Hello members....this is my 40th powerpoint...published in GOOGLE SLIDESHARE!! :) :)
I wish to thank each and everyone who have supported me all the way...!!!
This presentation deals with DIABETIC NEUROPATHY ...the causes, epidemiological statistics, pathogenesis.
A deeper insight into manifestations, complications, management & natural remedies have been provided....!!
Do go through this...and let me know you reviews!!!
When you THINK DIFFERENTLY, it becomes an INNOVATION,
When u infuse DEDICATION into that INNOVATION, it becomes an INVENTION..!!
HAPPY READING!!
#RxVichuZ-alwz4uh!! :)
Diabetic neuropathy is a serious and common complication of type 1 and type 2 diabetes.
Ocurres over 90% of diabetes people.
Presence of symptoms and or signs of nerve dysfunction in people with diabetes after all other causes have been excluded.
It’s a type of nerve damage caused by long-term high blood sugar levels.
The condition usually develops slowly, sometimes over the course of several decades.
Distal Symmetrical Neuropathy(DSN) most common form of DN.
DSN affects the toes and distal foot, but slowly progresses proximally to involve the feet and legs in a stocking distribution.
It is also characterized by a progressive loss of nerve fibers affecting both the autonomic and somatic divisions, thereby diabetic retinopathy and nephropathy can occur.
Foot ulceration and painful neuropathy are the main clinical consequences of DSPN, linked with higher morbidity and mortality
Diabetic neuropathy is a serious and common complication of type 1 and type 2 diabetes.
Ocurres over 90% of diabetes people.
Presence of symptoms and or signs of nerve dysfunction in people with diabetes after all other causes have been excluded.
It’s a type of nerve damage caused by long-term high blood sugar levels.
The condition usually develops slowly, sometimes over the course of several decades.
Distal Symmetrical Neuropathy(DSN) most common form of DN.
DSN affects the toes and distal foot, but slowly progresses proximally to involve the feet and legs in a stocking distribution.
It is also characterized by a progressive loss of nerve fibers affecting both the autonomic and somatic divisions, thereby diabetic retinopathy and nephropathy can occur.
Foot ulceration and painful neuropathy are the main clinical consequences of DSPN, linked with higher morbidity and mortality
The presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes is called diabetic peripheral neuropathy.
The diagnosis is principally a clinical one. Patients with type 1 diabetes for 5 or more years and all patients with type 2 diabetes should be assessed annually.Treatment goals include
good glycemic control,symptomatic treatment and halt progressive nerve damage.
This slide is for the educational purpose.Prepared by medical student during their medical presentation. Please comment if any changes are required in this slides. i will be happy to make changes in knowledge.
The presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes is called diabetic peripheral neuropathy.
The diagnosis is principally a clinical one. Patients with type 1 diabetes for 5 or more years and all patients with type 2 diabetes should be assessed annually.Treatment goals include
good glycemic control,symptomatic treatment and halt progressive nerve damage.
This slide is for the educational purpose.Prepared by medical student during their medical presentation. Please comment if any changes are required in this slides. i will be happy to make changes in knowledge.
Global Medical Cures™ | Diabetic Neuropathies
DISCLAIMER-
Global Medical Cures™ does not offer any medical advice, diagnosis, treatment or recommendations. Only your healthcare provider/physician can offer you information and recommendations for you to decide about your healthcare choices.
Peripheral Neuropathy Diabetic Connection? - A Critical AnalysisGraMedica
Peripheral nerve damage is blamed solely as a result of diabetes. This presentation takes a hard look at the evidence, asks and answers the hard questions to show that diabetes should be the last consideration after all other causes are eliminated.
Learn more at www.GraMedica.com.
This presentation deals with pathophysiology of Parkinson's Disease.
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Purely based on clinical pharmacist perspective.
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Summarized version of drug, including chief ADRs, interactions, and patient and health-care professional counselling tips have been mentioned.
This PDF deals with important catchpoints regarding the use of 5-alpha reductase inhibitors, their safety and efficacy stats, and important counselling tips.
This PDF deals with important guidelines, with respect to usage of antibiotics. This PDF outlines the important strategies involved while using antibiotics, and important factors involving antibiotic selection.
This word document deals with summarized drug profile of cotrimoxazole. Important pharmacological headings, along with important counselling tips and drug catchpoints have also been elucidated.
This is my first word document, converted into pdf format!
This document deals with AMOXICILLIN drug profile in brief.
It includes significant pharmacological headings, including an additional heading, stating important catchpoints with respect to amoxicillin!
Food drug interactions with penicillins: by RxVichuZ!RxVichuZ
This is my 107th powerpoint...it deals with significant drug-food interactions when taking specific penicillins.
This is my first powerpoint that deals with drug interactions.
Do support!
Snake bite poisoning and its treatment by RxVichuZ!RxVichuZ
My 106th powerpoint...that deals with snake bite poisoning.
Different types of venomous snakes, their characteristics, envenomation features and treatment strategies have been explained in a summary.
Hope it is effective for the readers involved.
This powerpoint is a case presentation, that explains the case of ADCHF, with comorbidities, comprising HTN, CAD and DLP.
A summary on the recent advancements in HF management, along with justification of therapy provided, has been elucidated.
A note on home remedies and counselling tips has also been provided.
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This presentation deals with visceral leishmaniasis induced by directly acting antivirals in a patient with Hepatitis C infection.
Case details in summary, along with case report publication details have been summarized.
References have been provided below each slide.
...and this is my 100th powerpoint.....!!
Sincerely thanking everyone who have supported me in my journey till now :) :)
This powerpoint deals with drug mnemonics, easy to remember mnemonics, that can be helpful for easy memory of some aspects of Pharmacology!!
Happy reading!!
Acute coronary syndrome management by RxVichuZ! ;)RxVichuZ
This is my 99th powerpoint...
Deals with ACS(Acute coronary syndrome), its clinical features, and management strategies, based on standard guidelines and literatures.
RNTCP guidelines for tuberculosis management: Extended versionRxVichuZ
This presentation is an extension of the already made presentation before, that deals with RNTCP guidelines for some special aspects encountered during tuberculosis management, other than management of individual diagnoses alone.
Have a look!
Journal club presentation: by RxVichuZ!! ;)RxVichuZ
My 97th powerpoint... deals with the comparative study of efficacy of piperacillin-tazobactam, as compared to meropenem in the treatment of ESBL(Extended spectrum beta-lactamases) infections.
A summarized insight has been provided, using research article from JAMA.
PPI-INDUCED BICYTOPENIA: MATTER OF CONCERN by RxVichuZ! ;)RxVichuZ
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References have been provided as a separate textbox under each slide, for extensive referencing into the same.
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Principles of cancer chemotherapy: a deep insight by RxVichuZ!RxVichuZ
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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Diabetic neuropathy- a Precise Insight , by RxVichuZ!! ;) ;)
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).
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).
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.
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.
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.
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.
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.
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).
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.
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.
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).