Diabetic neuropathy SIN Flashcards
1
Q
What is the most common neuropathic complication of diabetes?
A
Distal symmetric polyneuropathy (DSP)
50% or more of patients with diabetes develop DSP, and up to 20% have clinical features of neuropathy at the time of diagnosis.
2
Q
Describe the sensory symptoms associated with distal symmetric polyneuropathy (DSP).
A
Positive and negative sensory symptoms in a length-dependent pattern affecting the toes and distal foot
Positive symptoms include paresthesias, allodynia, and hyperalgesia.
3
Q
What percentage of diabetic patients with DSP experience neuropathic pain?
A
40%
Neuropathic pain is often the principal source of disability.
4
Q
What are common descriptions of neuropathic pain in DSP patients?
A
- Deep aching
- Burning
- Electric
- Tingling
- Sharp
Pain is typically moderate to severe and most severe at nighttime.
5
Q
What are the potential complications of severe distal symmetric polyneuropathy?
A
- Painless injury
- Foot intrinsic muscle atrophy
- Exaggerated foot arch
- Hammer toes
- Falls and other orthopedic injuries
Loss of protective sensation can lead to foot ulcers and amputations.
6
Q
What should be evaluated during the assessment of diabetic neuropathy?
A
Focused questions about pain, paresthesias, sensory loss, and weakness
An exam should be tailored to detect length-dependent nerve injury.
7
Q
What is the typical presentation of diabetic autonomic neuropathy?
A
Asymptomatic or vague symptoms such as dizziness, poor balance, nausea, abdominal pain, or sexual dysfunction
A high index of suspicion is required for diagnosis.
8
Q
What are the major risks associated with diabetic autonomic neuropathy?
A
- Increased risk for cardiac death
- Orthostatic hypotension
- Syncope
- Erectile dysfunction
- Gastroparesis
- Diarrhea
- Hypoglycemia
Coronary artery disease is often evaluated due to its impact on mortality.
9
Q
What are the common forms of compressive mononeuropathies in diabetes?
A
- Ulnar
- Median
- Peroneal
Bilateral and dominant median mononeuropathy at the wrist are more common.
10
Q
What is diabetic lumbosacral radiculoplexus neuropathy (DLRPN)?
A
A condition presenting with abrupt onset of severe unilateral thigh pain followed by muscle atrophy and weakness
Typically affects older patients with type 2 diabetes.
11
Q
What defines metabolic syndrome?
A
Presence of three of the following: increased fasting glucose, hypertriglyceridemia, decreased HDL-C, central obesity, elevated blood pressure
Active treatment for any of these conditions also meets criteria.
12
Q
Which metabolic syndrome features have been linked to neuropathy?
A
- Obesity
- Dyslipidemia
These factors are significant independent of hyperglycemia.
13
Q
What is the impact of aggressive glycemic control on diabetic neuropathy?
A
Reduces neuropathy risk in type 1 diabetes
The Diabetes Control and Complications Trial (DCCT) showed that intensive control reduced neuropathy incidence.
14
Q
What are the potential medications for diabetic symmetric polyneuropathy (DSP)?
A
- Alpha lipoic acid
- Acetyl-L carnitine
- Benfotiamine
These medications reduce oxidative stress, a key component of neuropathy pathogenesis.
15
Q
What are some key pathophysiological mechanisms of distal symmetric polyneuropathy?
A
- Direct axonal injury from hyperglycemia
- Insulin resistance
- Endothelial injury
- Microvascular dysfunction
These factors lead to nerve ischemia and functional deficits.
16
Q
True or False: Exercise has been shown to significantly improve glycemic control in neuropathy patients.
A
False
While exercise improves fitness and reduces neuropathy incidence, it does not significantly improve HgbA1c.
17
Q
What is the effect of alpha lipoic acid (ALA) on neuropathic pain?
A
Subjects treated with ALA reported a significantly greater reduction in neuropathic pain than placebo-treated controls
ALA is available in the United States as a dietary supplement and is regulated as a drug in many European nations.
18
Q
What are the potential side effects of ALA?
A
ALA may lower blood glucose and thiamine stores, and has unpredictable effects on thyroid function.
19
Q
What is the recommended starting dose for oral ALA?
A
300 mg by mouth daily, titrated as high as 600 mg twice daily.
20
Q
What does acetyl-L carnitine (ALC) do in diabetic patients?
A
Inhibits lipid peroxidation and increases nitric oxide synthase and nitric oxide.
