Diabetes Care

Diabetes Care

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Diabetes Care Maryann Hopkins, BSP, CDE Date of Revision: November 2013

Introduction

The Canadian Diabetes Association (CDA) estimates that over 2 million Canadians have diabetes mellitus (> 6% of the population)1 and that by 2019, this number will grow to 3.7 million. Diabetes is a serious health problem worldwide and a leading cause of blindness, kidney failure and nontraumatic amputation in Canada. Diabetes, once primarily known as a disease of the elderly, has become prevalent in the working age or younger population. In fact, type 2 diabetes in children and adolescents is considered a major concern as data from the United States report a 10–30-fold increase in children with type 2 diabetes over the last 10–15 years. According to the CDA, more than 75% of individuals with diabetes in Canada will die due to diabetes-related coronary and cerebrovascular events. The increase in the number of Canadians with diabetes has a substantial effect on health care costs, both for individuals with diabetes and the health care system. It is estimated that an individual may spend anywhere from $1000 to $15 000 per year on medications and other supplies, while the Canadian health care system spends approximately $15–16 billion on services such as lab tests, physicians' fees and dialysis per year.2 Diabetes has a significant impact on those with the disorder. The CDA states that the lifespan of individuals with type 1 diabetes may be shortened by up to 15 years, and by as much as 5–10 years in those with type 2 diabetes.

Pathophysiology

The 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada define diabetes as a “metabolic disorder characterized by the presence of hyperglycemia due to defective insulin secretion, insulin action or both.”1 The cause of type 1 diabetes is multifactorial; both genetics and environment contribute. Development follows several stages. An environmental trigger occurs (e.g., viruses such as mumps, rubella, coxsackievirus), often in the presence of certain human leukocyte antigen (HLA) genes, which initiates an autoimmune process, i.e., the immune system aggressively fights the virus and also destroys pancreatic islet cells.3 Beta cells in the pancreas are progressively less able to produce insulin, and overt diabetes mellitus develops. Most often, this autoimmune type 1 diabetes occurs in the young and develops fairly rapidly over days or weeks. Other postulated environmental causes of type 1 diabetes include toxic chemical agents. Type 2 diabetes is distinctly different from type 1.1,3,4 Heredity plays a major role in its development. A noninflammatory beta cell abnormality occurs, which diminishes the insulin secretory ability of the pancreas; therefore, the beta cells do not respond appropriately to hyperglycemia. Decreased sensitivity to insulin is paramount to the disease, exhibited as insulin resistance in the liver and peripheral tissues (primarily muscle and adipose tissue). For instance, insulin circulating in the blood normally suppresses the production of glucose by the liver. However, in type 2 diabetes, the liver is less sensitive to insulin so it persistently produces glucose, raising fasting blood glucose levels. The specific mechanism by which insulin resistance occurs in the tissues is not fully known. Another physiologic effect seen in a person with type 2 diabetes involves two gut hormones known as incretins.3 Glucagon release from the alpha cells of the pancreas is suppressed postprandially in a nondiabetic individual by these incretins. In type 2 diabetes, glucagon release is not suppressed after eating, which results in an inappropriate increase in the production of glucose by the liver. The incretin hormones are also responsible for enhancing insulin secretion from the beta cells after the ingestion of food in a glucose-dependent manner. Individuals with type 2 diabetes, who have a diminished supply of these incretins, have less insulin secreted from the beta cells in response to glycemic excursions post-eating. Gestational diabetes is first recognized or has its onset during pregnancy. Those with gestational diabetes are at high risk of developing type 2 diabetes in subsequent years. Although not an official classification, “type 1½ diabetes” describes diabetes that clinically fits the pattern of type 2

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https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/... diabetes but frequently exhibits diabetes-associated antibodies, indicating an autoimmune disease.5,6,7 For example, patients with latent autoimmune disease in adults (LADA) exhibit insulin resistance, elevated glucagon levels and a slowly progressing autoimmune effect on the beta cells, resulting in an increased likelihood of the need for insulin.3 Diabetes mellitus may also be caused by other endocrine diseases (e.g., Cushing's disease, acromegaly), drugs (Table 1) or toxins, other genetic defects or infections. 1,8

Table 1: Examples of Drugs Known to Induce Hyperglycemia Antipsychotics, 2nd generation

Nicotinic acid

Glucocorticoids

Phenytoin

Pentamidine

Cyclosporine

Tacrolimus

Highly Active Antiretroviral Therapy (HAART)

Thyroid supplements

Interferon alfa

There are no known strong risk factors for the development of type 1 diabetes. A slightly increased risk seems to exist if a close family member (mother, father, sibling) has diabetes. If a mother has type 1 diabetes, her child has a 3% risk of developing diabetes. If the father has type 1 diabetes, the child has a risk of 6%. The highest risk is for identical twins: 25–50% if the other twin develops type 1 diabetes. Table 2 describes possible risk factors for type 1 diabetes. Table 3 lists known risk factors for type 2 diabetes. The risk of a person developing type 2 diabetes can be estimated using a validated tool such as the CANRISK questionnaire (available from www.publichealth.gc.ca/CANRISK). 9

Table 2: Possible Risk Factors for Type 1 Diabetes Mellitus Ethnicity/race (more common in Caucasians) Genetic susceptibility

Unknown environmental factors (e.g., viruses, chemicals, food)

