Diabetes complications can be divided into two types -- acute
and chronic. This article discusses these complications and strategies to
prevent the complications from occurring in the first place.
- Diabetic Ketoacidosis (DKA)
- Hyperglycemic Hyperosmolar Non-Ketotic Syndrome (HHNS)
Acute complications of diabetes can occur at any time in the course of the disease.
- Cardiovascular: Heart disease, peripheral vascular disease, stroke
- Eye: Diabetic retinopathy, cataracts, glaucoma
- Nerve Damage: Neuropathy
- Kidney Damage: Nephropathy
Chronic complications are responsible for most illness and death
associated with diabetes. Chronic complications usually appear after several
years of elevated blood sugars (hyperglycemia). Since patients with type 2
diabetes may have elevated blood sugars for several years prior to diagnosis,
these patients may have evidence of complications at the time of diagnosis.
Basic principles of prevention of complications of diabetes
- Take your medications (pills and/or insulin) as prescribed by your doctor.
- Monitor your blood sugars closely.
- Follow a sensible diet. Do not skip meals.
- Exercise regularly.
- See your doctor regularly to monitor for complications.
Diabetic Ketoacidosis (DKA)
- Results from untreated hyperglycemia
- Blood sugars typically range from 300 to 600
- Occurs mostly in patients with type 1 diabetes (uncommon in type 2)
- Occurs due to a lack of insulin
- Body breaks down its own fat for energy and ketones appear in the urine and blood
- Develops over several hours
- Can cause coma and even death
- Typically requires hospitalization
Symptoms of DKA
- Nausea, vomiting
- Abdominal pain
- Drowsiness, lethargy
- Deep, rapid breathing
- Increased thirst
- Fruity-smelling breath
Causes of DKA
- Inadequate insulin administration
- Heart attack (myocardial infarction)
Prevention of DKA
- Take your medications as prescribed
- Monitor your blood sugar closely, especially when you are ill
- Maintain a balanced diet with regularly scheduled meals
- Keep yourself well-hydrated
- Exercise regularly
- Call or see your doctor if you or family members notice symptoms
suggestive of DKA and/or your blood sugar is elevated (above 300).
Hyperglycemic Hyperosmolar Non-Ketotic Syndrome (HHNS)
- More gradual onset than DKA (days to even weeks).
- Occurs in patients with type 2 diabetes, especially the elderly.
- Usually occurs when patients are ill or stressed.
- Blood sugars typically are greater than 600.
- Symptoms include frequent urination, drowsiness, lethargy, and decreased
intake of fluids. HHNS is not typically associated with nausea, vomiting, or abdominal pain.
- Not associated with ketones in the blood.
- Can cause coma or death.
- Typically requires hospitalization.
Prevention of HHNS
- Similar to DKA
- Take your medications as prescribed by your doctor.
- Monitor your blood sugars carefully, especially when ill.
- Keep yourself well-hydrated.
- Call or see your doctor if you, or a family member, suspect that you may
have symptoms of HHNS and/or your blood sugars are elevated.
Cardiovascular complications in diabetes
- Cardiovascular disease is the most deadly complication of diabetes.
- 75 to 85% of patients with diabetes die from heart disease or stroke.
- Diabetes is one of the leading risk factors for cardiovascular disease.
- Patients with diabetes are considered to have the same risk for
cardiovascular disease as patients without diabetes who have had a prior
- Men with diabetes are two to three times more likely to develop
cardiovascular disease than are men without diabetes.
- Women with diabetes are four to six times more likely to develop
cardiovascular disease than are women without diabetes.
- Patients with diabetes often do not have the classic symptoms of heart
disease, such as chest pain.
Risk factors for heart disease
- High blood pressure
- High cholesterol
- Tobacco use
- Family history
General principles for prevention of heart disease in patients with diabetes
- Aggressive control of blood sugar
- Aggressively treat other modifiable risk factors for heart disease (high
blood pressure, high cholesterol, and smoking)
- Aspirin has been shown to be protective in patients with known
cardiovascular disease. Although it has not definitively been shown
to prevent heart disease, it should be considered in patients with diabetes,
especially those with other risks for heart disease (high blood pressure,
high cholesterol). Ask your doctor if aspirin is appropriate for you.
