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1. DIABETIC
NEUROPATHY: A BRIEF
INSIGHT
PRESENTED BY:
VISHNU.R.NAIR, ALEESHA RAHUMAN, SHEENA.S. SIBI,
PRESENTED TO: DR. EMILL JAME DAVID
PHARM.D STUDENTS,
NATIONAL COLLEGE OF PHARMACY(NCP).

2. WHAT’S INSIDE THIS WORK???

3. GENERAL INTRODUCTION

4. • The term “NEUROPATHY” refers to “DAMAGE TO NERVES”
• In Diabetic Neuropathy (DN)  Damage occurs to nerves, due to uncontrolled
DM
• Since in DM, Blood Glucose Levels(BGLs) are very high  Nerves are
EXTREMELY SUSCEPTIBLE TO DAMAGE
• High BGLs  affects nerves of ganglia outside of skull, spinal cord  causes
impacts on heart, kidney, bladder, stomach & intestine
• DN  affects PERIPHERAL NERVES(in limbs), & those that control
AUTONOMIC FUNCTIONS of body (like digestion, heart rate, etc).

5. TYPES OF DIABETIC
NEUROPATHY

6. A. PERIPHERAL NEUROPATHY:
- In this condition  DN affects PNS, like:
a. Feet
b. Legs
c. Hands
B. AUTONOMIC NEUROPATHY:
- In this condition  DN affects the nerves that control involuntary movements,
like:
a. Digestion
b. HR
c. Bladder muscles(for voiding).

7. C. PROXIMAL NEUROPATHY:
- In this type  DN affects the nerves that pass through thighs, hips & buttocks
D. FOCAL NEUROPATHY:
- In this condition  nerves at any site can be damaged due to DM.

8. EPIDEMIOLOGICAL
STATISTICS

9. - DN affects approx. 132 million people globally
- Greatest cause for morbidity & mortality in DM
- DN affects 25% of people with DM
- Contributes to 50-75% causes of non-traumatic amputations
- Women  have 50% high risk of painful neuropathy symptoms compared to
males.

10. PATHOPHYSIOLOGY

11. • Prolonged hyperglycemia  increases flux of POLYOL PATHWAY  increases
formation of GLYCATION END PRODUCTS  end products act on specific
receptors in VASCULAR CELLS  activates MONOCYTES & ENDOTHELIAL
CELLS to release adhesion molecules & cytokines  causes activation of
PROTEIN KINASE C  Causes exaggeration of OXIDATIVE STRESS  Causes
development of GLUCOSE INTOLERANCE in vascular tissue  damages nerve
fibers in vascular lining  Nerves undergo FAST DEGENRATION/ IMPAIRED
DEGENERATION  Nerves exert exciting impulses with Sx like PAIN &
PARESTHESIA
• With complete fiber degeneration  loss of touch & pain sensation occurs 
SENSORY LOSS OCCURS.

13. PATHOGENESIS OF DIABETIC NEUROPATHY

15. RISK FACTORS FOR DN

16. • Include:
A. POOR BLOOD SUGAR CONTROL:
- Greatest risk factor
- It is always recommended to keep BGL(Blood glucose levels) consistently within
target range, to protect health of nerves & blood vessels
B. DURATION OF DM:
- As duration increases  risk of DN increases(direct proportion)
- Higher risk observed with poor DM control
C. OBESITY:
- Patients with BMI > 24  are at high risk of developing DN

17. D. KIDNEY DISEASE:
- DM  damages kidneys  results in increased toxin levels in blood  causes
nerve damage.
E. SMOKING:
- Smoking  narrows & hardens arteries  reduces blood flow to hands & feet 
makes wounds difficult to heal  damages integrity of peripheral nerves.
F. MISCELLANEOUS FACTORS:
Include:
i. Increased TG levels
ii. HTN
iii. Reduced HDL, & high LDL levels

18. iv. Age (>50 years)
v. Genetic predisposition
vi. CAD
vii. High alcohol intake, etc.