Prevention Type 1 Diabetes

First-degree relatives of someone with type 1 diabetes may have detectable immune abnormalities or reduced first-phase insulin secretion during an intravenous glucose tolerance test. This indicates that they are in the asymptomatic phase of type 1 diabetes. Potential strategies to prevent further development of type 1 diabetes in these patients have been attempted; however, there are no known successful strategies to prevent type 1 diabetes mellitus.1

Type 2 Diabetes

Two of the modifiable risk factors for developing type 2 diabetes are obesity and lack of physical activity. No studies have demonstrated long-term prevention of type 2 diabetes; however, weight loss accomplished by healthy eating and increased physical activity has been shown to at least delay the onset of type 2 diabetes in the short term. Pharmacologic interventions have also been attempted. For instance, the Diabetes Prevention Program provided data to determine the success of lifestyle interventions or use of metformin in the short term (3 years) in patients considered at high risk of developing type 2 diabetes.10 In the placebo or standard therapy group, 11% of patients developed diabetes per year.11 Participants who lost 5–7% of their body weight and maintained physical activity on average 30 minutes per day reduced their risk of developing diabetes by 58%. Those who took metformin 850 mg twice daily reduced their risk by 31%. The study was stopped a year early as it was clear that both arms of the study (lifestyle changes and metformin) were successful interventions when compared to placebo. Following a brief washout period, an extension of this trial revealed lifestyle and metformin interventions were effective for at least a decade.12

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https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/... Table 3: Known Risk Factors for Type 2 Diabetes Mellitus

1

Abdominal obesity

Aboriginal, African, Asian, South Asian or Hispanic descent Acanthosis nigricans Age ≥40 y

Dyslipidemia

First-degree relative with type 2 diabetes Giving birth to a macrosomic infant

History of impaired glucose tolerance or impaired fasting glucose History of gestational diabetes Hypertension Overweight

Polycystic ovary syndrome

Presence of complications associated with diabetes, e.g., nephropathy, retinopathy Schizophrenia

Vascular disease (coronary, cerebrovascular or peripheral) A smaller randomized controlled study (the Finnish Diabetes Prevention Study) also studied patients with impaired glucose tolerance associated with an annual rate of progression to diabetes of 1–10%.13 The study design assumed a 35% cumulative incidence of diabetes over the 6-year period.14 Researchers had 5 goals in the intervention arm: weight reduction (5% or more); reduction of fat intake to less than 30% of energy intake; reduction of saturated fat intake to less than 10% of energy intake; an increase in fibre intake to 15 g per 1000 calories; and an increase in exercise to 30 minutes per day. The incidence of diabetes was 58% less in the intervention group, and those who achieved more of the goals had a lower incidence of diabetes whether they were in the control or intervention group.14 Previous studies in China15 and Sweden16 showed similar results with lifestyle interventions, but these studies had methodological weaknesses.14 Acarbose (100 mg 3 times a day) reduces the risk of developing diabetes by 25–36% when impaired glucose tolerance (IGT) has been diagnosed. STOP NIDDM, a 5-year study, concluded that acarbose could be used in patients with IGT with, or as an alternative to, lifestyle changes to delay the development of type 2 diabetes.17 In summary, encourage lifestyle modification (weight loss and increased physical activity) and consider medications (metformin or acarbose) in individuals with IGT or impaired fasting glucose (IFG) to delay the onset or progression to diabetes.

Patient Assessment

The diagnosis of diabetes mellitus is based on laboratory blood tests and symptoms of high blood glucose; however, not all patients experience the classic symptoms of diabetes (Table 4). For example, the elderly are often asymptomatic or attribute symptoms of diabetes to aging or other illnesses. Table 4: Classic Symptoms of Diabetes Mellitus Blurred vision

Nocturia

Frequent infections

Polyuria

Fatigue Hunger

Polydipsia Weight loss

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Diagnostic Criteria for Diabetes Mellitus The diagnosis of diabetes mellitus is dependent upon blood glucose or HbA1c results obtained in the laboratory.1 Capillary blood glucose readings that fall within the criteria for the diagnosis of diabetes should be confirmed with plasma glucose levels. Random plasma glucose ≥11.1 mmol/L and classic symptoms, or

Fasting plasma glucose (no caloric intake for at least 8 hours) ≥7 mmol/L, or A plasma glucose level 2 hours after a 75 g glucose load ≥11.1 mmol/L An HbA1c ≥6.5% using a standardized, validated assay

Target levels for blood glucose have been established for adults with diabetes (Table 5). Using a slightly higher target for HbA1c (7.1–8.5%) may be appropriate in some patients, e.g., those with limited life expectancy or multiple comorbidities.1 A lower target of <6.5% might be considered if the benefit would outweigh the increased risk of hypoglycemia.1 Evidence that optimal blood glucose control can decrease the severity and frequency of diabetesrelated complications comes from the Diabetes Control and Complications Trial (DCCT) for those with type 1 diabetes, and the United Kingdom Prospective Diabetes Study (UKPDS) for those with type 2 diabetes.18,19 In the DCCT, a 10% reduction in HbA1c was associated with about a 40% reduction in the progression of retinopathy, less so at lower HbA1c levels. In the intensive insulin group, the risk of cardiovascular disease and death from cardiovascular disease was decreased by 42–57%. In the UKPDS, each 1% reduction in HbA1c yielded a 37% reduction in the risk of microvascular complications. Table 5: Targets for Adults with Type 1 or Type 2 Diabetes

1

Fasting or pre-meal plasma glucose

4–7 mmol/L

Plasma glucose 2 h after meals

5–10 mmol/L (or 5–8 mmol/L if HbA1c targets not being met)