- There are no specific recommendations regarding routine stress testing
to look for heart disease in patients with diabetes. Ask your physician if
he or she thinks you need a stress test.
Peripheral vascular disease
- Decreased blood flow in the legs and feet.
- Symptoms: Pain in the calf, thigh, and buttocks with walking.
Symptoms are relieved with rest. These symptoms are known as
- Claudication is associated with an increased risk of heart disease,
leg ulcers/ infections, and lower extremity amputation.
- If you think you have symptoms suspicious for claudication, please
tell your physician.
Cholesterol and diabetes
A fasting cholesterol profile should be checked at least every year in patients with diabetes.
- Total cholesterol
- LDL cholesterol (bad cholesterol)
- HDL cholesterol (good cholesterol)
- Triglycerides (fats in the blood)
Goal for Patients with Diabetes
- < 200
- < 100 and < 70 for those with diabetes and heart disease
- Men: Above 45; Women: Above 55
- < 150
The typical cholesterol profile in patients with diabetes includes low HDL cholesterol and high triglycerides.
The initial focus of treatment of high cholesterol in patients with diabetes is to lower the LDL cholesterol. Studies have suggested that the risk for cardiovascular disease in patients with diabetes may increase with LDL cholesterol above 80.
Treatment of high cholesterol in diabetes
- Control blood sugars, blood pressure
- Low-fat diet
- Quit smoking
- Exercise and weight loss help raise the HDL cholesterol
Statin drugs (HMG CoA reductase inhibitors):
Examples: Lipitor®, Zocor®, Pravachol®, Crestor®, Mevacor®, Lescol®.
These medications are especially effective at lowering LDL and total
cholesterol. They can help lower triglycerides and raise HDL cholesterol. Statin
drugs are the most powerful drugs that we have to lower the LDL cholesterol. Two
potential side effects of statins that all patients on these medications need to
be aware of are liver inflammation and muscle damage. While these side effects
are rare, patients need to know what to look for. Symptoms suggestive of liver
inflammation include nausea, vomiting, right-sided abdominal pain, decreased
appetite, dark-colored urine, and light-colored stools. Symptoms suggestive of
muscle damage include any new muscle soreness or weakness. If you think you have
developed any of these symptoms while on statin drugs, please notify your doctor immediately.
The main effect of these medications is to lower triglycerides. These medications also can lower LDL cholesterol and
raise HDL cholesterol. These medications can also cause liver inflammation.
Niacin lowers triglycerides and LDL cholesterol while
raising HDL cholesterol. Niacin can make diabetes more difficult to control, but
does not necessarily mean that you cannot be started on this medication. Niacin
can also cause liver inflammation.
One study showed that the ACE inhibitor
Ramipril® (a blood pressure medication) decrease the rate of heart attack, stroke, and death from cardiovascular causes in patients with diabetes and cholesterol above 200 or a low HDL cholesterol.
Not all patients are suitable for these medications, so please consult with your doctor.
Eye complications with diabetes
- Diabetes is the leading cause of new blindness in adults ages 20 to 74.
- Patients with diabetes are 25 times more likely to become legally blind
than are patients without diabetes.
- There are three eye-related major complications: Retinopathy, Cataracts, Glaucoma.
- Blurred vision can occur as a result of high blood sugars. However, it
can also be a result of more serious eye problems. Contact your doctor if
your vision is blurred.
Prevention of eye complications
- Visit your eye doctor (ophthalmologist) at least yearly for a
comprehensive eye exam to screen for retinopathy, cataracts, and glaucoma.
- Maintain intensive control of blood sugars.
- Control your blood pressure.
- Damage to the retina (the lining of the interior of the eye)
- Patients with type 2 diabetes may have evidence of retinopathy when they
are diagnosed with diabetes.