21
Q
What were the results of trials involving ALC?
A
ALC significantly improved sural morphology and Visual Analog Pain Scale (VAS) scores.
22
Q
What is benfotiamine?
A
A vitamin B1 derivative with antioxidant properties.
23
Q
What was the outcome of the phase III study on benfotiamine?
A
Subjects showed significant improvement in neuropathy-specific Total Symptom Score and pain subscore.
24
Q
What are the challenges in delivering therapeutic agents for neuropathy?
A
Delivery to the target organ without limiting off-target side effects has proven challenging.
25
What is one proposed solution for targeted delivery of therapeutic agents?
Use of delivery vectors derived from the herpes simplex virus.
26
What types of therapies are purported to improve neuropathy?
Physical, surgical, or energy therapies that increase vascular or microvascular blood flow.
27
True or False: Diabetes is the most common cause of neuropathy and neuropathic pain in industrialized countries.
True.
28
What percentage of diabetic patients reported chronic painful neuropathy in a study?
16% of diabetic patients compared to 4% of controls.
29
What medications are commonly used to treat neuropathic pain?
Antidepressants, antiepileptic drugs, opiates, and mixed serotonin/norepinephrine reuptake inhibitors.
30
What is the typical dose of amitriptyline for neuropathic pain?
50-200 mg, taken 2 hours before bedtime.
31
What side effects are associated with tricyclic antidepressants?
Orthostatic hypotension, urinary hesitancy, fatigue, somnolence, and confusion.
32
What is gabapentin's mechanism of action?
Binding to the alpha 2 delta subunit of voltage-gated Ca2+ channels.
33
What is the typical dosing schedule for gabapentin?
Start at 300 mg taken 2 hours before bedtime, increasing in increments.
34
What is pregabalin and its FDA indication?
A medication for neuropathic pain associated with diabetes.
35
What are the common side effects of duloxetine?
Nausea, somnolence, dry mouth, and constipation.
36
What role do opiates play in treating neuropathic pain?
Adjunct treatment in poorly controlled neuropathic pain.
37
What is the most common side effect of low-dose oral opiate use?
Constipation.
38
How does capsaicin cream work?
Reduces pain sensation by depleting substance P from nociceptive fibers.
39
What is a significant risk factor for falls in diabetic patients with neuropathy?
Sensory loss and distal weakness.
40
What preventative measures are recommended for diabetic patients to avoid foot ulcers?
Daily self-examination, podiatric consultation, orthotic support, and protective footwear.
41
What are the mainstays of diabetic neuropathy management?
Effective management of hyperglycemia, symptom control, and prevention of ulcers and infection.
42
What innovative therapies are being developed for neuropathic pain?
Gene therapy approaches and other novel pain therapies.
43
What are some innovative therapies in development for pain management?
Gene therapy approaches
## Footnote
These therapies have shown promise in addressing pain.
44
What is a major risk factor for falls in patients with peripheral neuropathy?
Neuropathy, sensory loss, and distal weakness
## Footnote
These factors significantly increase fall risk in diabetic patients.
45
What percentage of diabetic patients over 55 experienced falls in the prior year?
Over one-third
## Footnote
This statistic highlights the prevalence of fall risk in older diabetic patients.
46
What should formal gait evaluation include for patients with neuropathy?
Testing conditions like uneven or irregular surfaces
## Footnote
Patients often fall in such conditions, making this evaluation crucial.
47
What percentage of diabetic patients developed foot ulcers in a tertiary care podiatric clinic study?
29%
## Footnote
This statistic indicates the commonality of foot ulcers among diabetic patients.
48
What increases the risk of ulceration and amputation in diabetic patients?
Diabetic sensorimotor polyneuropathy (DSP)
## Footnote
DSP increases ulceration risk sevenfold and contributes to over 60% of lower extremity amputations.
49
What are common complications contributing to foot ulcer risk in diabetic patients?
Lack of protective sensation, blood flow abnormalities, abnormal sweating, and poor wound healing
## Footnote
These factors combine to heighten ulceration risk.
50
What preventive measures are recommended for patients at risk for foot ulcers?
Daily self-examination, podiatric consultation, orthotic foot support, protective shoes
## Footnote
These measures help in reducing the risk of ulcers and complications.
51
What is the relationship between the duration of neuropathy and ulceration risk?
Longer duration of neuropathy increases ulceration risk
## Footnote
Severity of hyperglycemia also plays a significant role.
52
What therapies are appropriate if stasis ulcers develop?
