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
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
Normal BP and albumin excretion
- 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 creatinine and potassium levels
Monitor urine albumin excretion continually to assess therapeutic response, disease progression
If eGFR
- Evaluate, manage CKD complications
Consider specialist referral
- Uncertainty re: kidney disease etiology, difficult management issues, advanced kidney disease
- 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
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
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
