Assignment 4: Chronic disease management

User: Beatriz Duque

Email: bettyd2382@stu.southuniversity.edu Date: October 2, 2020 10:29PM

Learning Objectives
The student should be able to:

List the major causes of morbidity and mortality in diabetes mellitus.

Recognize the basic management of hypertension and hyperlipidemia in the diabetic patient. Perform a diabetic foot exam.

Counsel patient on behavior change.

Recognize value of a team approach to the management of diabetes.

Appreciate the impact diabetes mellitus has on a patient’s quality of life, well-being, ability to work, and the family.

Knowledge

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Hypoglycemia

It is important at each visit to ask diabetic patients if they have experienced any hypoglycemic symptoms or events that required the assistance of another person.

Often times, when a patient is hypoglycemic, he does not write it down because he is preoccupied treating the hypoglycemia.

Diabetic Neuropathies

It is estimated that 50% of patients with diabetes will eventually struggle with one or more neuropathies related to their diabetes.

Axonal loss and atrophy are responsible for the majority of clinical symptoms and loss of function in patients with neuropathy. There can also be evidence of demyelination and remyelination, with the actual number of large nerve fibers being reduced, while small nerve fibers increase.

Distal polyneuropathy

Distal polyneuropathy is the most common type of diabetic neuropathy. It is the progressive loss of sensation in the classic stocking/glove distribution. Diabetic foot ulcer incidence is greatly increased in patients with distal polyneuropathy.

Autonomic neuropathy

Autonomic neuropathy can take many forms and affect one or many organs. Specific types include:

cardiovascular (orthostatic hypotension, resting sinus tachycardia, postprandial hypotension) gastrointestinal (gastroparesis, chronic constipation, esophageal motility disorders) genitourinary (sexual dysfunction, neurogenic bladder) abnormal pupillary responses and disorders of hidrosis

Diabetic Retinopathy

Diabetic retinopathy, a microvascular diabetic complication, is the leading cause of preventable blindness in the developed world.

Prevention

Two large prospective trials (DCCT with Type 1 diabetics and UKPDS with Type 2 diabetics) revealed that intensive glucose management resulted in prevention or delayed onset and progression of diabetic retinopathy.

Coexisting hypertension, nephropathy, and tobacco abuse also contribute to retinopathy onset and progression.

Two types of diabetic retinopathy

1. Non-proliferative diabetic retinopathy

Involves cotton wool spots, hard exudates, microaneurysms, and retinal hemorrhages. Assignment 4: Chronic disease management

Vision loss usually results from severe macular edema, a thickening of the retina with resultant edema of the macula.

2. Proliferative diabetic retinopathy

Involves neovascularization of the retinal vessels or optic disc, retinal hemorrhage (dot-blot, flame), retinal fibrosis with traction detachment, and vitreous hemorrhage. Macular edema can occur as well.

Image of proliferative retinopathy with neovascularization

Onset

Development of diabetic retinopathy is directly related to disease duration and is generally not seen in patients who have had diabetes less than five years. The exception is Type 2 diabetic patients who were likely hyperglycemic more than five years prior to their diabetes diagnosis.

Screening

Annual dilated eye exams by an ophthalmologist are recommended for all Type 1 diabetic patients within five years of diagnosis and shortly after diagnosis in patients with Type 2 diabetes. Patients with progressive retinopathy are often seen quarterly or biannually.

Panretinal Treatment

Panretinal laser photocoagulation is the treatment of choice for proliferative diabetic retinopathy and severe cases of nonproliferative retinopathy. Screening is done aggressively due to the well-documented efficacy of laser photocoagulation in the prevention of vision loss. Ranibizumab, an anti-vascular endothelial growth factor, injected into the vitreous showed noninferiority to laser therapy and can also be used.

Diabetic Nephropathy

Epidemiology

Diabetic nephropathy occurs in 20% to 40% of diabetic patients and is the most common etiology of end-stage renal disease in the U.S.

Risk factors associated with the progression of diabetic nephropathy include: obesity, increasing age, African American race, and tobacco abuse.

