUMINURIA AND NEPHROPATHY

    "Microalbuminuria is defined as between 30-300mcg of albumin per milligram of creatinine. The presence of microalbuminuria is a strong risk factor for future kidney disease in T1 DM".
    • Diabetes Mellitus is the leading contributor to end-stage renal diseases.

    Normal Units:

    • The desirable value is less than 30mcg of albumin per milligram of creatinine.

    Diagnosis:

    • Early evidence of nephropathy is the presence of albumin in the urine. Therefore, as the disease progresses, larger amounts of protein spill into the urine.

    Screening:

    • The most common form of screening for protein in the urine is a random collection for measurement of the urine albumin-to-creatinine ratio.

    Therapy:

    • Glycemic control and blood pressure control are primary measures for the prevention and progression of nephropathy.
    • ACE Inhibitors and Angiotensin II receptor blockers prevent the progression of renal diseases in patients with T2 DM.
    • Treatment of advanced nephropathy includes dialysis and kidney transplant.

    Recommendations:

    • The ADA recommends urine protein tests annually in T2DM patients.
    • For children with T1 DM, annual urine protein testing should begin with the onset of puberty or 5 years after the diagnosis of diabetes.

    12.FOOT ULCERS

    "A foot ulcer is an open sore that develops and penetrates to the subcutaneous tissues".
    Complications of the feet develop primarily as a result of peripheral vascular disease, neuropathies and foot deformations.

    Pathophysiology:

    • Peripheral vascular disease causes ischemia to the lower limbs. This decreased blood flow deprives the tissues of oxygen and nutrients and impairs the ability of the immune system to function adequately.

    Symptoms:

    1. Intermittent claudication
    2. Cold feet
    3. Pain at rest
    4. Loss of hair on the feet and toes

    Treatment:

    • Treatment includes glycemic control, preventing infection, debriding dead tissues, treating edema and limiting ambulation.

    Therapy:

    • Smoking cessation is the single most important treatment for peripheral vascular disease.
    • In addition, exercising by walking to the point of pain and then resting and resuming can be a vital therapy to maintain and improve the symptoms of peripheral vascular disease.
    • Pharmacologic interventions with Pentoxifylline or Cilostazol also may be useful to improve blood flow and reduce the symptoms of peripheral vascular disease.

    Recommendations:

    • To prevent foot complications, the ADA recommends daily visual examination of the feet and a foot check performed at every physician visit.
    • Sensory testing with a 10-guage monofilament can detect areas of neuropathy.


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