DM Complications - Lewis

2 categories of diabetes complications

• macrovascular

• microvascular

macrovascular complications

• hyperglycemia → damage to larger blood vessels

  • cerebrovascular disease

  • coronary heart disease

  • peripheral vascular disease

• atherosclerotic cardiovascular disease (ASCVD)

  • major cause of morbidity and mortality in diabetes

Prevention strategy (ABCDE)

• A1c / antiplatelet therapy

• blood pressure control

• cholesterol management

• diet

• exercise

prevention strategy: A1c

• goal for most non-pregnant adults

  • FBG

  • PPG

• consider therapy w/ — benefit (regardless of A1c)

• A1c = <7%

  • FBG = 80 - 130 mg/dL

  • PPG = <180 mg/dL

• consider therapy w/ ASCVD benefit

therapy with ASCVD benefit

• GLP 1

  • Liraglutide (VIctoza)

  • Dulaglutide (Trulicity)

  • Semaglutide SQ / PO (Ozempic)

  • Tirzepatide (Mounjaro)

• SGLT 2

  • Dapagliflozin (Farxiga)

  • Empagliflozin (Jardiance)

  • Canagliflozin (Invokana)

B: start ozempic

prevention strategy: Antiplatelet Therapy

• primary prevention

  • consider in

  • not recommended for

  • > 70 yrs old

• consider in

  • pts w/ DM ≥ 50 yrs + 1+ major risk factor and w/o increased risk of bleeding

• not recommended for

  • low risk of ASCVD (pts w/ DM < 50 yrs and no major ASCVD risk factors)

• > 70 yrs old

  • risks > benefits

prevention strategy: Antiplatelet Therapy

• secondary prevention

• history of ASCVD (MI/stroke)

  • aspirin 75 - 162 mg daily

  • clopidogrel 75 mg daily if aspirin allergy

prevention strategy: Antiplatelet Therapy

• CAD/PAD

aspirin + low-dose Xarelto (Rivaroxaban) can be added

prevention strategy: Antiplatelet Therapy

• major risk factors

• increased risk of bleeding

C: appropriate to start aspirin

prevention strategy: Blood Pressure Control

• monitoring

• guideline recommended BP goals for diabetic patients

• monitor BP at every office visit (cross-reference w/ home monitors)

prevention strategy: Blood Pressure Control

• accurate assessement

• avoid smoking, caffeinated beverages, or exercise within 30 mins before measurement

• ≥ 5 min of rest before measurements

• sit w/ back straight and supported

• feet flat on the flood and legs uncrossed

• arm supported at heart level

• appropriate cuff size

A: per ADA, < 130/80

prevention strategy: Blood Pressure Control

• monitor

• BP control and adverse effects

• ACEi/ARB

  • BMP (SCr, K+)

  • 2 - 4 weeks after initiation and at least annually

recommendations for the treatment of HTN in people w/ Diabetes

D : olmesartan and amlodipine

prevention strategy: Cholesterol Management

• obtain lipid panel at:

• DM diagnosis

• initial medical evaluation

• at leasy every 5 years for pts < 40 yrs of age w/ DM

• 4 - 12 weeks after initiating or changing lipid-lowering therapy

• 3 - 12 months while on stable lipid lowering therapy

prevention strategy: Cholesterol Management

• add-on treatment (to max tolerated statin): LDL above goal

• if LDL remain above goal → add Ezetimibe or PCSK9 inhibitor

  • LDL goal < 55 mg/dL if ASCVD event

  • LDL goal < 70 mg/dL all others

prevention strategy: Cholesterol Management

• add-on treatment (to max tolerated statin): LDL controlled but TG 135 - 499 mg/dL

if TG 135 - 499 mg/dL → add Icosapent ethyl (Vascepa)

prevention strategy: Cholesterol Management

• add-on treatment (to max tolerated statin): TG ≥ 500 mg/dL

add omega-3 fatty acids as adjunct to diet

• if necessary, add fibrate therapy to prevent acute pancreatitis

  • safety: fenofibrate > gemfibrozil

Lipid Management for DM: Primary Prevention

Lipid Management for Dyslipidemia: Secondary Prevention

• clinical ASCVD at very high risk (hx of multiple ASCVD events, or 1 major event + multiple high-risk conditions)

  • high intensity statin to acheive ≥50% reduction in LDL and goal of LDL < 55 mg/dL

• clinical ASCVD NOT at very high risk

  • high intensity statin to acheive ≥ 50% reduction in LDL and goal of LDL < 70 mg/dL