19. CLINICAL MANIFESTATIONS

20. A. SYMPTOMS OF PERIPHERAL NEUROPATHY:
- Most common DN form
- Feet & legs are affected first  followed by hands & arms
- Symptoms worsen at nighttime
- Symptoms include:
i. Numbness (reduced ability to feel pain/ temp. changes)
ii. Tingling/ burning sensation
iii. Sharp pains/cramps
iv. Increased sensitivity to touch
v. Muscle weakness
vi. Loss of ankle reflexes

21. vii. Loss of balance & co-ordination
viii. Foot issues, like:
• Ulcers
• Infections
• Deformities
• Bone & joint pains, etc.

22. B. SYMPTOMS OF AUTONOMIC NEUROPATHY:
- ANS controls the following organs:
i. Heart
ii. Bladder
iii. Lungs
iv. Stomach
v. Intestines
vi. Sex organs
vii. Eyes

23. - DM  can affect nerves in any of the above organs, leading to:
i. Hypoglycemia Unawareness(lack of awareness that BGL is low)
ii. Bladder issues, like UTI, urinary incontinence/ retention
iii. Constipation, uncontrolled diarrhea, or combo of both
iv. GASTROPARESIS( slow stomach emptying  leads to N&V, bloating,
anorexia)
v. Dysphagia
vi. Erectile dysfunction
vii. Vaginal dryness
viii.Inability of body to adjust B.P & HR  causes orthostatic hypotension  high
risk for fainting/ light-headedness
ix. Problems in regulating body temp., etc.

24. C. SYMPTOMS OF RADICULOPLEXUS NEUROPATHY:
- Also known as :
i. Diabetic amyotrophy
ii. Femoral neuropathy
iii. Proximal neuropathy
- Symptoms usually occur on ONE SIDE of body
- As time progresses  symptoms spread to both sides
- Symptoms include:
i. Sudden severe pain in hip, thighs & buttocks
ii. Weak thigh muscles
iii. Difficulty in rising from a sitting position

25. iv. Abdominal swelling(if abdomen is involved)
v. Weight loss, etc.
D. SYMPTOMS OF MONONEUROPATHY:
- Involves damage to a SPECIFIC NERVE
- Also known as “FOCAL NEUROPATHY”
- Most common in older adults
- Symptoms include:
i. Difficulty in focusing vision
ii. Double vision
iii. Aching behind one eye

26. iv. BELL’S PALSY(Paralysis on one side of face)
v. Pain in :
• Shin/foot
• Lower back/pelvis
• Front of thigh
• Chest/abdomen.
- In some cases  nerve compression(like in CTS)  Leads to mononeuropathy
- Symptoms of CTS(Carpel Tunnel Syndrome) include:
• Numbness/ tingling in fingers/hand
• Tendency to drop things, etc.

27. COMPLICATIONS OF DN

28. 1. LOSS OF LIMB:
- With nerve damage  lack of sensation in feet  cuts & sores may go unnoticed
 leads to severe infections/ ulcerations(due to breaking down of skin & soft
tissues)
- With DM  reduced blood flow to heart  leads to GANGRENE of feet/toe 
requires amputation of toe, foot/ even the lower leg.
2. CHARCOT JOINT:
- Occurs when a joint(usually in foot)  deteriorates, due to nerve damage
- Charcot joint  leads to:
i. Loss of sensation
ii. swelling

29. iii. Instability
iv. Joint deformity.
C. UTIs & URINARY INCONTINENCE:
- Damage to nerves that control bladder  prevents it from emptying completely
 allows bacteria to multiply in bladder & kidneys  leads to UTI
- Nerve damage  affects ability to feel when you need to urinate/ control muscles
that release urine.

30. D. HYPOGLYCEMIA UNAWARENESS:
- In normal conditions  when BGL falls < 70 mg/dL  you tend to develop
symptoms like shakiness, sweating & fast heartbeats
- In Autonomic neuropathy  you may be unaware of symptoms of hypoglycemia.
E. LOW B.P:
- Damage to nerves that control circulation  affects body’s ability to adjust B.P
 leads to ORTHOSTASIS  leads to dizziness & fainting.

