Diagnosis and Chronic Complications of Diabetes

Expected Chronic Complications in This Case

This patient with poorly controlled diabetes of 15 years will develop or has already developed multiple microvascular and macrovascular complications that require systematic screening and aggressive management to prevent further morbidity and mortality. 1

Microvascular Complications

Diabetic Retinopathy: Progressive retinal microvasculature changes leading to visual impairment or blindness, the leading cause of vision loss in diabetic patients 2
Diabetic Nephropathy: Progressive kidney disease manifesting as albuminuria and declining eGFR, the leading cause of end-stage renal disease 1
Diabetic Neuropathy:
- Peripheral neuropathy with sensory loss in stocking-glove distribution, shooting pain, and numbness 1, 3
- Autonomic neuropathy affecting cardiovascular, gastrointestinal, and genitourinary systems 4
- High risk for foot ulcers and amputations due to loss of protective sensation 3

Macrovascular Complications

Atherosclerotic Cardiovascular Disease (ASCVD): Including coronary artery disease, myocardial infarction, stroke, and peripheral arterial disease—the leading cause of morbidity and mortality in diabetes 1, 5
Peripheral Arterial Disease (PAD): Contributing to non-healing ulcers and amputation risk 5

Screening and Diagnostic Tools

Diabetic Kidney Disease Screening

Annual screening is mandatory and should include: 1

Urine albumin-to-creatinine ratio on spot urine sample (two of three specimens over 3-6 months should be abnormal [>30 mg/g] to confirm albuminuria) 1
Estimated GFR (eGFR) calculation from serum creatinine 1
Classification criteria:
- Moderately increased albuminuria: 30-299 mg/g 1
- Severely increased albuminuria: ≥300 mg/g (higher risk for end-stage renal disease) 1
Referral to nephrologist when eGFR <30 mL/min/1.73m² or uncertainty about kidney disease etiology 1

Retinopathy Screening

Annual comprehensive eye examination by ophthalmologist or optometrist is required: 1

Begin at diagnosis for Type 2 diabetes 1
Begin after 5 years for Type 1 diabetes 1
Note: Retinal photographs alone are NOT a substitute for comprehensive examination 1
Progression from mild nonproliferative to proliferative diabetic retinopathy occurs rapidly after initial diagnosis 2

Neuropathy Screening

Annual screening should assess: 1

Peripheral neuropathy:
- 10-g monofilament testing for loss of protective sensation 3
- Vibration sensation using 128-Hz tuning fork 3
- Ankle reflexes 3
- Pinprick and temperature sensation 3
Autonomic neuropathy symptoms:
- Orthostatic hypotension (blood pressure drop >20 mmHg systolic or >10 mmHg diastolic on standing) 3
- Resting tachycardia 3
- Gastroparesis symptoms 4
- Erectile dysfunction 4

Cardiovascular Disease Screening

Systematic annual assessment of cardiovascular risk factors: 1, 5

Blood pressure measurement at every routine visit 1
Lipid profile at diagnosis, then every 5 years (or more frequently if abnormal) 1
10-year ASCVD risk calculation to guide preventive therapy 1
Ankle-brachial index for peripheral arterial disease screening 5
Cardiac stress testing if anginal symptoms present 5
ECG to assess for silent ischemia in high-risk patients 5

Foot Examination

Comprehensive foot examination at every visit for high-risk patients: 3

Visual inspection for ulcers, calluses, deformities 3
Vascular assessment (pulses, capillary refill) 3
Neurologic assessment (monofilament, vibration) 3

Management Goals

Glycemic Control Targets

HbA1c target <7% for most patients to reduce microvascular complications, with individualization based on: 6, 5

Duration of diabetes 6
Age and life expectancy 6
Presence of cardiovascular disease 6
Hypoglycemia unawareness 6
Critical caveat: Avoid aggressive near-normal targets in patients with advanced disease, frequent hypoglycemia, or limited life expectancy 6

Blood Pressure Management

Target blood pressure <140/90 mmHg for most diabetic patients: 1

First-line therapy: ACE inhibitor OR ARB (not both) 1, 5
Switch to the other class if one is not tolerated 1
Add thiazide diuretic as second-line therapy 5
Monitor serum creatinine/eGFR and potassium when using ACE inhibitors, ARBs, or diuretics 1
For patients with eGFR <60 mL/min/1.73m² and albuminuria >300 mg/g: ACE inhibitor or ARB therapy slows kidney disease progression 1

