Treatment of Comorbidities & Complications


Cultural Competence
  • Asian-Americans:
    – Develop diabetes at a lower body mass
     
  • (BMI =24, compared to African American = 26, Caucasian = 30)
    – Develop diabetes at a younger age
    – Develop more end-stage renal failure
     
  • African-Americans
    – Insulin resistance is higher
    – Develop retinopathy at a lower A1c level
    – Higher rates of renal failure and peripheral artery disease
     
  • Latino-Americans
    – Mortality rate 2X whites
    – 50% of Latino children will develop diabetes and the rate in Latinos will double in the next 10 years
Screening for Complications
  • Dilated eye exam: Yearly
  • Urine microalbumin/creatinine ratio: Yearly
  • Foot screening to prevent amputation:
    – Monofilament, pulses, vibratory: Yearly
    – Visual inspection of feet at every visit
     
  • Ask about autonomic neuropathies: Erectile dysfunction, postural hypotension, gastroparesis (best test is gastric emptying time*)
  • Screening for cardiac disease with stress echo/thallium if patient is symptomatic, develops microalbuminuria, or for high index of suspicion
Ketoacidosis
  • Insufficient insulin; increased gluconeogenesis and fatty acid oxidation resulting in metabolic acidosis
  • Uncommon in type 2 unless African-American or Hispanic
  • Criteria
    – Anion gap > 10
    – Glucose ≥ 250
    – pH < 7.3,
    – Bicarbonate ≤ 18
    – Serum and urine ketones

Ketoacidosis Treatment

  • Volume replacement
    – 1 L NS/hr until dehydration resolved
    Then ½ NS at 150-500 ml/hr* (usually down 5-8 L)
  • Insulin drip (1-2 units/hr—0.1 U/kg/h)
  • Hourly monitoring of electrolytes, glucose, and pH
  • Bicarb only for pH < 7 or HCO2 < 10 mEq/L *
  • Replace K+ as soon as it starts to fall *
  • Continue insulin drip until acidosis is resolved *
  • Add D5 when glucose is ~ 250 mg/dL *
    – Reduce but do not stop drip if hypoglycemic
Hyperosmolar, Hyperglycemic State*
  • Hospitalization (may need ICU)
    – Mortality >>> DKA
     
  • Insulin infusion (oral and SQ are inadequate) *
  • IV fluids (normal saline)
  • Replace K+ as it falls near normal range
  • Oral medications and/or subcutaneous insulin is restarted after blood sugars return to the 200 range
  • Delirium or altered mental status usua
Microvascular Complications
  • Nephropathy, Retinopathy, Neuropathy
  • All treated with:
    – Glycemic control
    – BP control

    – Lipid control
    – Smoking cessation
     
  • No evidence that ASA is helpful*

Treatment

  • Retinopathy
    – Increasing globally
    – Refer to ophthalmologist for any retinopathy
    – Ranibizumab (Lucentis) for macular edema, replacing laser
     
  • Neuropathy
    1st:
    amitriptyline, nortriptyline, gabapentin, pregabalin, duloxetine, venlafaxine, 5% lidocaine patch
    2nd:
    topiramate, lamotrigine, carbamazepine, capsaicin cream
    3rd:
    opioids, tramadol
    Also try: L carnitine, acupuncture
    Symptomatic treatment
     
  • Nephropathy
    • Avoid NSAIDS: they acutely reduce renal blood flow and may cause interstitial nephritis*
    • Aggressive management of blood sugar and BP
    • Treat with increased doses of ACE inhibitors or switch to ARB if creatinine is increasing despite ACE therapy
    • Don’t use ACE inhibitor and ARB together*
    • May continue to monitor urine albumin to monitor treatment
    • When hypoglycemia occurs in previously well controlled type 2, most likely cause is progressing renal failure*
    • Refer: rapid decline, difficulty managing, advanced disease
Diabetic Foot
  • Leading cause of non-traumatic foot amputation
  • Neuropathy, altered foot structure, vasculopathy
  • Best test for sensation: Monofilament*
  • Best treatment: Aggressive prevention
  • Diabetic foot ulcer:
    • Remove pressure; good wound care and debridement; no antibiotics if not infected
       
  • Osteomyelitis usually occurs in the foot*: best test =  MRI**
  • Best indicator for successful healing: intact vascular supply (pulses)* Assess decreased pulse with noninvasive vascular studies (ABI)*
     
  • Etiology:
    Untreated: Aerobic Gm+ staph and β-hemolytic strep
    Treated: Polymicrobial
     
  • Treatment:
    • Cover MRSA and Strep (dicloxacillin, cephalexin, augmentin, doxycycline, trimethoprim/sulfa)