31. F. DIGESTIVE PROBLEMS:
- Nerve damage in digestive system  leads to alternative episodes of constipation
& diarrhea  leads to N&V , bloating, anorexia, gastroparesis, etc.
G. SEXUAL DYSFUUNCTION:
- Autonomic neuropathy  damages nerves that affect sex organs  leads to :
i. Erectile dysfunction(in men)
ii. Problems with lubrication & arousal(in women).

32. H. INCREASED / REDUCED SWEATING:
- If sweat glands don’t function properly  body isn’t able to regulate temperature
properly
- ANHIDROSIS(lack of perspiration)  can be life-threatening
- Autonomic neuropathy  can cause excessive sweating(Especially at night/ while
eating).

33. DIAGNOSIS OF DN

34. - According to ADA(American Diabetes Association) guidelines :
a. All people with DM  should have a comprehensive foot examination(either by
doctor / a podiatrist), at least ONCE A YEAR
b. Feet should be checked for the following at every visit:
• Sores
• Cracked skin
• Calluses
• Blisters
• Bone & joint abnormalities.

35. A. FILAMENT TEST:
- Used to test sensitivity to touch
- Soft nylon fiber(known as MONOFILAMENT) is used
B. NERVE CONDUCTION STUDIES(NCS):
- Used to evaluate how quickly nerves in arms & legs conduct electrical signals
- Used to diagnose CTS.
C. ELECTROMYOGRAPHY(EMG):
- Performed along with NCS, and measures electrical discharges produced in
muscles.

36. D. QUANTITATIVE SENSORY TESTING:
- Non-invasive procedure
- Used to check how nerves respond to:
• Vibration
• Temp changes.
E. AUTONOMIC TESTING:
- If you have symptoms of Autonomic Neuropathy  physician may carry out
certain tests, to evaluate your B.P(in different positions), & assess your ability to
sweat.

37. F. ULTRASOUND:
- Ultrasound  uses sound waves to produce image of internal organs
- Ultrasound of bladder & urinary tract  helps to assess organ structure, their
functional status, etc.

38. MANAGEMENT OF DN

39. GOALS OF THERAPY:
i. To focus on tight & stable glycemic control
ii. To alleviate manifestations, and restore function
iii. To relive pain & discomfort associated with DN
iv. To prevent further disability & progression into complications
v. To focus on maximal therapeutical benefits, with minimal adverse effects
vi. To prevent morbidity & mortality
vii. To improve HRQoL
viii.To focus on proper patient counselling for DM control.

40. TREATMENT SUMMARY:
• Each type of pain/ combination of pain types  should be treated
• According to POSSIDENTE et al.  re-evaluation of painful neuropathy should
be performed every 6 weeks
• Every effort should be made to taper, & eventually stop therapies
• Therapies may need to be reinstated at later dates, if symptoms flare up.

41. PHARMACOTHERAPY:
A. NSAIDs:
- According to POSSIDENTE CJ et al.  in patients, with acute painful
neuropathy  simple analgesics like NSAIDs, acetaminophen may provide pain
control
- Can be used as FIRST LINE THERAPY in painful diabetic neuropathy(PDN)
- Drugs used include:
1. IBUPROFEN:
- Reduces inflammation & pain caused by DN
- DOSE: 200-400 mg PO; q4-q6hr

42. - ADRs:
• Epigastric pain(3-9%)
• Dizziness(3-9%)
• Fluid retention(1-3%)
2. NAPROXEN:
- Used for relief of mild-moderate pain
- Inhibits inflammatory reactions & pain, by reducing COX activity  reduces PG
synthesis
- DOSE: 1,000 mg/day(Max. dose)
- ADRs: Abdominal pain, constipation, GI bleeding and discomfort.