HbA1c

≤7%

Goals of Therapy

Develop a healthy lifestyle

Prevent long-term microvascular and macrovascular complications

Establish a regular medical follow-up schedule based on established recommendations Avoid symptoms of high or low blood sugars according to established targets Recognize, prevent and treat hypoglycemia

Nonpharmacologic Therapy To achieve these broad goals, targets for metabolic control and hypertension have been devised by the CDA.1 Lifestyle modifications such as weight reduction (at least 5–10%), calorie-restricted low cholesterol, low-fat diet, regular aerobic exercise and smoking cessation are recommended as adjuncts to lipid-lowering medications.1 Maintaining a healthy weight and limiting alcohol and sodium intake, should be considered along with antihypertensive medications to attain blood pressure targets. A systematic review of controlled trials revealed that several professional and organizational interventions—such as structured and regular review of patients with diabetes and diabetes education—improved the process of patient care and patient outcomes.20 The CDA guidelines recommend systematic diabetes care utilizing technology such as computers, clinical flow charts, telemedicine and automatic reminders for both patients and the health care team.1 The guidelines also suggest the diabetes health care team should include members from several disciplines (including

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Eye Care

The development of diabetic retinopathy is related to the duration of diabetes. Nearly all of those with type 1 and more than 60% of those with type 2 diabetes will have some degree of diabetic retinopathy after having diabetes for 20 years.21 Both macular edema and cataracts are more frequent in the diabetic population.3 Blindness is one of the most feared long-term complications of diabetes. Several factors predict progression of retinopathy, including pregnancy (in type 1 diabetes), high blood pressure, dyslipidemia, long duration of diabetes, low hematocrit and elevated HbA1c levels.1,3 In the DCCT, intensive insulin therapy in patients with type 1 diabetes

reduced or prevented the development of diabetic retinopathy.22 Of the 726 patients included in the primary prevention cohort, 24% treated with conventional therapy suffered retinopathy versus 7% with intensive therapy (NNT=6). In the secondary prevention group with 715 patients, 41% of patients using conventional therapy had progression of retinopathy compared to 21% in the intensive therapy group (NNT=5).22 The UKPDS involving patients with type 2 diabetes revealed that every percentage-point decrease in HbA1c resulted in a 35% reduction in the risk of microvascular complications, including retinopathy and nephropathy.21 Recommendations to prevent or delay the onset of diabetic retinopathy, or to prevent vision loss in the diabetic population are listed below.

Eye Care Recommendations for Patients with Diabetes

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Screen/evaluate for retinopathy annually 5 years after the onset of diabetes in all patients with type 1 diabetes (at or after age 15). Screen for retinopathy in all patients at the time of diagnosis of type 2 diabetes. Follow-up every 1–2 years unless severity dictates more frequent evaluation when it should be tailored to the severity of the retinopathy.

Evaluate women with diabetes prior to becoming pregnant when possible, in the first trimester, throughout the pregnancy as needed based on perceived changes and within the first year postpartum.1 Those with hypertension should comply with lifestyle and drug therapy for high blood pressure. Recommended lifestyle modifications include weight management, moderate alcohol intake (defined as no more than 2 drinks per day or 14 drinks per week for males and 9 drinks per week for females) and limiting salt intake.1

Those with abnormal lipid levels are considered at high risk for retinopathy. People with diabetes should aim to achieve optimal blood sugar levels (Table 5). Changes in vision should be reported to a physician or ophthalmologist.

Note: Individuals who start intensive diabetes management or pump therapy should have their eyes checked pre- and post-intervention as there is a risk of worsening retinopathy (short term) due to intensification of diabetes therapy.3

Care of the Kidneys The most common cause of end-stage renal disease in Canada is diabetic nephropathy.1 Approximately 25–40% of those with type 1 diabetes develop microalbuminuria after 7–15 years. Ninety percent of these will eventually develop proteinuria; however, fewer patients with type 2 diabetes progress to end-stage renal disease.23 After 10 years of proteinuria, chronic renal failure occurs in approximately 50% of those with type 1 and 11% of those with type 2 diabetes.23 Early detection of microalbuminuria and early intervention strategies (e.g., use of ACE inhibitors, angiotensin receptor blockers (ARB), blood pressure and blood glucose control)1,24 are important.

Strategies to Prevent Diabetic Nephropathy

1

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https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/... Screen with a random albumin to creatinine ratio (ACR) and a serum creatinine converted to an eGFR in those with type 1 diabetes 5 years post-diagnosis and annually thereafter. Those with type 2 diabetes should be similarly screened at diagnosis and then annually. Recent major exercise, fever, urinary tract infection, menstruation, heart failure and acute elevation of blood pressure or blood glucose can elevate the ACR. Screening for albuminuria should be delayed until these conditions are resolved.

If the ACR is >2 mg/mmoL repeat the test and confirm in 2 of 3 measurements taken at 1–8 week intervals.1 If there is persistent albuminuria (abnormal ACR), patients should receive an ACE inhibitor or ARB, even if they do not have hypertension, as a strategy to delay the progression of chronic kidney disease. Maintain optimal blood glucose to prevent or delay the onset of diabetic nephropathy (Table 5). Comply with hypertension treatment and have regular blood pressure checks.

Reduce or eliminate all modifiable risks for heart disease, e.g., smoking, excessive alcohol intake, stress, obesity, high cholesterol and blood pressure, physical inactivity. Obtain advice from a dietitian to determine appropriate protein intake.

Seek prompt treatment for symptoms of bladder infections or kidney stones.