Nonsurgical debridement, hydrogels application, empiric antibiotic coverage
## Footnote
These therapies aim to manage wound care effectively.
53
What remains the mainstays of diabetic neuropathy management?
Effective management of hyperglycemia, symptom control, prevention of ulcers and infection
## Footnote
These strategies have been central to neuropathy management for decades.
54
True or False: Rational therapies based on understanding diabetic neuropathy pathogenesis have been successful in humans.
False
## Footnote
Many therapies have largely been unsuccessful due to the advanced state of neuropathy in trial subjects.
55
What promising measures may help identify neuropathy patients early?
Skin biopsy for intraepidermal nerve fiber density, confocal corneal microscopy
## Footnote
These methods may allow for earlier detection of peripheral nerve injury.
56
What is the most common neuropathic complication of diabetes?
Distal symmetric polyneuropathy (DSP)
## Footnote
50% or more of patients with diabetes develop DSP
57
What percentage of patients may have clinical features of neuropathy at the time of diabetes diagnosis?
Up to 20%
## Footnote
This indicates that neuropathy can be present even before diabetes is fully diagnosed.
58
In what pattern does distal symmetric polyneuropathy (DSP) affect sensory symptoms?
Length-dependent pattern
## Footnote
Affects the toes and distal foot, spreading to the ankle and proximally over time.
59
What are 'positive' sensory symptoms associated with DSP?
* Paresthesias
* Allodynia
* Hyperalgesia
## Footnote
Paresthesias include sensations like pricking, tingling, or burning.
60
What percentage of diabetic patients with DSP experience neuropathic pain?
40%
## Footnote
Neuropathic pain is often the principal source of disability.
61
What type of pain is often experienced by patients with DSP?
* Deep aching
* Burning
* Electric
* Tingling
* Sharp
## Footnote
The pain is often worse with walking and most severe at nighttime.
62
What is the average pain intensity reported by patients with painful DSP?
5.8/10
## Footnote
This average was based on a survey of 105 painful DSP patients.
63
What complications can arise from severe distal symmetric polyneuropathy?
* Painless injury
* Foot intrinsic muscle atrophy
* Exaggerated foot arch
* Hammer toes
## Footnote
These complications can lead to instability and increased risk of falls.
64
What predisposes patients with DSP to foot ulcers and Charcot foot abnormalities?
* Loss of protective sensation
* Altered sweating
* Poor wound healing
## Footnote
These factors significantly increase the risk of serious foot complications.
65
What should the evaluation for DSP include?
* Focused questions about pain
* Paresthesias
* Sensory loss
* Weakness
## Footnote
An exam should be tailored to detect length-dependent nerve injury.
66
What might atrophy of hand muscles indicate in the context of neuropathy?
Focal compressive mononeuropathies of ulnar or median nerves
## Footnote
Atrophy of hand muscles is less common than foot muscle atrophy in DSP.
67
What is a characteristic finding in deep tendon reflexes for patients with DSP?
Reduced or absent at the ankles
## Footnote
Well-preserved distal reflexes may suggest other conditions like structural myelopathy.
68
Which types of nerve injury should be considered if sensory testing shows reduced reflexes?
* Structural myelopathy
* Dorsal column neuropathy (e.g., B12 deficiency)
## Footnote
These conditions can present with similar sensory loss features.
69
Fill in the blank: Distal symmetric polyneuropathy primarily affects the _______.
toes and distal foot
## Footnote
This is part of the length-dependent pattern of sensory loss.
70
What is the purpose of timed vibration with a 128 Hz tuning fork in neuropathy assessment?
Provides a semiquantitative measure with a broad dynamic range
## Footnote
This method helps to establish the proximal extent of sensory deficit.
71
What symptoms are commonly associated with diabetic autonomic neuropathy?
* Dizziness
* Poor balance
* Nausea
* Abdominal pain
* Sexual dysfunction
## Footnote
Most patients may be asymptomatic or present with vague symptoms.
72
True or False: Diabetic autonomic neuropathy significantly increases the risk of cardiac death.
True
73
What test can be used to evaluate coronary artery disease in patients with diabetic autonomic neuropathy?
Simple tests of vagal heart rate response to deep breathing or Valsalva maneuver
## Footnote
These tests help predict greater all-cause mortality.
74
What percentage of men with newly diagnosed diabetes report erectile dysfunction?
27%
75
What are common compressive mononeuropathies seen in diabetes?