43. B. TOPICAL ANALGESICS:
- Can be used for DYSESTHETIC PAIN (Unpleasant, abnormal sense of touch,
that presents with pain & discomforting sensations)
- Drugs used include:
1. CAPSAICIN CREAM:
- Natural chemical, derived from plants of Solanaceae family
- Agent  depletes & prevents accumulation of SUBSTANCE ‘P’ in peripheral
sensory neurons  reduces pain sensitivity
- Substance ‘P’ is considered to be the chemomediator of pain transmission ffrom
periphery to CNS

44. - Demerits of CAPSAICIN CREAM include:
a. May cause pain during initial few applications
b. Reduced patient compliance (due to frequent dosing)
c. Cream can mess with socks and footwears
- DOSING:
a. Apply 0.025-0.075% cream locally (TID/QID)
b. Duration: 4 weeks
c. May take 2 weeks to gain full analgesic effects
d. Wash hands after applying.

45. 2. LIDOCAINE GEL(5%):
- In some recent studies(placebo-controlled studies)  lidocaine has been
suggested as topical treatment for POSTHERPETIC NEURALGIA
- LIDOCAINE TAPE  reduces pain severity.

46. C. ANTICONVULSANTS:
- According to Backonja M et al.,  GABAPENTIN has been reported to be
effective in dysesthetic pain
- According to Ziegler D et al.  CBZ can be used as 3rd line therapy for
PERIPHERAL NEUROPATHY(refractory cases)
- CBZ  effective for chronic neuropathic pain
- According to Lesser H et al.,  PREGABALIN is advocated for the treatment of
GENERALIZED PERIPHERAL DIABETIC NEUROPATHIC PAIN(1st line
agent)
- In October 2017  FDA approved LYRICA CR(Pregabalin Extended Release
tablets) for the treatment of DPN, as well as POSTHERPETIC
NEURALGIA(PHN).

47. - Drugs used include:
1. GABAPENTIN:
- Effective for dysesthetic pain
- Used as 2nd line choice
- Drug  shows 2 actions:
a. Binds to alpha-2-delta subunit of calcium channels
b. Increases GABA levels in CNS
- ADRs:
a. Ataxia(1-13%)
b. Dizziness (16-20%)
c. Diplopia(6-10%)

48. - DOSING: (Off-label indication)
900 mg/day PO(initially)  may increase dose gradually (every 3 days) to 1.8-3.6
g/day.
2. CBZ:
- Used as 3rd line agent
- Slows recovery rate of voltage-gated Na+ channels
- Has minor calcium channel antagonist effect
- ADRs:
a. Ataxia(15%) c. Drowsiness(32%).
b. Dizziness(44%)

49. - DOSING:
100-200 mg PO every day  increase dose slowly to 1.2 g/day.
C. PREGABALIN:
- FDA-approved for treatment of pain due to generalized DPN
- Can be used as 1st line agent for dysesthetic pain
- 1st line agent for DPN
- Drug binds to alpha-2-delta subunit of voltage-gated Calcium channels 
reduces calcium influx into hypersensitized cells
- ADRs: Dizziness, somnolence, peripheral edema
- DOSING: 50 mg PO q8hr  may increase dose to 100 mg PO q8hr (Max. dose 300
mg/day).

50. D. TRICYCLIC ANTIDEPRESSANTS(TCAs):
- According to Bomholt SF et al.  TCAs are effective as analgesics for paresthetic
pain
- Drugs include:
1. AMITRIPTYLINE:
- Drug  inhibits 5-HT, NE reuptake in presynaptic neuronal membranes 
increases their concentration in CNS
- Useful as analgesic for chronic & neuropathic pain
- ADRs: Anticholinergic effects, agitation, arrhythmias.
- DOSE( Off-label indication) : 65-100 mg PO/day(for 3 weeks).

51. 2. IMIPRAMINE: Same MOA & ADRs as amitriptyline
3. NORTRIPTYLINE:
- Effective in treatment of chronic pain
- DOSING(Off-label):
10-25 mg PO, HS (Max. dose : 160 mg/day)

52. E. SNRIs:
- DULOXETINE was the first drug to be approved specifically for the treatment of
DN
- According to WIFFEN PJ et al.  AAN/AANEM/AAPMR guidelines recommend
use of VENLAFAXINE for treatment of pain due to DN
DULOXETINE:
- Potent inhibitor of neuronal 5-HT & NE reuptake
- ADRs: Nausea, dry mouth, insomnia, hyperhidrosis, etc
- DOSING:
60 mg/day PO.

