© IDF (Europe) 1999
A Desktop Guide to
Type 2 Diabetes
Sections 15-19: Ischaemic heart disease, and kidney, eye, foot, and nerve damage
TYPE 2 DIABETES - 15 - ISCHAEMIC HEART DISEASE
15 ISCHAEMIC HEART DISEASE
Ischaemic heart disease develops in over three-quarters of
people with Type 2 diabetes, and kills half of them
It is often silent, often accompanied by cardiac failure, and is
less amenable to surgical intervention than usual
15.1 Assessment and diagnosis
Investigate if :
- classical angina or suspicious symptoms
- unexplained breathlessness
- cardiac failure, cardiomegaly, or cardiac rhythm disorder
- arterial thrombotic event
The threshold for investigation is lower if albumin excretion rate is abnormal
Investigate by :
- standard 12-lead ECG and chest X-ray
- cardiac ultrasound scan
- exercise stress ECG
- angiography / stress echo if indicated
15.2 Management
Intensify :
- management of arterial risk factors
- education on life-style management including smoking
Review :
- choice of blood pressure lowering drugs ( indication for beta-adrenergic blockers )
- use of aspirin / other anti-thrombotic therapy ( all patients )
- use of cardiac failure drugs ( indication for ACE-inhibitors )
Advise :
- early coronary bypass therapy / angioplasty / stenting if indicated
Use :
- intravenous insulin to control blood glucose levels after admission for myocardial infarction
Consider :
- hormone replacement therapy in post-menopausal women ( if agreed )
TYPE 2 DIABETES - 15 - ISCHAEMIC HEART DISEASE
TYPE 2 DIABETES - 16 - KIDNEY DAMAGE
16 KIDNEY DAMAGE
16.1 Detection and surveillance
Raised albumin excretion rate in Type 2 diabetes is often a sign of general vascular
damage rather than specific renal damage. It is a useful arterial risk marker
Abnormal serum creatinine in Type 2 diabetes is often due to renal arterial disease and/or
diuretic therapy for cardiac failure rather than to diabetic nephropathy
Detection and surveillance of specific kidney problems therefore depends on identifying
progression of albumin excretion rate and serum creatinine, in the absence of other causes
- Check for proteinuria yearly using reagent strips
Measure urinary albumin excretion yearly ( if not proteinuric ) using :
- pre-breakfast albumin:creatinine ratio, or
- pre-breakfast urinary albumin concentration
If ratio >2.5 mg/mmol ( >30 mg/g ) in men or >3.5 mg/mmol ( >40 mg/g ) in women
- or concentration >20 mg/l :
- repeat to confirm
- monitor any progression of kidney damage by more frequent measurement
Check for infection and consider other renal disease if proteinuria positive
- exclude infection with leucocyte/nitrate strips and microscopy / culture if positive
Measure serum creatinine yearly ( more often if abnormal, or rising and metformin-treated )
Measure blood pressure yearly for surveillance purposes ( sitting, after 5 min rest, 1st/5th phase )
16.2 Management if raised albumin excretion rate
If serum creatinine normal :
- monitor albumin excretion rate yearly to detect progression suggestive of specific kidney damage
- intensify management of modifiable arterial risk factors ( glucose, lipids, blood pressure )
If serum creatinine abnormal :
- review other specific causes of renal impairment ( recurrent infection, renal arterial / hypertensive damage, loop diuretic therapy / cardiac failure, glomerulonephritis )
- monitor albumin excretion and serum creatinine more frequently to detect progression of renal damage
If specific diabetic kidney damage ( diabetic nephropathy ) suspected :
- treat blood pressure aggressively with a target of <130/80 mmHg
- reduce salt intake
- use ACE-inhibitors as first-line drug therapy
- add loop diuretics, other agents if necessary
- reduce protein intake with target of <0.8 g/kg
- maintain good blood glucose control and tight arterial risk factor control
- treat urinary infections aggressively; consider papillary necrosis if recurrent
- arrange evaluation by a nephrologist before creatinine rises to 250 µmol/l ( 3.0 mg/dl )
TYPE 2 DIABETES - 16 - KIDNEY DAMAGE
TYPE 2 DIABETES - 17 - EYE DAMAGE
17 EYE DAMAGE
17.1 Detection and surveillance
Detection and surveillance of eye problems are a routine part of Annual Review
Organize a recall system to ensure it occurs regularly for every individual
Measure or assess yearly :
- visual acuity ( glasses or pinhole )
- the lens and vitreous ( ophthalmoscopy )
- the retina ( dilated pupils, retinal photography or skilled ophthalmoscopy )
- related factors ( smoking / blood pressure )
Reassess after shorter interval ( 3-6 mo ) if :
- pregnant
- new or progressive early or moderate non-proliferative retinopathy
- blood glucose control recently improved in people with retinopathy
17.2 Eye disease management