* Ulnar
* Median
* Peroneal
## Footnote
Bilateral and dominant median mononeuropathy at the wrist is particularly common.
76
Fill in the blank: Hand numbness suggests bilateral median mononeuropathies at the wrist, also known as _______.
carpal tunnel syndrome
77
What is the typical presentation of diabetic lumbosacral radiculoplexus neuropathy (DLRPN)?
* Abrupt onset of severe unilateral thigh pain
* Progressive atrophy and weakness
* Involvement of proximal more than distal muscles
## Footnote
Patients may also experience significant weight loss and wheelchair dependence.
78
What is a characteristic finding in cerebrospinal fluid examination of DLRPN?
Elevated protein concentration without pleocytosis
79
True or False: The risk of diabetic lumbosacral radiculoplexus neuropathy is related to the duration of diabetes.
False
80
What defines metabolic syndrome?
Presence of three of the following:
* Increased fasting glucose
* Hypertriglyceridemia
* Decreased HDL-C
* Ethnicity-specific central obesity
* Elevated blood pressure
## Footnote
Active treatment for any of these conditions also meets criteria.
81
What two metabolic syndrome features are linked to neuropathy independent of hyperglycemia?
* Obesity
* Dyslipidemia
## Footnote
These factors are significant risk factors for diabetic neuropathy.
82
What percentage of type 1 diabetic patients were found to have diabetic sensory polyneuropathy (DSP) in the EuroDiab study?
28%
83
Fill in the blank: Glycemic control has long been the cornerstone of _______ therapy.
DSP
84
What independent risk factors for neuropathy did the EuroDiab study identify?
* Hypertension
* Serum lipids and triglycerides
* Body mass index (BMI)
* Smoking
## Footnote
These factors contributed to the development of neuropathy in patients with diabetes.
85
What is the relationship between obesity and autonomic function?
Obesity is associated with abnormal autonomic function and early or subclinical autonomic neuropathy.
86
How does hypertriglyceridemia relate to neuropathy?
Hypertriglyceridemia is significantly more common in those with idiopathic neuropathy and may be involved in its development and progression.
87
What was found regarding serum triglyceride levels in diabetic patients?
Serum triglyceride level was an independent step-wise risk factor for lower extremity amputation among diabetic patients.
88
What correlation was observed in a cohort study regarding triglycerides and nerve fiber density?
Elevated triglycerides significantly correlated with loss of sural nerve myelinated fiber density over 52 weeks, independently of disease duration, age, or diabetes control.
89
What impact does aggressive glycemic control have on neuropathy risk in type 1 diabetes?
Aggressive glycemic control has been shown to reduce the neuropathy risk in type 1 diabetes.
90
What were the findings of the Diabetes Control and Complications Trial (DCCT) regarding neuropathy?
Patients with 5 years of intensive control during the DCCT were less likely to have neuropathy 14 years later compared to those with standard therapy (25% vs 35%, p < 0.001).
91
True or False: The ACCORD study found a reduction in clinical neuropathy risk among early diabetic subjects receiving intensive therapy.
False.
92
What did the Steno-2 trial reveal about metabolic syndrome control?
The trial showed that aggressive multimodal therapy significantly reduced the likelihood of developing nephropathy, retinopathy, and autonomic neuropathy.
93
What role does exercise play in the prevention and therapy of neuropathy?
Exercise may help prevent neuropathy; a study found that clinical neuropathy developed in 30% of nonexercisers compared to 7% of exercisers (p < 0.05).
94
Fill in the blank: The pathophysiology of diabetic sensorimotor polyneuropathy (DSP) involves direct axonal injury due to _______.
[hyperglycemia]
95
What are some identified pathways contributing to DSP?
* Direct axonal injury due to hyperglycemia
* Insulin resistance
* Toxic adiposity
* Endothelial injury
* Microvascular dysfunction
96
What are advanced glycation end products and their significance in neuropathy?
They are metabolic products that contribute to oxidative stress and microvascular injury, playing a role in neuropathy pathogenesis.
97
What has been the result of trials for small vessel vasodilatory agents in treating diabetic neuropathy?
Multiple trials showed no clinical response.
98
Which medications are related to neuropathic pain relief and may affect neuropathic injury?
* Alpha lipoic acid
* Acetyl-L-carnitine
* Benfotiamine
99
What is a key component of neuropathy pathogenesis in diabetes?
Oxidative stress.
100
What has been the general efficacy of aldose reductase inhibitors in humans?