53. F. SSRIs:
- PAROXETINE  can be used as 2nd/3rd line treatment in PDN
- According to Bomhalt SF et al  CITALOPRAM can be used as 2nd/3rd line
treatment in paresthetic pain
- Drugs used include:
1. CITALOPRAM:
- ADRs :
a. Xerostomia (20%)
b. Ejaculation disorder(8%)
c. Somnolence(18%).

54. - DOSE:
• 20 mg PO/day
• Avoid using doses > 40 mg/day(due to risk of QT-prolongation)
2. PAROXETINE:
- Good for DN patients, who are already depressed
- ADRs:
a. Ejaculation disorder
b. Insomnia
c. Dizziness
- DOSING (Off-label): 10 mg/day PO(initially) increase dose to 20-60 mg/day.

55. G.PROKINETICS:
- Effective for diabetic gastroparesis
- Drugs used include:
a. Erythromycin
b. Cisapride
c. Metoclopramide
- In 2009  FDA issued a black-box warning that long-term use of metoclopramide
 can lead to Tardive Dyskinesia(TD)

56. 1. ERYTHROMYCIN:
- Macrolide antibiotic
- Drug  binds to MOTILIN receptors  activates them  increases gastric
emptying rate of liquids & solids
- Effects seen in both i.v & oral dosing
- Substitution of ENTERIC COATED FORM may be tolerated better by the
patient
- ADRs:
a. Abdominal pain
b. Diarrhea
c. Cholestatic hepatitis
d. Flatulence
- DOSE (Off-label) : 250-500 mg PO TID (Before meals).

57. 2. METOCLOPRAMIDE:
- Drug  stimulates ACh release in myenteric plexus  causes prokinetic effects
- ADRs:
a. TD
b. EPS
c. Tachyphylaxis
- DOSING:
a. 10 mg (i.v/i.m/ PO) every 6 hours (30 mins before meals & at bedtime)
b. Go for i.v/ i.m route IF SEVERE SYMPTOMS are observed.

58. 3. CISAPRIDE:
- Drug  releases Ach at myenteric plexus  increases gastric emptying
- ADRs:
a. Headache
b. Diarrhea
c. EPS
- DOSE:
5-10 mg, QID, 15 mins before meals & at HS.

59. 8. SYNTHETIC ADRENOCORTICAL STEROIDS:
- FLUDROCORTISONE ACETATE  used in SEVERELY ORTHOSTATIC
HYPOTENSION if salt tablets & pressure stockings fail to alleviate hypotension
- Drug  shows 2 actions:
a. Expands plasma volume
b. Increase sodium retention.
- Used to increase STANDING B.P
- ADRs: Acne, adrenal suppression, hypokalemic alkalosis
- DOSING(Off-label):
Max. dose : 1 mg/day PO(in combo with high salt diet & adequate fluid intake).

60. 9. CHOLINERGIC AGENT:
BETHANECHOL HYDROCHLORIDE:
- Drug  causes selective stimulation of bladder  initiates micturition & bladder
emptying
- ADRs:
a. Hypotension
b. Flushing
c. Abdominal cramps
- DOSE:
a. Initial : 5-10 mg TD/QID
b. Maintenance: 10-50 mg TD/QID.

61. 10. LAXATIVES(BOWEL EVACUANTS):
POLYETHYLENE GLYCOL(PEG):
- For treatment of occasional constipation
- Low risk of dehydration, or electrolyte imbalance, compared to other hypertonic
sugar solutions
- PEG  not absorbed  continues to hold water by osmotic action(through small
bowel & colon)  results in mechanical cleansing
- ADRs: Abdominal bloating, cramping, diarrhea.
- DOSE:
17 g, in 4-8 oz of water(PO) OD, for less than 1 week.