Dental Care

Those with poor blood glucose control and those who have had diabetes for many years are at higher risk for infections of periodontal tissue and increased calculus formation.4 To prevent dental complications, patients with diabetes should have dental visits twice a year or as often as their dentist recommends, brush and floss at least twice daily and use other dental cleaning aids as recommended by their dentist (see ). Good glycemic control helps to minimize dental problems.3 Smoking cessation is recommended.

Pneumonia and Influenza Vaccinations

Patients with diabetes are at increased risk for mortality and morbidity associated with S. pneumoniae and should receive the pneumococcal vaccine. A one-time revaccination is recommended for those over the age of 65 if the first vaccination was given when they were <65 years, and it should be given at least 5 years after the first dose.1,25 Like other patients with chronic diseases, patients with diabetes should receive the influenza vaccine yearly.

Diabetic Neuropathy

Diabetic neuropathy can affect many areas of the body. It develops within 10 years of the onset of type 1 or 2 diabetes in 40–50% of patients.1 The most common type affects the feet, legs or hands, producing symptoms such as tingling, numbness, aching, sharp, stabbing pain and other abnormal sensations. The neuropathy can lead to serious consequences such as foot or leg ulcerations or amputations. Other types of diabetic neuropathy include autonomic neuropathies such as gastroparesis and those causing bladder dysfunction, erectile dysfunction, sweating abnormalities and postural hypotension.

Self-care Strategies to Prevent or Delay Progression of Diabetic Neuropathy

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Encourage patients to maintain optimal blood glucose control (Table 5). Offer help with smoking cessation.

Advise patients to limit/avoid alcohol intake.

Advise adherence to triglyceride- and hypertension-lowering strategies.

Promote healthy weight strategies. High body mass index is a risk for neuropathy.

Suggest screening for peripheral neuropathy in individuals with type 2 diabetes at diagnosis and annually. For those with type 1 diabetes, annual screening should begin 5 years after puberty.

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Cardiovascular Health and Hypertension in Patients with Diabetes

The prevalence of coronary artery disease is 2–3 times higher in age- and sex-matched groups in the diabetic population than the nondiabetic population.1 Those over the age of 30 who have had diabetes for 15 years or more are considered to be at high risk of developing coronary artery disease.1 Cardiovascular disease is responsible for more than 75% of deaths in the diabetic population. Age is the strongest predictor of cardiovascular risk, and diabetes confers the same risk as aging about 15 years. High coronary risk is also associated with micro- and macrovascular end organ damage (stroke, cardiac ischemia, peripheral artery disease, retinopathy, nephropathy, neuropathy) and having more than 1 cardiac risk factor (smoking, dyslipidemia, hypertension, family history of early coronary artery disease in first-degree relative). In patients with diabetes, antilipemic medications and lifestyle changes should be considered if LDL >2 mmol/L.1 To promote optimal cardiovascular health, the treatment of patients with diabetes should include:1 Optimal blood glucose control (Table 5)

Blood pressure less than 130/80 mm Hg Healthy body weight

Regular physical activity Smoking cessation Healthy diet

In those with stable cardiovascular disease, consider low-dose acetylsalicylic acid (ASA) (81–325 mg) once daily as secondary prevention.1 If the patient is unable to tolerate ASA, clopidogrel may be considered for vascular protection. Routine use of ASA as primary prevention of cardiovascular events is not recommended due to lack of evidence in the diabetic population and the potential for side effects with long-term use. The decision to use ASA for primary prevention should be made based on individual assessment.

Skin Care

Hyperglycemia, poor circulation due to vascular abnormalities and peripheral neuropathy contribute to impairing host defenses against infection.4 Nerve damage from diabetic neuropathy may also decrease sweating, especially in the hands and feet, which normally helps to keep the skin moist.26 Patients with diabetes are at increased risk of skin infections and a slower rate of healing.3,4 Therefore, careful skin care is important in order to prevent serious skin problems. Table 6 suggests strategies for skin care in this population. Table 6: Skin Care for Patients with Diabetes Activity/ Condition Bathing

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Skin Care Bathe daily with a mild soap. Avoid harsh chemicals including iodine-containing products, astringents or any agent that may worsen peripheral neuropathy or circulation, e.g., alcohol, tobacco. Check water temperature with elbows, not hands or feet, to avoid burns. Use warm (not hot) water.

Do not take long showers/baths. Bathe/shower less frequently in winter. Cuts and abrasions

Keep clean; use paper tape to hold a sterile dressing or wrap gauze around wound as required.

Dry skin

Use a moisturizing lotion or cream (see Dry Skin).

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Skin Care

Existing skin problems

Ensure proper care and healing.

Inspect the skin daily (total body)

Check for dry, cracked skin, irritation, injury and infection.

New skin problems

See a physician.

Sun exposure

Practise sun safety by using sunscreen and limiting exposure to sun.

Foot Care

Individuals with diabetes are more prone to developing serious foot problems than the general population. Foot ulcers and amputations are a major cause of disability and morbidity in those with diabetes.1,27 It is estimated that 15% of those with diabetes will develop a lower limb ulcer during their lifetime and 20% of these will require an amputation;3 50% of those with foot ulcers will have a recurrence within 2 years. Complications of diabetes such as vascular abnormalities, peripheral neuropathy, previous ulceration/amputation, limited joint mobility, renal replacement therapy (especially dialysis), smoking, poor glycemic control and structural deformities of the feet contribute to the increased risk of developing these conditions. Peripheral neuropathy, characterized by numbness, tingling, weakness and reduced sweating, decreases the sensation of pain. This lack of sensation makes an individual with diabetes vulnerable to undetected injury from trauma, heat or irritation.