Lipid Management

Statin therapy is recommended for most diabetic patients aged 40 years or older: 1

High-intensity statin for patients with ASCVD to achieve LDL-C <1.4 mmol/L (55 mg/dL) and >50% reduction from baseline 5
Moderate-intensity statin for primary prevention in patients aged 40-75 years 1
Add ezetimibe if LDL-C target not achieved with maximally tolerated statin 1, 5
Consider PCSK9 inhibitor if still not at target after statin plus ezetimibe 5
Lifestyle modifications: Reduce saturated/trans fats, increase omega-3 fatty acids, viscous fiber, and plant stanols/sterols 1, 5

Antiplatelet Therapy

Aspirin 75-162 mg daily for: 1, 5

Primary prevention: 10-year ASCVD risk >10% 1
Secondary prevention: All patients with established ASCVD 1, 5
Do NOT use for primary prevention if 10-year risk <5% 1
Clopidogrel 75 mg daily if documented aspirin allergy 1
Dual antiplatelet therapy for up to one year after acute coronary syndrome 1, 5

Neuropathy Management

Optimize glycemic control to prevent or delay progression: 1

For painful neuropathy: Consider pregabalin, duloxetine, or gabapentin 3
For autonomic neuropathy: Treat orthostatic hypotension with fludrocortisone or midodrine 3
Foot care education to prevent ulcers and amputations 3

Pharmacologic Therapy Algorithm

For Type 2 Diabetes: 1, 6, 5

Initial therapy: Metformin (if not contraindicated) plus lifestyle modifications 1, 6, 5
If HbA1c not at target after 3 months: Add second agent based on comorbidities:
- If ASCVD present: Add SGLT2 inhibitor with proven cardiovascular benefit OR GLP-1 receptor agonist with proven cardiovascular benefit 5
- If heart failure or CKD: Prioritize SGLT2 inhibitor 5
- If no ASCVD: Consider sulfonylurea, DPP-4 inhibitor, or basal insulin based on patient factors 1, 6
Consider combination SGLT2 inhibitor plus GLP-1 receptor agonist for additive cardiovascular and kidney protection 5

For Type 1 Diabetes: 1, 6

Multiple-dose insulin injections (≥3 per day) or continuous subcutaneous insulin infusion 1, 6
Use insulin analogues to reduce hypoglycemia risk 1, 6
Consider continuous glucose monitoring to reduce severe hypoglycemia 1, 6

Lifestyle Modifications

All patients require: 6, 5

Diabetes self-management education and support (DSME) 6
Medical nutrition therapy by registered dietitian (Mediterranean or DASH diet preferred) 6, 5
Physical activity: At least 150 minutes/week moderate-intensity aerobic exercise plus resistance training twice weekly 6, 5
Weight loss goal: 5-10% of body weight if overweight/obese 6, 5

Monitoring Schedule

Regular follow-up every 3 months until targets achieved: 5

HbA1c every 3 months 5
Blood pressure at every visit 1
Lipid profile periodically to monitor therapy response 1
Annual screening for all microvascular complications 1, 6, 5

Critical Pitfalls to Avoid

Therapeutic inertia: Intensify therapy promptly when targets are not met within 3 months 6
Polypharmacy without monitoring: Watch for drug interactions and hypoglycemia when combining multiple agents, especially with beta-blockers 5
Ignoring hypoglycemia: Severe or frequent hypoglycemia mandates immediate treatment modification 6
Metformin in advanced CKD: Can continue with dose reduction down to GFR 30-45 mL/min, but discontinue if GFR <30 mL/min 1
Dual ACE inhibitor and ARB therapy: Never use both together—increases adverse events without benefit 1
Neglecting foot care: High-risk patients need examination at every visit to prevent amputations 3
Delayed nephrology referral: Refer when eGFR <30 mL/min/1.73m² or uncertainty about diagnosis 1

What is the diagnosis and management plan for a patient with suspected chronic complications of diabetes?

Help us tailor your experience