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		Literature Compendium

Current Concepts in Type 2 Diabetes

Volume 3
Special Considerations in the Management of Diabetes and Its Complications

Chapter 3
Management of Diabetic Complications: Diabetic Peripheral Neuropathy, Retinopathy, and Nephropathy

The microvascular complications of diabetes are serious and can be life threatening. They include injury to the blood vessels in the nervous system, kidney, and eyes. Minimizing the risk for microvascular complications involves controlling glucose concentration, blood pressure, and lipids, along with healthy lifestyle changes. Early identification of these complications, with appropriate interventions, may slow or prevent the progression of complications. In this chapter, 4 key papers addressing the management of diabetic microvascular complications are reviewed.

Diabetic peripheral neuropathy is the most common complication of Type 2 diabetes. Although the exact origin is not fully understood, a number of factors have been implicated as potential causes. Microvascular abnormalities can lead to neural ischaemia, and sorbitol-induced myoinositol deficiency can impair normal intracellular metabolism. In addition, neurotrophic factors involved in the development, maintenance, and regeneration of the nervous system are impaired in individuals with diabetes. Diabetic peripheral neuropathy can manifest in a variety of ways. Some individuals experience painful diabetic neuropathy, while others experience an asymptomatic, progressive loss of peripheral nerve function. Diabetic peripheral neuropathy can affect both the autonomic and the somatic nervous systems.

Evidence-based consensus guidelines for the treatment of diabetic peripheral neuropathic pain were published recently by Argoff and colleagues.¹ They stress the importance of preparing a comprehensive treatment plan for individuals with diabetic peripheral neuropathic pain and review the classes of drugs used to treat this condition—antidepressants (serotonin-norepinephrine reuptake inhibitors and tricyclic antidepressants), anticonvulsants, opioids, and topical agents. The authors suggest establishing realistic goals; however, they caution that setting 'realistic' goals should not lead to a less aggressive pursuit of maximum relief. They suggest that the primary goal should be zero pain and that secondary goals should include restoration or improvement in functional measures and quality of life. The guidelines include recommendations for first-line therapy, recommendations for monitoring the response to therapy, and suggestions for modifying therapy if individuals do not respond adequately to first-line treatment or complain of adverse events.

Vision loss and blindness from diabetic retinopathy usually are the result of vascular leakage or ischaemia. Screening for retinopathy should be performed shortly after the diagnosis of Type 2 diabetes, with annual follow-up examinations. In individuals with diabetic retinopathy, severe vision impairment is less common and less readily corrected than mild vision impairment, and vision impairment is more common and less readily corrected in elderly than in younger individuals with diabetes. Modifiable risk factors for diabetic retinopathy include HbA_1c level, hypertension, and dyslipidaemia. Tight control of blood glucose concentrations and blood pressure may reduce the risk for and progression of diabetic retinopathy.

In an American Telemedicine Association report,² the mission and goals of an ocular telehealth program are delineated. Telehealth (the delivery of health-related services and information via telecommunications technologies) is said to hold the promise of increased adherence to evidence-based medicine and improved consistency of care. The report addresses current diabetic retinopathy telehealth clinical and administrative issues and provides recommendations for designing and implementing a diabetic retinopathy ocular telehealth care program. Recommendations are based on careful review of current clinical practice and evidence from 5 key trials—the Diabetic Retinopathy Study (DRS), the Early Treatment Diabetic Retinopathy Study (ETDRS), the Diabetic Retinopathy Vitrectomy Study (DRVS), the Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) study, and the United Kingdom Prospective Diabetes Study (UKPDS). The domains reviewed in the paper are guiding principles of a telehealth diabetic retinopathy program: ethics, communication, qualifications of personnel, equipment specifications, legal requirements, validation, quality control, and financial factors.

Diabetic foot ulcers are very common; a recent study showed that even with regular screening and education in foot care, foot ulcers occurred in 1 in 10 individuals with diabetes. The majority of foot ulcers result from traumatic wounds due to loss of pain sensation caused by peripheral neuropathy, and these injuries frequently lead to deep infection, sepsis, and lower extremity amputation.³

Recently, the International Working Group on the Diabetic Foot (IWGDF), the Infectious Diseases Society of America (IDSA), and the Société de Pathologie Infectieuse de Langue Française issued guidelines for diabetic foot infections. These recommendations have been synthesized in a recent review by Lipsky³ of the latest information and data on epidemiology, wound scoring, pathogenic agents, and diagnostic methods, as well as treatment options including both topical and systemic antimicrobial agents. Management is frequently complicated by the presence of antibiotic resistant pathogens, a mix of pathogenic organisms, or both. Nevertheless, treatment typically resolves in up to 80% of soft tissue infections and over 60% of bone infections. Additional, ongoing studies continue to define the optimal approaches to foot infection management.

Diabetic nephropathy is a clinical syndrome characterized by persistent albuminuria that is confirmed on at least 2 occasions 3 to 6 months apart, a relentless decline in the glomerular filtration rate, and elevated arterial blood pressure. Diabetic nephropathy is the leading cause of chronic renal failure in the United States and Western world. It is also one of the most significant long-term complications of diabetes in terms of morbidity and mortality. Diabetes is responsible for 30% to 40% of all cases of end-stage renal disease in the United States. Although both Type 1 and Type 2 diabetes can lead to end-stage renal disease, the majority of individuals are those with Type 2 diabetes.

In a thorough review, Wolf and Ritz⁴ discuss the prevention and management of nephropathy in Type 2 diabetes. They review the pathogenesis of the disease, discuss the heterogeneity of its presentation, and summarize the evidence for control of hyperglycaemia, hypertension, and dyslipidaemia as a means of prevention. They suggest that nephrologists be involved early in the care of individuals with Type 2 diabetes.

Taken collectively, the papers reviewed in this chapter provide a compelling argument for performing comprehensive risk assessment and globally managing major risk factors in individuals with Type 2 diabetes. Tight glycaemic control, aggressive blood pressure control, and modification of diabetic dyslipidaemia are now considered cornerstones of care. Clinicians can have a significant impact on cardiac risk reduction by identifying diabetic patients and evaluating their risk factors for CVD. Educating patients about the goals of treatment and counselling them on the expected outcomes of therapy are also important goals.

References

1. Argoff CE, Backonja M-M, Belgrade MJ, et al. Consensus guidelines: treatment planning and options. Mayo Clin Proc. 2006;81(4, suppl):S12-S25.

2. American Telemedicine Association, Ocular Telehealth Special Interest Group, and National Institute of Standards and Technology Working Group. Telehealth practice recommendations for diabetic retinopathy. Telemed J E Health. 2004;10:469-482.

3. Lipsky BA. New developments in diagnosing and treating diabetic foot infections. Diabetes Metab Res Rev. 2008;24(suppl 1):S66-S71.

4. Wolf G, Ritz E. Diabetic nephropathy in type 2 diabetes prevention and patient management. J Am Soc Nephrol. 2003;14:1396-1405.

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The Literature Compendium is funded by an educational grant from Pfizer Inc.

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