● Electrocardiogram abnormalities Following are recommendations for treatment of coronary heart disease for patients with diabetes (American Diabetes Association, 2021a): ● Among patients with type 2 diabetes who have established atherosclerotic cardiovascular disease or established kidney disease, a sodium–glucose cotransporter 2 inhibitor or glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular disease benefit is recommended as part of the comprehensive cardiovascular risk reduction and/or glucose- lowering regimens. ● In patients with type 2 diabetes and established atherosclerotic cardiovascular disease, multiple atherosclerotic cardiovascular disease risk factors, or diabetic kidney disease, a sodium–glucose cotransporter 2 inhibitor with demonstrated cardiovascular benefit is recommended to reduce the risk of major adverse cardiovascular events and/or heart failure hospitalization. ● In patients with type 2 diabetes and established atherosclerotic cardiovascular disease or multiple risk factors for atherosclerotic cardiovascular disease, a glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular Diabetic neuropathy Diabetic neuropathy is a group of nerve disorders caused by diabetes mellitus. Over the course of time, nerve damage can occur throughout the body. Some persons have no symptoms of nerve damage, but others may feel pain, tingling, or numbness in the hands, arms, feet, and legs. Neuropathy can occur in every organ system throughout the body (NIDDK, n.d). The following persons are at highest risk for diabetic neuropathy (Mayo Clinic, 2021b): ● Those who have elevated cholesterol ● Those who have advanced renal disease ● Those who drink large amounts of alcohol ● Those who smoke The American Diabetes Association (2021i) advocates the following screenings and treatments: ● Assess all patients for diabetic peripheral neuropathy beginning at diagnosis of type 2 diabetes and five years after the diagnosis of type 1 diabetes. After these initial assessments, patients should be evaluated at least annually. ● Include a careful history and assessment of either temperature or pinprick sensation as part of the assessment for distal symmetric polyneuropathy. ● Assess for signs and symptoms of autonomic neuropathy in patients who have microvascular complications. ● Optimize glucose control to prevent or delay the development of neuropathy or to slow its progression. ● Assess and treat patients to reduce pain related to diabetic peripheral neuropathy and symptoms of autonomic neuropathy. ● Prescribe either pregabalin or duloxetine as initial pharmacologic treatments for neuropathic pain in diabetes. There are four types of diabetic neuropathy (NIDDK, n.d.): 1. Peripheral 2. Autonomic 3. Proximal 4. Focal Peripheral Diabetic neuropathy Peripheral neuropathy is the most common type of diabetic neuropathy. The areas of the body most affected are the feet and legs. Rarely, other areas of the body—the arms, abdomen, and back—may be affected by peripheral neuropathy. Nerve damage can lead to a loss of sensation in the feet and legs placing the patient at significant risk for foot problems. Injuries, lesions, blisters, and sores on the feet may go unnoticed because of a lack of sensation. Infection can easily occur, and if not treated promptly, the infection can spread to the bone. Such infections may lead to amputation of toes, feet, and lower limbs. Many amputations can be prevented with meticulous skin care and swift recognition and treatment of infections (Dansinger, 2021b; Mayo Clinic, 2021e; NIDDK, 2018). ● Those who are overweight ● Those who are hypertensive
benefit is recommended to reduce the risk of major adverse cardiovascular events. ● In patients with type 2 diabetes and established heart failure with reduced ejection fraction, a sodium–glucose cotransporter 2 inhibitor with proven benefit in this patient population is recommended to reduce risk of worsening heart failure and cardiovascular death. ● In patients with known atherosclerotic cardiovascular disease, particularly coronary artery disease, ACE inhibitor or angiotensin receptor blocker therapy is recommended to reduce the risk of cardiovascular events. ● In patients with prior myocardial infarction, β -blockers should be continued for 3 years after the event. ● Treatment of patients with heart failure with reduced ejection fraction should include a β -blocker with proven cardiovascular outcomes benefit, unless otherwise contraindicated. ● In patients with type 2 diabetes with stable heart failure, metformin may be continued for glucose lowering if estimated glomerular filtration rate remains >30 mL/min/1.73 m2 but should be avoided in unstable or hospitalized patients with heart failure. Common symptoms of diabetic peripheral neuropathy are tingling (resembling a “pins and needles” sensation), numbness (which can become permanent), burning (especially in the evening), and pain. Discomfort related to these symptoms may be reduced or controlled when blood glucose levels are under control (NIDDK, 2018c). Painful diabetic neuropathy may be treated with oral medications (NIDDK, 2018c): ● Tricyclic antidepressants and other types of antidepressants as appropriate ● Anticonvulsants ● Skin creams, patches, or sprays (e.g., lidocaine) Healthcare professionals must instruct patients and families in skin care, especially the care of the feet, because the nerves to the feet are the longest in the body and are the nerves most often impacted by neuropathy. Education should include the following instructions (Dansinger, 2021b; Mayo Clinic, 2021e): ● Clean the feet daily using warm, not hot, water and a mild soap. Do not soak the feet. Dry the feet gently but thoroughly with a soft towel, paying special attention to the skin between the toes. ● Apply gentle, non-perfumed lotion to the feet if they are dry. Do not put lotion between the toes. ● Inspect the feet and toes every day for cuts, blisters, redness, sores, calluses, or other problems. Use a mirror to check the bottom of the feet. If any abnormalities are noted, notify a health care provider immediately. Rigorous attention to leg and foot ulcers may include debridement, hyperbaric oxygen therapy, or intensive would care. ● Go to a podiatrist, if possible, to avoid injuring the toes when toenails need to be trimmed. ● Never go barefoot. Wear properly fitting shoes or slippers at all times to protect the feet from injuries. Shoes should not be tight; the toes should be able to move when wearing them. New shoes should be broken in gradually by wearing them for only an hour at a time initially. ● Examine shoes and slippers before putting them on, including feeling the insides. This is done to be sure that shoes and slippers are free from tears, sharp edges, or objects that might damage the feet. ● Participate in regular, gentle exercise. Routines such as yoga and tai chi might be of benefit. ● Stop smoking. ● Eat healthy meals. ● Avoid excessive amounts of alcohol. ● Monitor blood glucose levels per health care provider instructions. Autonomic diabetic neuropathy Autonomic neuropathy is damage to the nerves that are responsible for the control of the internal organs. Autonomic neuropathy can lead to problems in the cardiovascular, digestive, and renal systems. It can also cause sexual dysfunction, vision
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