62. 11. FOR SEXUAL DYSFUNCTION:
- SLIDENAFIL, TADALAFIL, VARDENAFIL  may improve sexual function in
some men
- Not effective/ safe for everyone
- Mechanical vacuum devices  may increase blood flow to penis
- Women may find relief with vaginal lubricants.

63. NON-PHARMACOTHERAPY
ALTERNATIVE MEDICINES include:
A. TENS(TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION):
- Prevents pain signals from reaching brain
- TENS  delivers tiny electrical impulses to specific nerve pathways (through
small electrodes placed on skin)
- Safe & painless
- Doesn’t work for everyone, & for all types of pain

64. B. ACUPUNCTURE:
- Helps relieve pain due to neuropathy
- Without side-effects
- It should be kept in mind that immediate pain relief is not achieved with
acupuncture (may require more than 1 session).

65. NATURAL REMEDIES FOR DIABETIC NEUROPATHY :
1. MANAGE BLOOD GLUCOSE LEVELS:
- Best thing to help prevent / control neuropathy is to manage blood glucose levels
- Maintaining optimal BGL is vital to prevent damage to eyes, nerves, blood
vessels, skin & other body parts
- Best ways to manage BGLs include:
a. Frequent blood glucose testing
b. Eating a healthy diet
c. Exercising
d. Proper medication adherence.

66. 2. FOLLOW A HEALTHY DIET:
- Diet  has direct impact on BGL
- Limit/ reduce intake of REFINED CARBS, ADDED SUGARS & SUGARY
DRINKS
- Prefer DRINKING WATER/ HERBAL TEA over SODA, JUICE & other
SWEETENED DRINKS
- Prefer HEALTHY FATS & LEAN PROTEINS over REFINED CARBS
- Buy less packaged foods
- Check labels for added ingredients/ sugars when you purchase
- Manage weight by cooking at home & by using techniques like roasting, baking,
steaming/ broiling over FRYING.

67. - Eat plenty of HIGH-FIBER FOODS, including:
a. VEGETABLES & WHOLE FRUITS:
• Rich in antioxidants, fibers, vitamins & essential electrolytes(minerals, K+)
b. WILD-CAUGHT FISH:
• Omega-3 fatty acids from fish oils  lower TG & APOPROTEIN levels 
prevent risk for diabetic complications
c. HEALTHY FATS:
• Include Coconut oil/ milk, olive oil, nuts, seeds & avocado
d. LEAN PROTEIN FOODS:
• Include poultry, eggs, sprouted beans/ legumes

68. - Avoid most grains if possible
- Avoid refined wheat flours
- Limit your intake of high-sodium foods
- Keep sodium intake to not more than 2,300 mg/day
- Drink 6-8 glasses of water each day to stay hydrated
3. EXERCISE & PHYSICAL THERAPY:
- One of the most simplest ways to manage diabetes symptoms
- Also helps to maintain healthy weight, control blood sugar & B.P symptoms
- According to a 2012 study published in the JOURNAL OF DIABETES
COMPLICATIONS  it was shown that regular exercise causes significant
reductions in pain & neuropathic symptoms .

69. - Exercise for 30-60 mins daily
- Do low-impact exercises, like:
a. Cycling
b. Swimming
c. Walking
- Exercise also helps protect nerves by the following mechanisms:
a. Improving circulation
b. Reducing cholesterol levels
c. Lowering stress.
- Benefits of physical therapy include:
a. Increased muscle strength

70. b. Improves mobility
c. Improves daily functioning.
4. REDUCE EXPOSURE TO TOXINS & QUIT SMOKING:
- People with DN  more likely to develop kidney stone problems
- Thus it is important to reduce added stress to kidneys in order to prevent toxins
accumulation
- Avoid exposure to pesticides, chemical household cleaners, unnecessary
prescriptions/ antibiotics & too much alcohol, cigarettes/ recreational drugs.
- Smoking  increases risk of developing nerve damage, heat attacks/ strokes.

