Chronic Care Plan

Programme

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Long-term complications

Co-morbid conditions

Long-term complications

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Complications

• 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

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Amputations

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Long-term complications

• 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

• 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

• Symptoms

• Neurological examination

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Nephropathy

• 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

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• 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

• 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

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Cataract Retinal hemorrhage

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Retinal Microvascular Complications

Normal retina Proliferative retinopathy

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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)

• 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)

• 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

• 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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