Introduction
Many of the vascular complications of diabetes present atypically, or are asymptomatic, so screening is an important part of diabetes care. This also means that complications can be recognised early, when treatment is more successful. Although glucose control is central to diabetes management and the prevention of vascular disease, managing hypertension and dyslipidemia are even more effective, so don’t forget these in your care plan.
This section provides you with a guide to screening and managing the many diabetes complications.
Screening schedule
| Schedule | Investigation |
| 3-monthly | HbA1c |
| 6-monthly | Fasting lipids – if treatment has been started recently |
| Urinary albumin – if ACE inhibitor or ARB started or increased recently | |
| 12-monthly investigations | Fasting lipids |
| Electrolytes & liver function test | |
| B12 and folate if patient taking Metformin | |
| Morning urine collection for urinary albumin:creatinine ratio | |
| 12-monthly assessments | Full medical assessment – review all the annual results |
| Retinal screening with optometrist or ophthalmologist | |
| Podiatry review | |
| Diabetes educator & Dietitian assessment | |
| Mental health assessment | |
|
Drivers’ license assessment if:
|
| Schedule | Investigation |
| 3-monthly | HbA1c |
| 6-monthly | Fasting lipids – if treatment has been started recently |
| Urinary albumin – if ACE inhibitor or ARB started or increased recently | |
| 12-monthly investigations | Fasting lipids |
| Electrolytes & liver function test | |
| B12 and folate if patient taking Metformin | |
| Morning urine collection for urinary albumin:creatinine ratio | |
| 12-monthly assessments | Full medical assessment – review all the annual results |
| Retinal screening with optometrist or ophthalmologist | |
| Podiatry review | |
| Diabetes educator & Dietitian assessment | |
| Mental health assessment | |
|
Drivers’ license assessment if:
|
Regular screening tests and assessments are recommended in the following schedule:
Peripheral neuropathy – feet and hands
Neuropathy develops as a result of microvascular disease affecting the nerves distally and progresses proximally as it worsens. Damage to the three different nerve fibres causes the clinical presentations:
Non-diabetic causes of neuropathy include:
Peripheral neuropathy – feet and hands
Neuropathy and vascular disease coexist, so management needs to focus on improving vascular flow as well as analgesia and glycaemic control.
Neuropathic pain
Neuropathy develops due to ischemia caused by underlying microvascular disease. It affects the three different nerve fibres in a pattern unrelated to typical dermatomes, causing a mix of clinical presentations:
Non-diabetic causes of neuropathy include:
While management focuses on pain relief and glucose control, remember to investigate and managing underlying vascular disease which coexists with neuropathy.
Gastrointestinal complications
Constipation affects 75% of all people with type 2 diabetes but is often overlooked. It is a neuropathic complication of diabetes, where the damaged enteric nervous system leads to dysmotility and dysfunction of the entire gastrointestinal system. The clinical manifestations relate to neuropathy of three different nerve fibres in the gut wall:
Gastroparesis can be difficult to manage, because the promotility agents are not effective for long, and are associated with cardiac conduction abnormalities. It is more effective to manage the constipation, which leads to improved upper gastrointestinal motility and lower glucose levels.
Where constipation is due to neuropathy, the aperients need to be given regularly and in combination - a stimulant aperient added to a stool softener is more effective.
Faecal impaction may present with pelvic pain, tenesmus and overflow diarrhoea. It requires treatment with enemas before oral aperients are effective.
Foot ulcers and infection
Peripheral neuropathy and peripheral vascular disease in the feet increase the risk of skin ulceration and infection for people with diabetes. The neuropathy means that the skin loses its normal protective mechanisms and inadequate blood flow means that the skin is unable to heal properly.
Neuropathic ulcers appear over bony prominences, can be deep and “punched out” with thickened skin at the edges. These are at risk of deeper infection and osteomyelitis.
Retinopathy
Retinopathy can be asymptomatic until it is very severe and life-threatening. Therefore, regular screening is recommended to detect and treat retinal disease early in its pathogenesis. Apart from optimal glucose control, lowering blood pressure and managing lipids delay the onset and progression of retinal disease, so these need to be part of your patients’ management plan.
Nephropathy
Diabetic nephropathy is the commonest indication haemodialysis, and its presence increases the risk of cardiovascular disease. Given that nephropathy is asymptomatic and early management of albuminuria can prevent or delay overt nephropathy, annual screening is critical for kidney care. Once renal disease is established, diabetes medications need to be revised as many are contraindicated in overt nephropathy and the risk for hypoglycemia is high.
Cardiac disease: CCF, cardiomyopathy
Although coronary artery disease is the most common cause of cardiac failure in people with diabetes, the hyperglycemia and hyperinsulinemia may contribute independently. Active management of hyperglycemia, but lifestyle strategies aimed at reducing insulin resistance are particularly important – See Lifestyle Strategies.
The symptoms are similar to non-diabetic individuals but can be overlooked if fatigue is the main presenting complaint. Have a low threshold for investigating for CCF, but active management can prevent it.
Stroke
Diabetes is the commonest cause of stroke and transient ischaemic attacks. Although glucose control is central to diabetes management, lowering lipids and blood pressure are more effective strategies to prevent CVAs and to prevent recurrence.
Remember that a severe hypoglycemic event can mimic a stroke, particularly if your patient has already suffered a stroke. Check the glucose level with any acute presentation and revise the diabetes medications to minimize the risk of hypoglycaemia.
Coronary artery disease
Cardiovascular disease is the commonest cause of death in people with diabetes.
Coronary artery disease is typically extensive, inflammatory and highly calcified throughout the length of all three coronary arteries. Diffuse coronary artery disease is better treated with CABG or medical therapy rather than percutaneous coronary artery stents
Erectile dysfunction
Erectile dysfunction develops as a result of peripheral neuropathy and microvascular disease. It is an important predictor of cardiovascular disease, so its presence should be a prompt to undertake cardiac investigations and start cardio-protective medications.