Refer to ophthalmologist if :
- severe non-proliferative retinopathy
- proliferative retinopathy
- macular oedema or exudative maculopathy
- visual disability from cataract
- unexplained deterioration of visual acuity
- other eye disease of visual significance
- unrecognized eye lesions
Review and intensify management of :
Attend to the psychological and social aspects of visual impairment where it develops
The primary management of diabetic eye disease is by careful attention
to blood glucose control targets from the time of diagnosis
TYPE 2 DIABETES - 17 - EYE DAMAGE
TYPE 2 DIABETES - 18 - FOOT PROBLEMS
18 FOOT PROBLEMS
18.1 Detection and surveillance
Detection and surveillance of foot problems are a routine part of Annual Review
- Organize a recall system to ensure it occurs regularly for every individual
Examine yearly :
- foot shape, deformity, joint rigidity, and shoes
- foot skin condition ( fragility, cracking, oedema, callus, ulceration )
- foot and ankle pulses
- sensitivity to monofilament or vibration, and pin prick
Assess yearly :
- history of foot problems since last review
- visual and mobility problems preventing self-care of feet
- self-care behaviours and knowledge of foot care ( including carer if appropriate )
Categorize as :
| 1. Foot ulcer | : | active foot ulceration, OR
|
| 2. High risk | : | neuropathy or vascular disease or previous ulcer or Charcot foot, OR
|
| 3. At risk | : | deformity or self-care problem or simple skin problem, OR
|
| 4. Low current risk
|
Monitor related factors ( blood glucose control, claudication, drug therapy, smoking )
18.2 Foot management - preventative
High risk foot
Involve a specialist in diabetes foot care
Provide :
- regular foot assessment
- local preventative attention to callus
- relief of pressure using foam spacers, made-to-order shoes, customized insoles
- regular foot care education - the commandments of foot care
- vascular referral if symptoms or critical arterial supply
At risk foot
- Provide :
- routine foot care according to need
- advice on appropriate footwear
- foot care education at routine visits
- advice to carers
18.3 Foot management - advanced disease
Established foot ulceration / infection
Involve your local diabetes foot team without delay
Use local measures including :
- debridement and trimming of callus
- dressings to absorb exudate
|
- foot casts to relieve pressure
- surgical drainage
|
Use systemic and proximal measures including :
- intravenous or oral antibiotic therapy - usually staphylococcal coverage, plus wider spectrum, anaerobes, or streptococcal as specifically indicated
- vascular referral, investigation, and reconstruction / angioplasty if indicated
Reserve amputation for :
- uncontrolled pain ( secondary to vascular disease )
- debilitating, long-term, non-healing ulceration
- a useless and disabling infected or Charcot foot
Foot ulceration is usually preventable
Amputation, even if foot ulceration occurs, is nearly always preventable
TYPE 2 DIABETES - 18 - FOOT PROBLEMS
TYPE 2 DIABETES - 19 - NERVE DAMAGE
19 NERVE DAMAGE
For Foot problems see above
19.1 Detection and surveillance
Detection and surveillance of nerve damage are a routine part of Annual Review
- Enquire yearly for :
Enquire for other manifestations of autonomic neuropathy if :
- other complications (especially kidney)
- before anaesthesia
- erratic blood glucose control
19.2 Management of painful neuropathy
Counsel for the depressing and disabling nature of the condition
Consider initially :
- bed foot cradles for night-time problems
- simple analgesia taken in advance of diurnal symptoms
- contact dressings
Consider therapeutic trials of :
- tricyclic drugs ( amitriptyline )
- carbamazepine at high doses ( 600-1200 mg/day )
19.3 Management of autonomic neuropathy
Erectile impotence
- sildenafil may be helpful if not contraindicated ( beware of nitrate therapy )
- intracavernosal/intraurethral alprostadil can be useful in some men
- referral to professionals with specialist expertise can be useful for :
- advice on vacuum devices, or mechanical or surgical prostheses
- vascular investigation and reconstruction
- psychological assistance
Gastroparesis
- investigation using radiological or radioisotope methods may help in diagnosis
- investigation of cardiovascular autonomic neuropathy may help diagnosis
- cisapride and domperidone are worth a trial
Diabetic nocturnal diarrhoea
- investigation must exclude other causes of intestinal upset
- may be helped by high doses of codeine, loperamide or diphenoxylate, or by erythromycin / tetracycline
Gustatory sweating
- explanation and counselling are often required
- try topical or oral anticholinergic agents
TYPE 2 DIABETES - 19 - NERVE DAMAGE