They have generally shown no efficacy in humans.
101
What are free radicals and their effect on axonal mitochondria?
Free radicals directly damage axonal mitochondria and divert nitric oxide from its normal vasodilatory role, resulting in impaired vasoregulation and ischemia of nutritive arterioles.
102
What is Alpha Lipoic Acid (ALA) and its significance in diabetic neuropathy?
ALA is an orally bioavailable antioxidant that has shown significant reduction in neuropathic pain in diabetic neuropathy subjects compared to placebo.
103
What was the purpose of the SYDNEY Study?
To evaluate the effectiveness of oral ALA in reducing neuropathic pain in diabetic neuropathy subjects.
104
What was the outcome of the SYDNEY Study regarding neuropathic pain?
Subjects treated with ALA reported a significantly greater reduction in neuropathic pain than those on placebo.
105
What are the available dosages for Alpha Lipoic Acid (ALA)?
ALA may be started at a dose of 300 mg daily, titrated as high as 600 mg twice daily.
106
What are the potential side effects of ALA?
ALA may lower blood glucose and thiamine stores, and has unpredictable effects on thyroid function.
107
What is Acetyl-L Carnitine (ALC) and its role in diabetic neuropathy?
ALC is an antioxidant that inhibits lipid peroxidation and increases nitric oxide, with significant improvements in neuropathy measures in diabetic subjects.
108
What were the results of the trials using Acetyl-L Carnitine (ALC)?
ALC significantly improved sural morphology and pain scores in diabetic neuropathy subjects compared to placebo.
109
What is Benfotiamine and its effects on diabetic neuropathy?
Benfotiamine is a vitamin B1 derivative with antioxidant properties that showed significant improvement in neuropathy symptoms in a phase III study.
110
What is one challenge in delivering therapeutic agents for neuropathy?
Delivering agents to the target organ without off-target side effects has proven challenging.
111
What is the role of herpes simplex virus in neuropathy treatment?
Delivery vectors derived from herpes simplex virus have been used to target dorsal root ganglia neurons for therapy.
112
What types of therapies are purported to improve neuropathy?
Physical, surgical, or energy therapies, including triple decompressive surgery and magnetic field therapy.
113
What is the most common cause of neuropathy and neuropathic pain in industrialized countries?
Diabetes.
114
What percentage of diabetic patients experienced chronic painful neuropathy in a Liverpool study?
16% of diabetic patients experienced chronic painful neuropathy.
115
What are common treatments for neuropathic pain?
Antidepressants, antiepileptic drugs, opiates, and mixed serotonin/norepinephrine reuptake inhibitors.
116
What are tricyclic antidepressants and their role in treating neuropathic pain?
Tricyclic antidepressants like amitriptyline are mainstays of treatment, proven effective in several studies.
117
What is the typical starting dose for amitriptyline in treating neuropathic pain?
A typical starting dose is 50-200 mg, taken 2 hours before bedtime.
118
What are common side effects of tricyclic antidepressants?
Orthostatic hypotension, urinary hesitancy, fatigue, somnolence, and confusion.
119
True or False: Gabapentin acts as a GABA agonist.
False.
120
What is the mechanism of action of Gabapentin?
Gabapentin is thought to bind to the a2 delta subunit of calcium channels.
121
What is the primary use of gabapentin in treating neuropathic pain?
Gabapentin is used to significantly reduce neuropathic pain and improve sleep.
122
What is the starting dose for gabapentin and how should it be escalated?
Start at 300 mg taken 2 hours before bedtime, increasing in 300 mg increments every 3 to 7 days.
123
What is the maximum daily dose of gabapentin that some patients may require?
Some patients may require up to 4800 mg daily in divided doses.
124
What are the common side effects of gabapentin?
Dizziness and somnolence.
125
How does pregabalin compare to gabapentin in terms of pharmacokinetics?
Pregabalin is structurally similar to gabapentin and has a similar pharmacokinetic, metabolic, and side-effect profile.
126
What is the starting dose for pregabalin and how should it be escalated?
Start at 75 mg twice daily, increasing by 75 mg increments to 150 mg twice daily.
127
What is duloxetine indicated for besides neuropathic pain associated with diabetic DSP?
Duloxetine is also indicated for depression, anxiety, pain associated with fibromyalgia, and chronic musculoskeletal pain.
128
What was the outcome of duloxetine in randomized controlled trials for diabetic subjects with painful DSP?
