Diabetic Complications and Foot Infections

Question 1

How can a doctor lower the risk of cardiovascular disease in patients with diabetes?

Answer 1

ACE inhibitor (or angiotensin II receptor inhibitor

Lipid-regulating drugs

Lifestyle changes

Question 2

Provided there are no contra-indications, what should all diabetic patients with nephropathy causing proteinuria or with established microalbuminuria be treated with?

Answer 2

ACE inhibitor or angiotensin II receptor antagonist, even if blood pressure is normal

Question 3

Why do patients need to be careful and monitor themselves closely when starting an ACE inhibitor with diabetic treatments?

Answer 3

ACE inhibitors can potentiate the hypoglycaemic effect of insulin and oral antidiabetic drugs; this effect is more likely during the first weeks of combined treatment and in patients with renal impairment.

Question 4

What anti-depressant mono-therapy’s can be given for the management of painful neuropathy?

Answer 4

• Amitriptyline hydrochloride
• Imipramine hydrochloride (unlicensed use)
• Duloxetine
• Venlafaxine

Question 5

What anti-epileptic drugs can be considered for the treatment of painful diabetic peripheral neuropathy?

Answer 5

• Pregabalin
• Gabapentin

Opioid analgesics in combination with gabapentin can be considered if pain is not controlled with mono-therapy.

Question 6

In autonomic neuropathy, how can diabetic diarrhoea be managed?

Answer 6

• Tetracycline (unlicensed)

Alt:

• Codeine phosphate
• Other antidiarrhoeal preparations can also be tried

Question 7

How can neuropathic postural hypotension be managed?

Answer 7

• Increased salt intake
  &
• Fludrocortisone acetate (unlicensed use)

The above may help by increasing plasma volume, but uncomfortable oedema is a common side effect

Fludrocortisone can also be combined with flurbiprofen and ephedrine hydrochloride (both unlicensed).

Midodrine (unlicensed) an alpha agonist may also be helpful

Question 8

How can gustatory sweating be managed?

Answer 8

Anti-muscarinics such as:

- Propantheline bromide (side effects are common)

Question 9

How can neuropathic oedema be managed?

Answer 9

Ephedrine hydrochloride (unlicensed) offers some patients effective relief.

Question 10

How can visual impairment be prevented?

Answer 10

Optimal diabetic control (HbA1c ideally around 7% or 53 mmol/mol) and blood pressure control (<130/80 mmHg) should be maintained to prevent onset and progression of diabetic eye disease

Question 11

What are the 1st line anti-bacterial therapy choices for mild diabetic foot infections?

Answer 11

Mild infection:
- Flucloxacillin

alt in penicillin allergy:

- Clarithromycin 
or 
- Doxycycline 
or 
- Erythromycin

Question 12

What are the 1st line anti-bacterial therapy choices for Moderate or Severe Infection diabetic foot infections?

Answer 12

• Flucloxacillin with or without IV gentamicin and/or metronidazole
  or
  Co-amoxiclav with or without IV gentamicin, or IV ceftriaxone with metronidazole.
• Alternative in penicillin allergy:
  co-trimoxazole [unlicensed] with or without IV gentamicin and/or metronidazole.
• If Pseudomonas aeruginosa suspected or confirmed:
  IV piperacillin with tazobactam, or clindamycin with ciprofloxacin and/or IV gentamicin.
• If (MRSA) confirmed/ suspected add:
  IV vancomycin, or IV teicoplanin, or linezolid