Together we are stronger
A multissistemic and pluridisciplinary approach to diabetes

HPA Magazine 11

Recent numbers on the prevalence of diabetes remain daunting, leading inevitably to macro and micro vascular complications, which can lead to devastating consequences.
Due to the various possible complications involved and despite regular follow-up by one’s family doctor, it is important be seen by other medical specialists. Nowadays there is a demanding approach as far as the diagnosis and treatment is concerned.
This is the reason why we brought together six specialties/specialists in this field so that we can voice this year's motto together to celebrate World Diabetes Day: BE FASTER THAN YOUR RISK.

Glycaemic control and the need for a holistic approach

Dr Ricardo Louro

Specialist in Internal Medicine
Responsible for the Diabetes Consultation

Type 2 Diabetes Mellitus (DM) is a disease with a growing prevalence (9.9% according to the OECD report) with a significant number of undiagnosed patients.
Guidelines for the diagnosis and treatment of diabetic disease have been regularly updated and the most recent published in October 2018 reinforces prevention, complication delays and promoting quality of life, the main goals in the treatment of type 2 DM.
DM has been seen for some time as a multidisciplinary disease due to its complex pathophysiology and its multiple complications that require the intervention of several specialists in this area of medicine.
With the aim of treating patients and not diseases, it sought to get together the various professionals needed, to follow up each pathology and its associated complications.
The diabetic patient is followed regularly by the Nursing Team of the Out-Patients Unit of the Diabetics Day Care Hospital. Parallel to this regular control, the patient must also been seen by a Nutritionist and by a Physiatrist. These professionals will implement healthy lifestyles, which are the basis for the patient’s metabolic control. Metabolic control aims to prevent complications associated with DM. However, when complications occur, it is necessary, for the patient to be seen by a Specialist for treatment or monitoring, to avoid a worsening of the situation. Once the patient has been monitored by the various doctors, the next step is a meeting between all the specialists involved with the particular case. The complications involved in each one’s area of expertise of DM, is discussed, such as how they can prevent, monitor and/or treat the patient. 

Treating the feared diabetic foot

Dr César Carvalho

Specialist in General Surgery

General Surgery is one of the specialties that is part of the multidisciplinary approach team in the follow-up of the diabetic patient, be it in the prevention or treatment of complications frequently associated with this pathology.
Diabetic foot infections, is one of the most feared complications, it is also one of the most challenging in terms of resolution, often requiring rapid and adequate surgical intervention, to remove diseased or dead tissue, increasing success rate and reducing treatment time.
In this context, a multidisciplinary approach is extremely important, aiming at not only an early referral, but a synchronous and structured treatment plan to optimise patient recovery, avoiding in many cases the amputation of toes (and sometimes of more extensive areas), controlling localized infection and preventing potentially fatal generalised infections.
However, it is extremely important to note that strict glycaemic control appears to be the most important element in both the treatment and prevention of these complications. Follow-up by a specialist in diabetes as an Out-Patient is also a fundamental component in the planning of programmed surgeries in order to optimise healing and avoid surgical wound infections.

Cardiovascular diseases in diabetes: always symptomatic?

Dr Gonçalo Cardoso

Specialist in Cardiology

In Europe, in 2017, about 700 000 people died from DM complications. Most of these deaths were caused by Cardiovascular Diseases (e.g.: Acute Myocardial Infarction, Stroke, Heart Failure, etc.). About 60% of diabetic patients develop Cardiovascular Disease, which is often asymptomatic. Up to 60% of strokes are "silent" and often only detected with a routine ECG.
In cardiology, the patient’s risk of cardiovascular disease should be assessed. Based on these calculations, the patient is classified as low, moderate, high or very high risk. The intensity of the medication prescribed depends on the patient risk. Therapeutic goals are more demanding for patients with higher risk levels. Patients with DM and another cardiovascular risk factor are classified as very high risk, whereas patients with diabetes only, are classified as high risk.
Prevention through control of risk factors is always the best strategy.

