Diabetes and the foot

Diabetes is a group of metabolic disorders characterized by hyperglycemia (high blood sugar). This is caused by defects in insulin secrection, insulin action, or both. Classical signs of diabetes is continual urination, continual thirst, weight loss, and fatigue.

Types of Diabetes

Type I Diabetes Mellitus

Requires insulin
10% of all diabetes
onset at any age most people are before 18 years old
Beta cells of pancreas are destroyed
Fasting glucose is >180 mg/dl
Treatment of type I is to keep blood glucose levels normal to prevent or delay the long-term complications

Type II Diabetes Mellitus

Effects both insulin secretion and action
Most diabetics have this type
Aging, obesity, and genetics can lead to this type
Insulin resistance type of diabetes
Treatment is to normalize blood glucose levels and maintaining desirable body weight through a diet and exercise program
Oral medications should be used as an adjunct to diet and exercise

5 types of medications

Sulfonylureas: Stimulate insulin secretion by blocking the K+ channel of the beta cells in the pancreas
Glucotrol, Amaryl, Micronase, Glynase
Biguanides: decreases the liver glucose production and intestinal absorption of glucose and increases peripheral glucose uptake
Glucophage (Metformin)
Contraindicated with patients undergoing bone scan
Contraindicated in patients with renal disease
Alpha-glucosidase inhibitors: delays the digestion of carbohydrates
Precose, Glyset
Contraindicated in patients with IBD, colonic ulceration, other GI problems
Thiazolidinediones: decreases insulin resistance at perpheral receptor sites such as liver, muscle, and fat
Rezulin, Avandia, Actos
Indicated for people on insulin with poor control
Meglitinides: similar to sulfonylureas
Prandin

Diabetic Foot Problems

The big problem with diabetic and there feet is the development of ulcers.
Ulcers can develop in diabetics more often because of neuropathy. There are 3 different types of ulcerations: 1. Pressure, 2. Ischemic, 3. Neuropathic

Pressure ulcers

Absolute vertical pressure of 32mmHg can occlude vascular supply enough to produce ischemia and possible death of skin
Lying supine (head up) in bed can generate heel-bed pressures of 50-94 mmHg
Shear Pressures caused by a sliding motion of a parallel object against the skin. This develops friction which can cause ulceration.

Ischemic ulcers

Arterial insufficiency (bad circulation)
Smoking can cause
Symptoms are rest pain, thin shinny skin, absence of hair growth, no pulses

Neuropathic ulcers

Most common with diabetes; 82% with foot wounds
NEUROPATHY ASSOCIATED WITH DM LIKELY THE MOST COMMON CAUSE OF NEUROPATHY IN THE WORLD

Neuropathy
Symptoms: SENSORY
AUTONOMIC
MOTOR
COMBINED

Etiology

Drugs
Nerve Compression (Entrapment)
Nutritional (Vit B)
Alcohol

Treatment

METABOLIC CONTROL is necessary to delay onset of symptoms
And slow progression of neuropathy. If patient diagnosis is nerve entrapment then patient may require surgical release or modalities to decrease entrapment such as physical therapy.
Medications are treatment for neuropathic pain and paraesthesias:

VITAMIN SUPPLEMENTATION

HIGH DOSE VITAMIN E
1,800 IU/day x 4 month
HIGH DOSE B VITAMINS
FOLTX/FOLGARD (folic acid, pyridoxine,cobalamin) Metanx
B Complex, B Complete, all B
Brewer’s yeas

Treatment for diabetic foot ulceration can be seen here for list of wound care products.

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