Chronic Care Plan

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Chronic Care Plan
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Programme
Long-term complications
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Co-morbid conditions
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Long-term complications
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Complications
Slide no 4

• Eyes (retinopathy) ? blindness
• Also cataracts
• Kidneys (nephropathy) ? kidney failure
• Nerves (neuropathy) ? decreased pain perception
• Blood vessels
• Limbs ? peripheral vascular disease
• Heart ? heart attacks
• Brain ? strokes

Amputations
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Long-term complications
Slide no 5

• Take years to develop
• May occur in childhood
• Glucose control (HbA1c) related to risk of
  complications
• Early control in childhood important (metabolic
  memory)
• Complications due to injury to blood vessels
• Cause of mortality

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Screening programmes

• Limited joint mobility (LJM)

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Neuropathy
Slide no 7

• Peripheral neuropathy
• Painful neuritis
• Glove and sticking distribution
• Loss of sensation
• Reduced reflexes
• Autonomic neuropathy
• Alteration in gastric function (gastroparesis)
• Bloating, decreased appetite, constipation,
  diarrhoea
• Palpitations
• Urinary retention

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Neuropathy screening
Slide no 8

• Symptoms
• Neurological examination

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Nephropathy
Slide no 9

• Increase protein excretion
• Small increase early ? microalbuminuria
• Treatment can slow progression
• Large amount of protein excretion ?
  macroalbuminuria or proteinuria
• Can cause increased blood pressure
• Kidney failure
• Treatment is dialysis or transplant

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Nephropathy screening
Slide no 10

• Annual microalbumin tests
• Start 5 years after diagnosis or at start of
  puberty
• Monitor blood pressure
• Treat microalbuminuria proteinuria and/or high
  blood pressure with medication
• Improve control (i.e. decrease HbA1c)

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Retinopathy
Slide no 11

• Bleeding and new blood vessels in the eye
• 5-10 chance of blindness
• Rapid improvement of poor control can cause
  retinopathy to get worse
• Screen from 5 years after diagnosis or at start
  of puberty
• Eye examination
• Retinoscopy
• Fundus photography is better if available

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Cataract / Retinal hemorrhage
Slide no 12
Cataract
Retinal hemorrhage
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Retinal Microvascular Complications
Proliferative retinopathy
Normal retina
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Nonproliferative diabetic retinopathy (NPDR)
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Proliferative diabetic retinopathy (PDR)
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Post Laser/Severe PDR Treatments
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Co-morbid conditions
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Co-morbid conditions (1)
Slide no 18

• Not caused by diabetes
• More common in children adolescents with
  diabetes
• Common genetic predisposition
• Auto-immune disease
• Often no clinical symptoms
• Need laboratory screening

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Co-morbid conditions (2)
Slide no 19

• Thyroid dysfunction
• Goitre, hypothyroidism, hyperthyroidism
• Thyroid function tests, thyroid antibodies
• Coeliac disease
• Sensitivity to gluten ? bowel dysfunction
• Often asymptomatic positive transglutaminase or
  endomysial or gliadin antibodies
• Addisons disease
• Unexplained decrease in insulin doses,
  hypoglycaemia, slow growth, fatigue, increased
  skin pigmentation
• Refer for management

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Other issues
Slide no 20

• Osteopenia
• Necrobiosis lipoidica diabeticorum
• Itchy/painful hardened skin patches
• Lipohypertrophy (if injection sites are not
  rotated correctly)
• Lipoatrophy

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Necrobiosis lipoidica diabeticorum
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Skin complications of insulin injections
Lipohypertrophy
Lipoatrophy
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Questions
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