Pathogenesis

Kidney insult appears to originate with glomerular hypertension and hyperfiltration. Chronic hyperglycemia leads to mesangial expansion, deposition of matrix, increased amount of VEG-F and other cytokines, local inflammation, and activation of protein kinase C.

Prevention / Treatment

Two large prospective trials (DCCT with type 1 diabetics and UKPDS with Type 2 diabetics) revealed that intensive glucose management resulted in prevention or delayed onset and progression of diabetic nephropathy.

Aggressive blood pressure lowering is critical for treatment of increased urinary albumin excretion. In patients with hypertension with increased urinary albumin excretion, an ACE inhibitor or ARB therapy is recommended to delay the onset and decrease progression of diabetic nephropathy.

Referral

Referral to nephrology is appropriate if the cause of kidney disease is not certain, and or there are challenging management issues present, such as resistant hypertension or electrolyte derangement. The threshold for referral to nephrology varies across providers; however, nephrology should be consulted if Stage 4 or greater chronic kidney disease (GFR < 30 ml/min per 1.73 m2) develops since this has been found to reduce cost, improve quality of care, and keep people off dialysis longer.

Diabetes Patient Resources in Spanish

The ADA website has excellent resources for Spanish-speaking patients and their families.

When to Perform the Diabetic Foot Exam

It is important to do a thorough foot exam in a diabetic patient on an annual basis for low-risk patients and more often in patients at high risk for foot ulcer formation.

Patients at High Risk for foot Ulcer Formation

Patients with known diabetic polyneuropathy, sensory or vascular deficits, patients who smoke, and patients with a prior history of diabetic foot ulcer or amputation.

Foot Exam in Patients with Diabetes

Visually inspect the feet for callus formation, ulceration, nail infections, and bony deformities.

Assess skin integrity, especially between toes and under metatarsal heads. Assignment 4: Chronic disease management

Palpate the dorsalis pedis and posterior tibialis pulses to screen for peripheral vascular disease and look for signs of peripheral

Clinical Skills
vascular disease, such as hair loss.

Check sensation using a 128 Hz tuning fork (vibration) and a cool metal object, potentially the same tuning fork (temperature).

Check pressure sensation using a 10-g monofilament:

Show the monofilament to the patient and try it on their hand to show them it will not hurt.

Ask the patient to close their eyes or look at the ceiling and tell you each time they feel the monofilament touch their foot.

Randomly place the end of the monofilament on the 9 different areas of the foot (see image to the right) with enough pressure to bend the monofilament.

If the patient does not say “yes” at a particular site, continue to the next site and re-test that site at the end.

Check Achilles reflexes.

Effectiveness of Intravenous Insulin for Blood Glucose Control

Blood sugar control in critically ill patients has been the subject of considerable investigation. Previous research suggested that tight control (80-120 mg/dL) was desirable, but more recent research shows that aggressive blood sugar control can be associated with higher mortality.

Hypoglycemia (serum glucose concentration <70 mg/dL), with rates as high as 40% in some studies, is associated with tight glycemic control. A meta-analysis of 29 controlled trials involving more than 8,000 adult ICU patients showed no difference in inhospital mortality between the group assigned to tight glucose control versus usual care.

The current recommended blood glucose target for most hospitalized patients is 140 to 180 mg/dL.

Thiazolidinediones

Pioglitazone (D), a member of the class of drugs known as thiazolidinediones (TZD), is not recommended for use in patients who have newly developed heart failure and in those with known NYHA Class III and IV heart failure. The same is true for rosiglitazone, another TZD that has been associated with an increased risk of cardiovascular disease.

Management
Diabetes Chronic Disease Management

Evaluate for and optimize prevention of diabetic complications Assignment 4: Chronic disease management

Macrovascular complications:

Cardiovascular disease

Cerebrovascular disease

Microvascular complications:

Retinopathy

Nephropathy

Neuropathy

In particular, cardiovascular disease is the No. 1 cause of mortality for people with diabetes, and one of the top causes of morbidity.

Hypoglycemia, infections, foot ulcers, and amputations are additional causes of morbidity and mortality in patients with diabetes.