CBO guidelines on diagnosis, treatment, and prevention of complication in diabetes mellitus: retinopathy, foot ulcers, nephropathy and cardiovascular diseases. Dutch Institute for Quality Assurance

Early detection and adequate treatment of complications of diabetes mellitus (DM) are important for many patients in maintaining independence and ability to work. Diabetic retinopathy cannot be prevented. Limitation of damage is possible by aiming for normoglycaemia and normotension. While exudative as well as proliferative retinopathy can occur without any visual symptom, regular ophthalmological examination is necessary for timely laser coagulation. Fundus photography for screening is applicable under certain conditions; fluorescence angiography can be useful in patients with understood deterioration of visual acuity or diabetic maculopathy. In many patients foot disease can be prevented by simple measures: examining the foot at least once a year, recognition of the foot with a high level of risk, education of patient and family, adapted shoes and preventive foot care. Treatment of a foot ulcus consists of relief of mechanical pressure, repair of disturbed skin circulation, treatment of infection and oedema, optimal metabolic control, frequent local wound care and education. Patients with a diabetic foot have to be thoroughly followed up for the rest of their lives. For patients with diabetic nephropathy cardiovascular complications are the main causes of morbidity and mortality. Of all patient with DM older than 10 years urine has to be examined for loss of albumin at least once a year. Treatment of nephropathy consists of non-smoking, sufficient physical exercise, reduction of overweight, well-composed nutrition and particularly treatment of hypertension. Diagnosing cardiovascular diseases in patients with DM is in principle the same as for other patients. Treatment of hypercholesterolaemia has to be based on an absolute risk of 20% for cardiovascular disease in the following 10 years. The limit for treatment will be reached earlier in the presence of microalbuminuria, persistent high HbA1c > 8.5%, triglyceride concentration > 2.0 mmol/l, or a positive family history with myocardial infarction < 60 years. In proven cardiovascular disease one needs to strive for optimalization of the glucose metabolism, non-smoking and if necessary drug therapy.