- Two types exist: Non-proliferative and proliferative
- Non-proliferative: Typically occurs after several years of diabetes. The
non-proliferative form is common and usually mild. Patients do not typically
have symptoms with this form of retinopathy.
- Proliferative: Some patients with the non-proliferative form progress to
the proliferative form of retinopathy. New blood vessels grow in and around
the retina. Symptoms include blurred vision, black spots or holes in the
vision, blindness. Treatments include laser treatment and surgery
- Clouding or fogging of the lens
- Symptoms: Blurred or cloudy vision
- Treatment: Surgery, lens implants
- Increased pressure in the eyes
- Symptoms: Headache, nausea, vomiting, eye pain, decreased vision,
blurred vision, watering of the eyes
- Treatment: Eye drops, laser therapy, surgery
Nerve damage (Neuropathy) and diabetes
- Two forms: Peripheral and Autonomic
- 50 to 70% of patients with diabetes develop neuropathy.
- Neuropathy most likely develops due to long-term high blood sugars.
- Diabetes is the leading cause of non-traumatic lower limb amputation.
- Affects sensation, especially in legs and feet
- Can be permanent
- Symptoms: Burning, pain, tingling, or numbness in the extremities,
especially in the feet and legs
- Can have no symptoms
- Usually notice symptoms at rest; symptoms are often worse at night.
- Medications to help relieve symptoms of peripheral neuropathy: Tricyclic
antidepressants Elavil®, Neurontin®, Topamax®, Lyrica®
The development of peripheral neuropathy is potentially serious.
Since patients with diabetes have a decreased ability to perceive pain, minor
and even major injuries or trauma can go unnoticed. Similarly, because of
difficulty perceiving changes in position, patients with diabetes may have
difficulty bearing weight properly and are at risk for developing calluses and
ulcers on their feet.
Prevention of complications involving the feet and legs
- Control blood sugars.
- Keep your feet clean and moist.
- Wear properly fitting shoes and clean socks. Do not walk barefoot.
- Take warm (not hot) showers.
- Examine your feet every day for evidence of skin breakdown, sores, or ulcers.
- See your doctor for any foot injury or ulcer. Do not try to treat them yourself.
- Many patients with diabetes see a podiatrist (foot doctor) for foot and nail care.
- Symptoms: Low blood pressure, fast pulse, dizziness, passing out
- Treatment: Avoid standing up too quickly, medications, stockings
- Symptoms: Nausea, vomiting, decreased appetite, feeling
full more quickly, bloating, diarrhea, constipation.
- Treatment: Control blood sugar, smaller meals, medications
- Symptoms: Impotence, female sexual dysfunction, unable to
empty bladder fully
- Treatment : Erectile dysfunction medications (eg, Viagra®),
vaginal lubricants, self-catheterization
- Skin: Dry, cracked skin; impaired wound healing
Kidney damage (Nephropathy) and diabetes
- Diabetes is the leading cause of end-stage kidney disease in the United States.
- End-stage kidney disease requires dialysis and/or a kidney transplant.
- An early sign of kidney damage with diabetes is the presence of small
amounts of protein (albumin) in the urine.
- If protein in the urine goes undiagnosed or untreated, it can lead to
end-stage kidney disease.
Prevention of kidney damage in patients with diabetes
- Visit your doctor at least yearly for blood tests (BUN and creatinine)
to assess your kidney function.
- Your doctor should also check your urine once a year for protein in the urine.
- Maintain strict control of blood sugars and blood pressure.
- ACE inhibitors and angiotensin II receptor blockers (ARBs) (blood
pressure medications) have been shown to slow the rate of progression of
kidney disease in diabetes. Commonly prescribed ACE inhibitors include
Altace®, Accupril®, Zestril®, and Vasotec®.
Commonly prescribed ARBs include Diovan®, Cozaar®, and Avapro®.
- Monitor protein intake closely. Patients with evidence of protein in the
urine should modestly restrict their protein intake. You may want to consult
with a nutritionist or diabetic educator to determine the appropriate degree
of protein in your diet.
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 1/5/2009...#10675