Poor circulation prevents adequate nourishment or oxygenation of the tissues. This leads to dry, cracked skin and changes in nail growth, and prevents or delays healing of wounds or ulcers. Encourage smoking cessation.1,6 Improperly fitted shoes can put pressure or repetitive stress on foot deformities (e.g., hammer toes, calluses, bony prominences) found in the diabetic population. This can lead to foot ulcers. An infection in an individual with diabetes must be treated aggressively by heath care team members with expertise in this area in order to avoid amputation or the recurrence of ulcers.1

Clinical practice guidelines1 for diabetic foot disorders and a task force report on diabetic foot assessment and management of diabetic foot problems27 provide excellent management strategies for this common, complex and costly complication of diabetes. Treatment of foot ulcers involves assessment and evaluation, appropriate debridement, pressure relief (off-loading), wound management with dressings appropriate to the type of wound, management of infection and ischemia, medical management of comorbidities and surgical interventions if needed.1,28 Prevention of an initial lesion and prevention of recurrent wounds are of utmost importance. The patient at risk must practise careful foot care on a daily basis and seek immediate attention if changes occur in the integrity of the foot/lower limbs. There are many effective strategies to reduce the risk of severe foot problems and amputations. Half of amputations are preventable.3 (See Foot Care for People with Diabetes — What You Need to Know at the end of this chapter.) For discussion of the management of foot infections, see Diabetic Foot Infections.

Managing Hypoglycemia

One of the most serious adverse events associated with diabetes treatment regimens is hypoglycemia. Patients with diabetes taking oral insulin secretagogues or insulin are at risk for a hypoglycemic reaction. Teach patients to recognize the early signs and symptoms of hypoglycemia and how to treat it immediately with a fast-acting sugar source. Develop strategies to prevent hypoglycemic reactions. For example, meals and snacks should be on time;

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https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/... physical activity should be planned in advance. Patients, especially those with gastroparesis or who may not eat predictable quantities (e.g., the elderly, those with dementia or psychiatric disturbances), may need to use immediateacting insulin after eating if dosage adjustments do not prevent hypoglycemic reactions. Early signs and symptoms of hypoglycemia include: Sweating Hunger

Shakiness

Palpitations

Anxiety, irritability, mood or behaviour changes Numb lips or tongue Headache

If untreated, hypoglycemic symptoms may progress to: Blurred vision Confusion

Slurred speech Convulsions Coma Death Some medications that may contribute to hypoglycemia are listed in Table 7. Up to 25% of patients with type 1 diabetes may experience hypoglycemia unawareness, in which the patient loses the autonomic warning signs of low blood sugar.29 Avoiding hypoglycemic episodes increases beta-adrenergic sensitivity, thus restoring hypoglycemia awareness.3,29 Table 7: Examples of Drugs Known to Induce Hypoglycemia Alcohol

Beta-blockers Pentamidine

Quinine/Quinidine (high doses, e.g., 600–800 mg Q8H) Salicylates (high doses, e.g., ASA 4–6 g/day in adults)

Patients on acarbose who experience a hypoglycemic reaction must use commercially available glucose tablets or gel, honey or a lactose source of sugar (e.g., milk). Acarbose delays the absorption of other types of sugars. Some examples of commercially available products include: Insta-glucose gel (one 30 mL tube provides 24 g dextrose) (quite slowly absorbed, raises blood glucose 1 mmol/L in 20 minutes)1 BD Glucose tablets (one tablet contains 5 g glucose) (15 g raises blood glucose 3.6 mmol/L in 45 minutes)1 Dex4 (one tablet contains 4 g dextrose)

See also Low Blood Sugar (Hypoglycemia) — What You Need to Know at the end of this chapter.

Pharmacologic Therapy

The oral medications available in Canada target different pathophysiologic abnormalities associated with type 2 diabetes, such as insulin resistance, insulin deficiency and excessive glucose output by the liver. To achieve recommended glycemic targets, combinations of different oral agents may be used.

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https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/... The sulfonylureas and meglitinides are insulin secretagogues, and target insulin deficiency by stimulating the beta cells in the pancreas to release insulin. Metformin acts primarily by improving insulin action in the liver (reduces glucose production) and enhances insulin activity in the muscle and fat cells. Insulin sensitizers include pioglitazone and rosiglitazone. Acarbose slows the breakdown of certain sugars and starches in the gut, thereby slowing glucose absorption. New treatment options target the incretin system, reducing glucose production by the liver and stimulating insulin release from the beta cells in a glucose-dependent manner. They include the dipeptidyl peptidase-4 inhibitors (linagliptin, saxagliptin, sitagliptin) and the glucagon-like peptide agonists (exenatide, liraglutide). For more information on prescription therapy, see Diabetes Mellitus.

Insulin

To achieve normal blood glucose levels, those with type 1 diabetes mellitus require exogenous insulin. Those with type 2 diabetes also require insulin therapy if an adequate trial of meal planning and exercise is not successful, if oral antidiabetic agents are not effective or when there is a physical stress such as surgery or pregnancy. The insulin dose, type of insulin required and the time of day the insulin needs to be administered depend on individual circumstances. Table 8 describes some of the common insulin regimens used in the management of diabetes. Various insulin products are available in Canada. Their characteristics are listed in Table 9.

Insulin Absorption Factors affecting insulin absorption: Site used to inject (faster to slower: abdomen, arms, thighs, buttocks) Massage of the site

Exercise of the site of injection

Temperature of insulin (cold insulin absorbs more slowly)

Lipohypertrophy (accumulation of fat at injection site) or lipoatrophy (loss of subcutaneous tissue at the injection site). These conditions can be avoided by rotating the injection site.