T or F: RCT support use of fibrates and niacin as add-ons to statin therapy

F: no support → not shown to improve ASCVD outcome

C: add Zetia (Ezemtimibe)

prevention therapy: Diet and Exercise

• weight loss

• reduce —

• alcohol intake

• sodium restriction

• type of diet

• exercise

• Overweight or obese, weight loss of ≥7%

• Reduce overall carbohydrate intake (avoid sugar, sweetened bevs </3)

• Limit alcohol intake 

  • Women: ≤1 drink/day

  • Men:  ≤2 drinks/day

• Limit sodium <2,300 mg/day

• DASH diet or Mediterranean diet 

• Minimum 150 min/week of moderate-intensity aerobic exercise spread over at least 3 days

microvascular complications

• Hyperglycemia → damage to smaller blood vessels 

  • Retinopathy 

  • Nephropathy 

  • Neuropathy 

• Diabetes is the leading cause of acquired blindness, ESRD, and neuropathies

• Prevent or slow progression by controlling blood glucose

retinopathy

Damage to the eye that may lead to impaired vision or blindness

types of diabetic retinopathy

• Non proliferative 

• Proliferative 

• Diabetic macular edema

retinopathy: screening and monitoring

• retinal fundoscopy

diabetic retinopathy treatment

• refer if

• non-pharm

• pharm

• refer

  • Macular edema

  • severe nonproliferative diabetic retinopathy

  • proliferative retinopathy

• non-pharm

  • panretinal laser photocoagulation

• pharm

  • intravitreous injections of VEGF inhibitors:

    • Bevacizumab (Avastin)

    • Ranibizumamb (Lucentis)

    • Aflibercept (Eylea)

nephropathy

• Damage to the kidneys that may lead to proteinuria or even renal failure 

Nephropathy: screening and monitoring

• Monitor all patients who have had DM for ≥5 years 

• Monitor twice annually: Patients with DM and uACR ≥300 and/or eGFR 30-60

• False positive uACR readings: exercise within 24hr, infection/fever, CHF, marked hyperglycemia/HTN, menstruation

uACR reading

• normal

• microalbumnuria

• macroalbuminuria

monitoring

• renal function

• albuminuria

nephropathy: prevention/treatment

• A1c control

• BP control

• A1c control

  • Consider SGLT-2 for T2DM patients with eGFR ≥ 20 mL/min/1.73m²

  • If SGLT-2 intolerant or contraindicated:

    • Consider GLP-1 agonist or Finerenone (if eGFR ≥ 25 mL/min/1.73

• BP control

• if micro/macroalbuminuria present and/or eGFR <60 mL/min/1.73m²

  • First Line: ACEi or ARB

T or F: ACEi/ARB not recommended for primary prevention in patients with

  normal BP, normal uACR (<30mg/g), and normal eGFR

True

Finerenone (Kerendia)

• Aldosterone receptor antagonist (MRA)

• Indications: CKD in T2DM, HFpEF

• Dosing for CKD in T2DM: 

  • Initial: 

    • eGFR ≥60: 20 mg daily 

    • eGFR 25-59: 10 mg daily 

    • eGFR <25: do not use

  • Maintenance: based on K+ levels and eGFR (must monitor!) after 4 weeks

A: Farxiga (Dapagliflozin) - SGLT2i

B: Losartan - ARB

• Albuminuria → ACEi/ARB.

• Diabetes + CKD → SGLT2 inhibitor

types of neuropathy

• Peripheral neuropathy (Neuropathic pain and loss of coordination)

• Autonomic neuropathy (Gastroparesis, ED, orthostatic hypotension)

neuropathy screening/follow up

peripheral neuropathy screening tests

• small fiber function

• larger fiber function

• small fiber function

  • pinprick sensation

  • temp sensation

• larger fiber function

  • vibration

  • ankle reflexes

  • 10 g monofilament

oral treatment for peripheral neuropathy

D : clean socks and replace daily

autonomic neuropathy - gastroparesis

• symptoms

• monitor

• medications to avoid

• Symptoms

  • early satiety, N/V, bloating, constipation, abdominal pain, weight loss

• Monitor annually to assess for signs and symptoms 

• Medications to avoid: 

  • Opioids (depressive/sedating - decrease GI motility)

  • Anticholinergics (sedating - decrease GI motility)

  • TCAs (serotonin – GI)

  • GLP-1 RAs (GI d/t action on pancreas and gut)

  • Pramlintide (acts on pancreas)

autonomic neuropathy treatment

recommended vaccines for pts w/ DM

clinical pearls on DM management

• A2c every 3 months

  • if A1c at goal every 6 months

• BP at every visit and assess

• lipid panel 1x year unless not at goal and making therapy changes

  • dont forgert ASCVD 10 yr risk PREVENT score

• kidney and liver function, electrolytes, CBC at least annually

• UACR 1 - 2x / yr, B12 periodically

• eye/foot exam 1x year

• immunizations