Subjects showed statistically better cumulative pain relief over 12 weeks when administered duloxetine 60 mg daily compared to placebo.
129
List common side effects of duloxetine.
* Nausea
* Somnolence
* Dry mouth
* Constipation
130
True or False: Gabapentin, pregabalin, and duloxetine have been compared head-to-head in clinical trials.
False.
131
What role do opiates have in treating neuropathic pain?
Opiates have a defined role as adjunct treatment in poorly controlled neuropathic pain.
132
What is a common side effect of low-dose oral opiate use?
Constipation.
133
What should be done to prevent constipation in patients taking opiates?
Prophylactic institution of a bowel control regimen.
134
What is tramadol's mechanism of action?
Tramadol binds to opiate receptors and blocks reuptake of serotonin and norepinephrine.
135
What were the findings of the study regarding tramadol's effectiveness in treating neuropathic pain?
Tramadol was significantly more effective than placebo in treating neuropathic pain.
136
What is mexiletine and its effect in diabetic neuropathy?
Mexiletine is an orally active local anesthetic that showed statistically significant reduction in pain ratings.
137
What is the mechanism of action of capsaicin cream?
Capsaicin depletes substance P from nociceptive C-fibers, reducing pain sensation.
138
What is a limitation of capsaicin therapy for neuropathic pain?
Capsaicin is practical only for patients with small areas of neuropathic pain.
139
Fill in the blank: A therapeutic trial of gabapentin should involve at least ______ weeks at a therapeutic dose.
4
140
True or False: Psychological dependence and addiction are common risks when using opiates for pain management.
False.
141
What should patients at higher risk of addiction do when using opiates?
They may require referral to a pain specialist.
142
What type of therapies are being studied for neuropathic pain?
Anticonvulsants and antidepressants with mixed results, and innovative pain therapies including gene therapy approaches
## Footnote
These therapies are aimed at addressing the complexities of neuropathic pain management.
143
What is a major risk factor for falls in patients with peripheral neuropathy?
Neuropathy, sensory loss, and distal weakness
## Footnote
These factors contribute significantly to the increased fall risk among diabetic patients.
144
What percentage of diabetic patients over 55 years old experienced falls in the prior year?
Over one-third
## Footnote
This statistic highlights the heightened risk of falls in older diabetic patients with peripheral neuropathy.
145
True or False: Bedside gait examination is a sensitive predictor of fall risk.
False
## Footnote
Bedside gait examination may not accurately predict fall risk in patients with neuropathy.
146
What should formal gait evaluation include for patients with neuropathy?
Testing conditions on uneven or irregular surfaces
## Footnote
This is important to accurately assess the fall risk of patients with neuropathy.
147
What is the common diabetic complication related to foot health?
Foot ulceration and potential amputation
## Footnote
Foot ulcers can lead to serious outcomes, including digit, foot, or limb amputation.
148
What percentage of diabetic patients developed foot ulcers in a study followed for 30 months?
29%
## Footnote
This statistic underscores the prevalence of foot ulcers among diabetic patients.
149
How much does diabetic small fiber neuropathy (DSP) increase the risk of ulceration?
Sevenfold
## Footnote
DSP significantly contributes to the risk of developing foot ulcers in diabetic patients.
150
What factors contribute to the increased risk of ulceration in diabetic patients?
Lack of protective sensation, blood flow abnormalities, abnormal sweating, and poor wound healing
## Footnote
These factors collectively increase the likelihood of foot ulcers and amputations.
151
What recommendations are made for patients at risk for foot ulcers?
Daily self-examination, podiatric consultation, orthotic foot support, and protective footwear
## Footnote
These measures are essential for preventing foot ulcers in at-risk diabetic patients.
152
What are appropriate therapies for stasis ulcers?
Nonsurgical debridement, application of hydrogels, and empiric antibiotic coverage
## Footnote
These therapies help manage ulceration and promote healing.
153
What remains the mainstay of diabetic neuropathy management?
Effective management of hyperglycemia, symptom control, and prevention of ulcers and infection
## Footnote
These strategies have been fundamental in managing diabetic neuropathy for decades.
154
What challenges have rational therapies faced in human trials for diabetic neuropathy?
They have been largely unsuccessful
## Footnote
This may be due to the advanced stage of neuropathy present in trial subjects.
155
What measures hold promise for early identification of neuropathy patients?
Skin biopsy for intraepidermal nerve fiber density and confocal corneal microscopy
## Footnote
These techniques may help identify patients at earlier stages of neuropathy.
