Treatment of diabetic complications
Diabetic complications can be divided into acute and chronic complications. Here we will consider both.
Acute metabolic complications
Hypoglycemia
Iatrogenic hypoglycemia in those with diabetes is the most frequent cause of low blood glucose concentration. The most common specific cause is sulfonylureas and insulin overdoses. In general, hypoglycemia is considered in those with a glucose level of less than 3 mmol/L/70mg/dL. Symptoms include neurocognitive impairment, fatigue, and malaise. In extreme cases this can lead to a coma and be potentially fatal. Hypoglycemia is much more common in those with T1DM compared to T2. In T1DM the most common causes are missed meals, deliberate weight loss attempts and insulin overdose
Education is the most important tool for preventing hypoglycemia, those taking insulin or sulfonylureas should be regularly monitoring their blood glucose levels. Mild or moderate episodes can be treated by ingestion of fast-acting carbohydrates (glucose tablets, gels, joists etc), it is recommended to ingest about 15g of carbohydrates. Avoid foods rich in fats as these delay glucose absorption. In severe cases parenteral 25g IV glucose is required.
Hyperglycemic states
The two most common are diabetic ketoacidosis (DKA) and Hyperosmolar Hyperglycemic state (HHS).
DKA may act as the first sign of T1DM in a child/adolescent, but may also be found in the setting of coexisting illness or poor adherence to an insulin regime. Illnesses require an additional insulin dose to prevent hyperglycemia, due to the increased cortisol that is released in the body. ‘Sick-day’ rules are vital in all diabetes treatment programs. DKA is secondary to absolute insulin deficiency or resistance, and presents with a triad of hyperglycaemia, ketonaemia and acidaemia.
The clinical picture of DKA is rapid onset, patients have abdominal pain and vomiting with ‘fruity’ breath due to ketosis. Patients will also often present with reduced consciousness with Kussmaul respiration (deep, laboured).
Investigations:
- Acidosis - pH<7.3
- Hyperglycemia - glucose >11.1mmol/L
- Ketonaemia - ketones >3mmol or ++ dipstick
Management
- Start fluid replacement 0 IV 0.9% sodium chloride 1L for the first hour, 1L for the next two, the next two again, then the next four and then the next six hours
- Administer insulin to reduce hyperglycemia but avoid potential hypoglycaemia
- Add 50u actrapid insulin to 50ml 0.9% sodium chloride and infuse
- Add IV actrapid at 0.1 u/kg bodyweight/hour. Then switch to 3u/hour after glucose <14mmol/L
- Administer potassium replacement if required (keep K+ at 4–5 mmol/L)
- Monitor sodium levels to prevent dehydration