Size of dose: A large dose (over 40 units/large volume) absorbs more slowly, leading to a lower maximum concentration and altered effect. To maintain the character of the insulin used, larger doses are often split into more than 1 injection per administration.32,33

Care of Insulin Unopened insulin may be refrigerated until its expiry date.

Opened insulin that has been stored in the refrigerator should be discarded after 1 month (a slight potency loss occurs after 30 days if the vial has been in use).3,30 Opened insulin in vials may be kept at room temperature, out of direct sunlight, away from fluctuating temperatures for one month.34 Insulin in cartridges may be stored according to the manufacturer's recommendations (e.g., up to 1 month at ambient temperatures; for Novolin brand up to 37°C) or in the refrigerator.30 All insulin should be protected from heat and freezing and excessive shaking or vibration (e.g., avoid the glove compartment of a car). Insulin detemir may be stored at room temperature for 42 days. Insulin that has clumps, is difficult to mix, has a frosted appearance or clear insulin that has a colour change or cloudy look should be discarded.

Insulin should not be stored in the luggage hold of an airplane and should be kept in an insulated container if travelling in winter or summer temperatures. 1,3

Table 8: Some Common Insulin Regimens

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https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/... Regimen Single daily injections

(usually bedtime NPH, combined with oral agents during the day)

Advantages Reduces the nightly output of glucose by the liver Induces less weight gain than insulin-only regimen

Patient starts the day with lower blood glucose, enhancing overall diabetes management

Disadvantages Only appropriate for those with an endogenous supply of insulin

Daytime blood glucose may not be optimal

Easy method to start patients on insulin Split mixed regimens

(usually regular/NPH or analogue mixes at breakfast and supper)

Good control obtained Convenient—only 2 injections per day

Less flexibility (must adhere to schedule)

More difficult to schedule exercise without eating more (increased risk of weight gain) May need snacks (increased risk of weight gain) Risk of fasting hyperglycemia (NPH effects do not last until morning)

Risk of hypoglycemia in the late afternoon or overnight Intensive insulin regimen (basal insulin is NPH, glargine or detemir given once or twice daily and either rapid-acting or shortacting insulin is given at mealtimes)

Optimal control possible Flexibility for mealtimes

Useful for those with shift work or unpredictable lifestyle

Requires frequent blood sugar monitoring Requires extensive training Inconvenience of multiple injections

Increased risk of weight gain Risk of hypoglycemia

Nonprescription Therapy in Patients with Diabetes

It is important for individuals with diabetes to seek medical attention for more severe health problems before they become catastrophic; however, many minor conditions may be safely treated with the same nonprescription choices used by the general public. Instruct patients with diabetes to use low-sugar/sugar-free products, as many liquid pharmaceuticals may contain significant amounts of sugar. Low-calorie options (60 kJ/14 calories or less per dose) should be selected whenever possible. Also, the frequency of glucose monitoring may have to be increased during illness to avoid loss of glucose control.

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https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/... Table 9: Characteristics of Insulin and Analogues

3,30,31

For product selection, consult Products for Minor Ailments. Diabetes Products: Insulin.

a

Class

Type

Onset (h)a

Peak (h)a

Duration (h)a

Rapid-acting insulin analogues

Lispro/Aspart /Glulisine

0.5–0.75

0.75–2.5

3.5–6

Short-acting insulin

Human insulin regular, Toronto

0.5–1

0.75–4.5

5–7.5

Pork insulin

0.5

2–4

5–7

Intermediate-acting insulin

Human NPH

1–2

4–12

12–24

Pork NPH

1–3

6–12

24–28

Long-acting insulin analogues

Glargine

1

No peak

24

Detemir

0.8–2

6–8 but essentially a flat curve

12–24 dependent on dose

Onset, peak and duration may vary depending on product and patient characteristics.

Occasional use of nonprescription analgesics has little or no effect on blood sugar levels; however, analgesic doses of ASA, ibuprofen and naproxen can adversely affect blood pressure. Regular use of acetaminophen and ASA can exacerbate chronic renal failure in a dose-dependent manner.34 Therefore, refer patients with diabetes requiring regular analgesia to their physicians. Topical capsaicin has successfully reduced the pain associated with peripheral neuropathy, although sometimes the effect is not seen for 3–4 weeks and it may not be effective in many cases.1 Its use may be associated with burning and itching.35 Patients with the pain of peripheral neuropathy should be encouraged to normalize their blood glucose levels in order to relieve the pain and prevent progression of the neuropathy.1 Prescription products are available to effectively treat this condition, e.g. amitriptyline, gabapentin. Oral decongestants should be avoided in those with diabetes and hypertension, but data linking them to a rise in blood sugars are weak.36,37 Another reason for cautious use in patients with diabetes is the vasoconstriction caused by these agents, which can be more significant in those with vascular complications related to the disease such as poor circulation. Topical decongestants are less likely to raise blood pressure than oral decongestants but should be used with caution, if at all, in patients with diabetes.36 Patients experiencing heartburn, indigestion or reflux can be treated with nonprescription H2-receptor antagonists or with low-sugar/sugar-free antacids. However, diabetes management may be complicated if significant gastroparesis is present. Encourage patients to discuss use of these nonprescription medications with their physician. Constipation or diarrhea can be treated with the usual nonprescription remedies (e.g., bulk-forming, sugar-free fibres, loperamide). However, repeated constipation or diarrhea may signal gastroparesis that requires referral to a physician. Patients may travel to other countries where medication accessibility is different from Canada. Advise patients to consult a physician if they are choosing foreign nonprescription products to treat serious conditions.

