2014糖尿病指南: 糖尿病小血管並發症DM Microvascular Complications

2014糖尿病指南: 糖尿病小血管並發症DM Microvascular Complications


Nephropathy Screening and Treatment

Optimize glucose and BP control to reduce risk or slow progression of nephropathy
 

Screening
Annually measure urine albumin excretion in type 1 patients with ≥5-yr diabetes

duration, and all type 2 patients starting at diagnosis
 

Treatment

Normal BP and albumin excretion <30 mg/24 h

     - ACEI or ARB for primary prevention of kidney disease not recommended
 

Nonpregnant with modest elevations (30-299 mg/24 h) or higher levels (≥300 mg/24 h) of urinary albumin excretion

     - Use ACEI or ARB (but not in combination)
 

Diabetic kidney disease (albuminuria >30 mg/24 h)

     - Limiting protein intake not recommended
 

When using ACEI, ARB, diuretic
     - Monitor creatinine and potassium levels
 

Monitor urine albumin excretion continually to assess therapeutic response, disease progression
 

If eGFR <60 mL/min/1.73 m2
    - Evaluate, manage CKD complications
 

Consider specialist referral
     - Uncertainty re: kidney disease etiology, difficult management issues, advanced kidney disease
 

Retinopathy Screening and Treatment

Optimize glucose and BP control to reduce risk or slow progression of retinopathy

Screening
Initial dilated and comprehensive eye exam by an ophthalmologist or optometrist

    • Adults with type 1 diabetes: within 5 yrs after diabetes onset

    • Patients with type 2 diabetes: shortly after diagnosis

    • If no retinopathy for ≥1 eye exam: consider exams every 2 yrs

    • If retinopathy: annual exam

    • Retinopathy progressing or sight threatening: more frequent exams
 

Fundus photographs: screening tool; not a substitute for comprehensive exam
 

Pregnant women or women planning pregnancy with preexisting diabetes

    • Retinopathy counseling, eye exam in first trimester

    • Close follow-up throughout pregnancy and 1 yr postpartum

Treatment
Macular edema, severe NPDR, any PDR
      - Refer to ophthalmologist specializing in retinopathy
Laser photocoagulation therapy
      - Indicated to reduce risk of vision loss for high-risk PDR, clinically significant macular edema, some  cases of severe NPDR

Anti-VEGF therapy
     - Indicated for diabetic macular edema

Retinopathy not a contraindication to aspirin therapy for cardioprotection

Neuropathy Screening and Treatment

Screening

Screen all patients for distal symmetric polyneuropathy
    • Type 2 diabetes: at diagnosis
    • Type 1 diabetes: 5 yrs after diagnosis and at least annually thereafter

Electrophysiological testing or neurologist referral rarely needed except with atypical clinical features

Screening for cardiovascular autonomic neuropathy
    • Type 2 diabetes: at diagnosis
    • Type 1 diabetes: 5 yrs after diagnosis

Treatment

Medications for relief of distal symmetric polyneuropathy and autonomic neuropathy symptoms

ACEI=angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker; BP=blood pressure; CKD=chronic kidney disease; eGFR=estimated glomerular filtration rate; NPDR=nonproliferative diabetic retinopathy; PDR=proliferative diabetic retinopathy; VEGF=vascular endothelial growth factor