1. Chronic Care Plan

2. Programme 1 2 Long-term complications Co-morbid conditions

3. Long-term complications

4. Slide no 4 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 Slide no 4 Amputations

5. Slide no 5 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 Slide no 5

6. Slide no 6 Screening programmes Limited joint mobility (LJM)

7. Slide no 7 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 Slide no 7

8. Slide no 8 Neuropathy screening Symptoms Neurological examination Slide no 8

9. Slide no 9 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 Slide no 9

10. Slide no 10 Nephropathy screening Slide no 10 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)

11. Slide no 11 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 Slide no 11

12. Slide no 12 Cataract / Retinal hemorrhage Slide no 12 CataractRetinal hemorrhage

13. Slide no 13 Retinal Microvascular Complications Normal retina Proliferative retinopathy

14. Slide no 14 Nonproliferative diabetic retinopathy (NPDR)

15. Slide no 15 Proliferative diabetic retinopathy (PDR)

16. Slide no 16 Post Laser/Severe PDR Treatments

17. Slide no 17 Co-morbid conditions

18. Slide no 18 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 Slide no 18

19. Slide no 19 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 Slide no 19

20. Slide no 20 Other issues Osteopenia Necrobiosis lipoidica diabeticorum Itchy/painful hardened skin patches Lipohypertrophy (if injection sites are not rotated correctly) Lipoatrophy Slide no 20

21. Slide no 21 Necrobiosis lipoidica diabeticorum

22. Slide no 22 Skin complications of insulin injections LipohypertrophyLipoatrophy

23. Slide no 23 Questions

24. Slide no 24 Changing Diabetes® and the Apis bull logo are registered trademarks of Novo Nordisk A/S