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Natural Health ProductsNumerous plant remedies and dietary supplements are promoted as lowering blood diabetes.1,39,40

glucose levels.38 Current evidence does not support the use of herbal remedies in

Several case reports and small studies of chromium in doses of 200–1000 µg per day have shown some lowering of blood glucose. Chromium has been associated with sleep disturbance if taken at bedtime and possible renal insufficiency with high doses.41 Gymnema sylvestre (400 mg per day) has also been shown to lower blood glucose.40 American ginseng has demonstrated significant postprandial blood glucose lowering when 3 g is used prior to a 25 g glucose challenge.42 Konjac-mannan has demonstrated improved metabolic control by improving blood glucose levels in insulin-resistant patients.43,44 In all of these cases, long-term results are lacking and there is conflicting evidence about the efficacy of these therapies in lowering blood glucose.1

Sweeteners

Many products sold in pharmacies contain either nutritive or non-nutritive sweeteners. Nutritive sweeteners such as sucrose, fructose and sugar alcohols (e.g., xylitol, mannitol, sorbitol) and non-nutritive sweeteners such as aspartame, acesulfame K (potassium), sucralose, cyclamate and saccharin, can be incorporated into a well-balanced meal plan, provided they are used in moderation. Avoid saccharin and cyclamate in pregnant and lactating women. Sugar substitutes are regulated as food additives in Canada. Although some have energy value, because they are extremely sweet only a very small amount is required in medicinal products. The effect on blood glucose is minimal if the dose contains less than 60 kJ/14 cal and less than 2.5 g of carbohydrate (see Weight Management).

Alcohol

Alcohol may be incorporated into a diabetes meal plan, provided blood glucose and lipids are appropriately controlled and there are no other contraindications to alcohol ingestion. Acceptable limits are defined as up to 2 drinks per day in men and 1 per day (up to a maximum of 9 drinks per week) in nonpregnant, nonlactating females with diabetes. Increased physical activity and reduced food intake or no food intake with alcohol ingestion can increase the risk of hypoglycemia. In those with type 1 diabetes, drinking alcohol a few hours after supper can induce hypoglycemia the following morning or up to 24 hours later.1 Those using insulin or insulin secretagogues (e.g., nateglinide, repaglinide, sulfonylureas) should eat a carbohydrate-containing food when drinking alcohol to avoid delayed hypoglycemia.45 Inform patients who use metformin that acute and chronic ingestion of large quantities of alcohol can contribute to the development of lactic acidosis, but that an occasional drink of alcohol is unlikely to be problematic.

Alcohol contains 29 kJ or 7 cal/g, and can therefore contribute to weight gain. Alcohol-containing medications are unlikely to contribute to poor blood glucose management or weight gain when used in moderation.

Resource Tips

Patients can find useful information from the Canadian Diabetes Association. Available from: www.diabetes.ca.

Suggested Readings

American Diabetes Association. Available from: www.diabetes.org. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care 2012;35:S11-63. Beaser RS, ed. Joslin's diabetes deskbook: a guide for primary care providers. 2nd ed. Philadelphia: Wolters Kluwer

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https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/... Health/Lippincott Williams & Wilkins; 2007. Canadian Diabetes Association. Current guidelines for management of diabetes available from: www.diabetes.ca. Gerstein HC, Haynes RB, eds. Evidence-based diabetes care. Hamilton: B.C. Decker; 2001.

References 1. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2013;37:S1-S212. 2. Conference Board of Canada. Mortality due to diabetes. Accessed July 2009. 3. Beaser RS, ed. Joslin's diabetes deskbook: a guide for primary care providers. 2nd ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2007. 4. Davidson JK. Clinical diabetes mellitus: a problem-oriented approach. 3rd ed. New York: Thieme; 2000. 5. Juneja R, Palmer JP. Type 1½ diabetes: myth or reality? Autoimmunity 1999;29:65-83. 6. Brooks-Worrell BM, Juneja R, Minokadeh A et al. Cellular immune responses to human islet proteins in antibody-positive type 2 diabetic patients. Diabetes 1999;48:983-8. 7. Carlsson A, Sundkvist G, Groop L et al. Insulin and glucagon secretion in patients with slowly progressing autoimmune diabetes (LADA). J Clin Endocrinol Metab 2000;85:76-80. 8. Koda-Kimble MA et al., eds. Applied therapeutics: the clinical use of drugs. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 50-1–50-81. 9. Gardner DG, Shoback DM, eds. Greenspan's basic & clinical endocrinology. 8th ed. New York: McGraw-Hill Medical; 2007. p. 64. 10. U.S. Department of Health and Human Services. HHS News. Diet and exercise dramatically delay type 2 diabetes. Diabetes medication metformin also effective. Available from: www.nih.gov/news/pr/aug2001/niddk08.htm. Accessed November 9, 2012. 11. Knowler WC, Barrett-Conner E, Fowler SE et al. Reduction in the incidence of Type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403. 12. Diabetes Prevention Program Research Group. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet 2009;374:1677-86. 13. Tataranni PA, Bogardus C. Changing habits to delay diabetes. N Engl J Med 2001;344:1390-2. 14. Tuomilehto J, Lindstrom J, Eriksson JG et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344:1343-50. 15. Pan XR, Li GW, Hu YH et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 1997;20:537-44. 16. Eriksson KF, Lindgarde F. Prevention of type 2 (non-insulin-dependent) diabetes mellitus by diet and physical exercise. The 6-year Malmo feasibility study. Diabetologia 1991;34:891-8. 17. Chiasson JL, Josse RG, Gomis R et al. Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet 2002;359:2072-7. 18. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993;329:977-86. 19. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352:837-53. 20. Renders CM, Valk GD, Griffin SJ et al. Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review. Diabetes Care 2001;24:1821-33. 21. American Diabetes Association. Diabetic retinopathy. Diabetes Care 2000;23:S73. 22. Intensive insulin therapy reduced microvascular and neurologic outcomes in type 1 diabetes mellitus. ACP J Club 1994;120:30. Revised Oct. 1999. 23. Diabetes Division, Bureau of Cardio-Respiratory Diseases and Diabetes, Laboratory Centre for Disease Control, Health Protection Branch, Health Canada. Diabetes in Canada: national statistics and opportunities for