71. 5. MANAGE STRESS:
- Stress  worsens inflammation  raises risk for diabetic complications
- Natural stress-relieving methods include:
a. Exercising
b. Involving in productive works/ hobbies
c. Being around family & friends
d. Acupuncture (excellent stress and pain reliever).

72. 6. LOWER PAIN NATURALLY:
- Natural remedies to help relieve pain include:
a. ALPHA LIPOIC ACID:
- Anti-inflammatory action
- Improves insulin sensitivity
- Helps defend against neuropathy
- Daily intake: 300-1,200 mg/day
b. EVENING PRIMROSE OIL:
- Anti-inflammatory
- Lowers tingling, numbness & burning associated with neuropathy
- Daily intake: 360 mg/day.

73. c. CINNAMON:
- Stabilizes BGLs
- Add 1-2 tsp to meal daily
d. OMEGA-3-FISH OILS:
- Helps lower inflammation
- Daily intake:1,000 mg daily
e. VITAMIN B12:
- Deficiency of Vitamin B12  worsens nerve damage
- Increase intake of Vitamin B12 rich foods like cottage cheese, eggs, salmon, etc.
f. ESSENTIAL OILS:
- Helps lower pain and inflammation (Eg: Lavender, peppermint oil, etc).

74. 7. PROTECT YOUR FEET:
- Foot problems, including sores that don’t heal, ulcers & even amputation 
comprise common complications of DN
- Above issues  can be prevented by:
a. Having a comprehensive foot exam (ATLEAST ONCE A YEAR)
b. Having your doctor check your feet at each office visit
c. Taking good care of feet at home.

75. - Here are some strategies to protect the health of your feet:
A. CHECK YOUR FEET EVERYDAY:
- Look for the following regularly:
i. Blisters
ii. Cuts
iii. Bruises
iv. Cracked & peeling skin
v. Redness
vi. Swelling
- Use a mirror/ ask a family member to help examine parts of your feet that are
hard to see.

76. B. KEEP YOUR FEET CLEAN AND DRY:
- Wash your feet everyday with lukewarm water & mild soap
- Avoid soaking your feet
- Dry your feet & between your toes carefully by BLOTTING/ PATTING WITH A
SOFT TOWEL.
- Moisturize your feet thoroughly to prevent cracking
- Avoid applying lotion between your toes (since it can induce FUNGAL
GROWTH)
C. TRIM YOUR TOENAILS CAREFULLY:
- Cut your toenails straight across
- Make sure that there are NO SHARP EDGES LEFT BEHIND.

77. D. WEAR CLEAN, DRY SOCKS:
- Look for socks made of COTTON/ MOISTURE-WICKING FIBERS
- Avoid socks with tight bands
E. WEAR CUSHIONED SHOES THAT FIT WELL:
- Always wear shoes/ slippers to protect your feet from injury
- Make sure that your shoes fit properly & that your TOES ARE FREE TO MOVE
- A PODIATRIST can teach you how to buy properly fitted shoes, in order to
prevent issues like CORNS & CALLUSES.

78. CONCLUSION

79. - Living with DN can be difficult and frustrating
- If you find yourself getting down  a counsellor / therapist
- There is no guarantee that you wont develop DN in your feet
- Maintaining a stable BGL  reduces risk of developing DN
- Preventive steps to reduce such risks include:
a. Daily checking of bottom of feet for any injuries
b. Quit smoking
c. Trim toenails carefully
d. Monitor BGLs frequently
e. Wear durable cushioned shoes at all times(even at your home).

80. BIBLIOGRAPHY/ REFERENCE:
1. https://www.medicinenet.com/diabetic_neuropathy/article.htm
2. https://www.healthline.com
3. https://www.webmd.com
4. https://medlineplus.gov
5. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0154654
6. https://www.medicalnewstoday.com/articles/317923.php
7. https://draxe.com/diabetic-neuropathy/
8. https://www.webmd.com/diabetes/news/20170324/what-drugs-work-best-for-
diabetic-nerve-pain#1

81. THANK YOU!!!!