Diabetes and Peripheral Neuropathy
People with diabetes have approximately a 50% lifetime risk of developing some type of neuropathy, the most common chronic complication of diabetes. Of the various types of neuropathies, diabetic peripheral neuropathy (DPN) is the most frequently encountered.
DPN Facts
- People with type 1 diabetes seldom develop DPN during the first 10 years post-diagnosis, but after that the incidence increases over the next 25 years to about 34%.
- DPN is more insidious in people with type 2 diabetes and is often found to be present at diagnosis.
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Half of all people with type 2 diabetes will develop symptoms of neuropathy over their lifetime.
- Other populations affected by DPN are young people with type 2 diabetes, people with pre-diabetes, and those with metabolic syndrome.
- Up to 50% of patients with DPN are asymptomatic. In this case, unless diagnosed in a timely manner, the foot can become insensate so that an injury or ulcer can go undetected.
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People with diabetes have a 30 times greater risk of having an amputation than those without diabetes.
For symptomatic individuals, the pain of diabetic neuropathy ranges in severity from mild stinging and burning to excruciating and life altering.
What can be done?
The Diabetes Control and Complications Trial (DCCT) and its long-term follow-up the Epidemiology of Diabetes Interventions and Complications (EDIC) study demonstrated that early intensive glycemic control in people with type 1 diabetes significantly reduces the cascade of events that lead to diabetic foot ulcers and lower extremity amputations. Controlling blood sugar in type 2 diabetes can slow the progression of neuropathy but does not reverse damage that has already occurred. Dyslipidemia and insulin resistance may also play a part in the pathogenesis of diabetic neuropathy.
The problem
- There are no treatments available to reverse nerve damage that has already occurred.
- There is little evidence that neuropathic pain responds to lifestyle changes and glycemic control, although some evidence points toward glycemic stability (less variability) as a possibility.
- The remaining option is to treat the pain with medication.
Be part of the solution
Pharmacists can reinforce the American Diabetes Association (ADA) DPN screening recommendations: at diagnosis for type 2 diabetes, 5 years after diagnosis of type 1, then annually thereafter for both. Here is a hand out to share with your patients
Glycemic control is paramount in preventing DPN, we should stress meaningful blood glucose monitoring and lifestyle management.
Familiarize yourself with the available therapies for neuropathic pain.
The 3-minute extra mile
There are specific recommendations for pharmacologic and nutraceutical treatments for painful DPN, and information about medications that cause or exacerbate DPN. Please see the attached documents for ideas and talking points to share with patients: Nerve Damage and Diabetes (ADA), Neuropathy (ADA), Nerve Pain customizable handout.
James Bennett BsPharm, CDCES, BCGP
Bozeman MT 59715
Management of Springtime Asthma
It is estimated that 25 million Americans are affected by asthma with more than two-thirds having an allergy.1,2 Asthma exacerbations, especially among children, are highest in the spring and fall.3 Prevention and treatment of asthma symptoms and exacerbations can be costly so knowing possible triggers, minimizing exposure, and proper medication use is important to minimizing costs and improving outcomes.
Springtime Triggers:
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- Tree, grass, and weed pollens
- Mold spores
- Dust
- Frequent temperature changes
- Pet dander
- Air pollution
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Pharmacist-provided patient education:
- Help patients identify triggers and how/when to avoid them.
- Remind patients to check air quality for pollen, pollution, and other potential triggers.
- Suggest people take shoes off inside since pollen can be tracked indoors.
- Suggest patients shower and wash hair before bed to remove any pollen.
- Remind people to wash bedsheets in hot water and vacuum often.
- Remind patients to change air filters in vehicles and at home when they are due to be changed.
- Remind patients to take asthma medications as directed
- Assess for proper inhaler technique.
- Suggest patients start taking proper allergy medications two weeks before allergy season starts.
- Recommend that patients speak to their provider about allergy shots, if appropriate.
- 2020 EPR-3 guidelines conditionally recommend subcutaneous immunotherapy as adjunct therapy in patients 5 years and older who have controlled asthma at the initiation, build-up, and maintenance phases of immunotherapy
- Encourage patients to speak to their primary care provider or specialist about creating an asthma action plan.
Tessa Hultgren, PharmD Candidate reviewed by Rachael Zins, PharmD, AE-C
References
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