Diabetic nephropathy: acting before failure 

Dr Alexandre Baptista

Specialist in Nephrology

The kidneys are primarily responsible for maintaining the internal balance of our body. In addition, they are responsible for the elimination of toxins, are an integral part of blood and bone regulation, help control blood pressure, regulate chemical balance and maintain control of the quantity of fluids in the human body.
When the kidneys fail, toxins accumulate in the blood and "uraemia" develops. This condition of "failure" or "insufficiency" is called Chronic Kidney Disease, which is characterised by the progressive and irreversible loss of kidney function. Diabetes, obesity and hypertension are the main causes for the development of Chronic Kidney Disease which results in the need for dialysis.
In the early stages of Chronic Kidney Disease it is usually symptomless, which causes a large part of the population to devalue, ignore, or put off taking care of their kidneys. This initial lack of symptoms results from the fact that the kidneys need to be badly damaged due to the accumulation of toxins for symptoms to be felt by the patient. 
Thus, it is only in the advanced stages of the disease that there are symptoms, when there is a frequency in the need to urinate (especially at night), pain or burning when urinating, pink (with blood) or foamy urine, swelling of the eyes, hands and feet or uncontrolled blood pressure. When the kidneys are already very damaged, patients might complain of difficulty in sleeping, easy fatigue, generalised weakness, nausea, vomiting or lack of appetite. Usually when these complaints arise, it means there´s almost total failure of the kidneys. When the kidneys no longer function properly, dialysis may be needed. Most of the time, when a kidney transplant is not possible, dialysis is the only alternative for the rest of the patient’s life.
Unfortunately, the only way to diagnose Chronic Kidney Disease is through blood and urine analysis, so frequent kidney health monitoring is recommended.
Treatment depends on the phase of the kidney disease. The main concern of the Nephrologist (specialist in kidney disease) is to control the major diseases that may damage the kidneys, so that progression of the disease can be delayed. This main concern will be present throughout the monitoring of kidney diseases. At a later stage, a patient may even receive an injection to control anaemia which will develop over time.
In the end, both the patient and the Nephrologist have the same expectations. To delay the progression of Chronic Renal Disease since it is irreversible when a moderate/advanced phase is reached.

Diabetic neuropathy: description of different types

Dr Romero Blanco

Specialist in Neuology

DM is responsible for a set of diseases of the peripheral nervous system known as Diabetic Neuropathy (DN). These neuropathies can be classified into polyneuropathies (affecting symmetric and distal peripheral nerves) and focal and asymmetric neuropathies (mononeuropathies of the extremities or cranial and radiculoplexopathies). DM is considered the most frequent cause of polyneuropathy in Western countries. The diagnosis of DN is based on symptoms and neurological examination, and is confirmed by an Electromyogram (EMG). Although the causes of DN are still unknown, metabolic and ischaemic factors seem to be implicated in its development.
Distal Symmetric Polyneuropathy: is considered to be the most frequent type of DN, occurring more frequently in long duration (type I and type II) diabetics. It begins with distal sensory alterations in the lower limbs that may later reach the hands (paraesthesia, pain, loss of different sensitivities), and can be confirmed in a neurological examination, due to the absence of Achillean reflexes. As the disease progresses, there may also be motor deficits of distal predominance in the lower limbs. Autonomic alterations appear in parallel with the evolution of the disease. These may consist of orthostatic hypotension, tachycardia, diarrhoea, constipation, neurogenic bladder, erectile dysfunction and sweating alterations.
Lumbosacral Radiculoplexux (Diabetic Amyotrophy): This form of DN mostly affects male patients, over the age of 50 suffering from type 2 DM. It does not correlate with disease control, nor with its duration. Typically, it is acute and unilateral, with pain in the hip joint followed, in days or weeks with paresis predominance of asymmetric proximal. It can be associated with serious weight loss. Recovering strength can take up to 24 months and in most cases is not total.
Mononeuropathies: may affect nerve extremities or cranial nerves and may be caused by compression (chronic stroke) or infarction (acute). The peripheral nerves most affected are the median in the wrist, the ulnar in the elbow and the external popliteal sciatic nerve of the fibula.
The most frequent Cranial Nerve Neuropathies are: Of the 3rd pair (oculomotor nerve), 4th pair (trochlear nerve) and 6th pair (external ocular motor nerve), which among other symptoms may cause double vision and less frequently, motricity of the face - 7th facial cranial nerve.
Prevention and treatment of DN is primarily through strict glycaemic control, but once established, DN is most often irreversible. Two multicentre studies have shown that alpha-lipoic acid has shown positive results in reducing symptoms and Neuropathic deficits.  
Yes, it is possible to treat autonomic symptoms (orthostatic hypotension, erectile dysfunction, digestive symptoms) and pain (pregabalin, gabapentin, duloxetine) symptomatically.

Diabetic retinopathy: where screening determines the future

Dr Argílio Caldeirinha

Specialist in Ophthalmoloy

Commonly referred to as "eye diabetes" (incorrect term), diabetic retinopathy consists of an alteration of the cytoarchitecture and consequent function of the retinal structures. It occurs due to micro vascular damage and subsequent inflammation. Approximately 25% of diabetics have some form of Diabetic Retinopathy and of these 2-10% present Diabetic Macular Oedema, the latter being responsible for the greater number of cases of bad vision in these patients.
Prevention of diabetic retinopathy is achieved through adequate metabolic control of the disease by a multidisciplinary team, usually coordinated by the Internal Medicine Specialist. Despite taking the best care, in some very severe cases, prevention will not stop the onset of this complication (for example in patients with Type I DM).
All patients with type I DM should be checked annually for diabetic retinopathy, and most patients after a 5 year diagnosis with type II DM, should also undergo annual screening.
With current screening programs available, diagnosis will usually occur in its early stages of the disease, with treatment plans possibly which will avoid more serious ophthalmological complications.