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https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/... improved surveillance, prevention and control. Ottawa: Health Canada; 1999. 24. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Heart Outcomes Prevention Evaluation Study Investigators. Lancet 2000;355:253-9. 25. Centres for Disease Control and Prevention; Immunization Action Coalition. Summary of recommendations for adult immunization (age 19 years & older). Available from: www.immunize.org/catg.d/p2011.pdf. Accessed November 9, 2012. 26. Canadian Diabetes Association. Skin problems. Accessed November 9, 2012. 27. Boulton AJ, Armstrong DG, Albert SF et al. Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care 2008;31:1679-85. 28. Frykberg RG, Armstrong DG, Giurini J et al. Diabetic foot disorders: a clinical practice guideline. American College of Foot and Ankle Surgeons. J Foot Ankle Surg 2000;39:S1-60. 29. Fritsche A, Stefan N, Haring H et al. Avoidance of hypoglycemia restores hypoglycemia awareness by increasing beta-adrenergic sensitivity in type 1 diabetes. Ann Intern Med 2001;134:729-36. 30. Canadian Pharmacists Association; Repchinsky C, ed. Compendium of pharmaceuticals and specialties: the Canadian drug reference for health professionals. Ottawa: CPhA; 2012. 31. Blackburn DF, Mansell K, Arnason T. Diabetes mellitus. In: Repchinsky C, ed. Therapeutic choices. 6th ed. Ottawa: Canadian Pharmacists Association; 2011. p. 380-411. 32. Soeborg T, Rasmussen CH, Mosekilde E et al. Absorption kinetics of insulin after subcutaneous administration. Eur J Pharm Sci 2009;36:78-90. 33. UpToDate. General principles of insulin therapy in diabetes. Available from: www.uptodate.com. Subscription required. 34. Fored CM, Ejerblad E, Lindblad P et al. Acetaminophen, aspirin, and chronic renal failure. N Engl J Med 2001;345:1801-8. 35. Chrubasik S, Roufogalis B. Efficacy and safety of topical capsaicin preparations. Austr J Pharmacy 2002;83:42-4. 36. Koda-Kimble MA et al., eds. Applied therapeutics: the clinical use of drugs. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 50-80, 50-81. 37. Pray WS. BP effects of nasal decongestants. US Pharm 2000;25:18-24. 38. Gori M, Campbell RK. Natural products and diabetes treatment. Diabetes Educ 1998;24:201-8. 39. Walji R, Kwan D, Boon H. Supplementation in diabetes OTC medications. Pharmacy Practice 2007 Oct;(Suppl). 40. Boon G. Botanical medicine and diabetes. Can Diabetes 2000;13:3-6. 41. Natural Medicines Comprehensive Database. Jellin JM, ed. Stockton: Therapeutic Research Facility. Subscription required. 42. Vuksan V, Sievenpiper JL, Koo VY et al. American ginseng (Panax quinquefolius L) reduces postprandial glycemia in nondiabetic subjects and subjects with type 2 diabetes mellitus. Arch Intern Med 2000;160:1009-13. 43. Vuksan V, Sievenpiper JL, Owen R et al. Beneficial effects of viscous dietary fibre from Konjac-mannan in subjects with the insulin resistance syndrome: results of a controlled metabolic trial. Diabetes Care 2000;23:9-14. 44. Yeh GY, Eisenberg DM, Kaptchuk TJ et al. Systemic review of herbs and dietary supplements for glycemic control in diabetes. Diabetes Care 2003;26:1277-94. 45. Wolever T, Barbeau MC, Charron S et al. Guidelines for the nutritional management of diabetes mellitus in the new millennium: a position statement by the Canadian Diabetes Association. Can J Diabetes Care 1999;23:56-69.

Self-Care for People with Diabetes — What You Need to Know Suggestions to help you manage your diabetes:

Follow a healthy, well-balanced meal plan. Ask to see a dietitian to establish a plan.

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https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/... Establish a regular exercise routine following your doctor's recommendations. Wear proper footwear and inspect your feet after exercising. Do not exercise if the weather is very hot or cold. Do not exercise if you are finding it unusually difficult to control your blood sugar levels. Aim to reach a healthy weight and stay there. Ask to see a dietitian.

Get advice on how to take care of your feet. (See: Foot Care for People with Diabetes — What You Need to Know.) See your doctor if you have difficulty sensing heat or cold or if you feel tingling in your hands or feet. Keep blood pressure and cholesterol levels at the target you and your doctor have established.

Keep blood sugar levels and HbA1c in your target range. (Follow your meal plan and activity plan, and take the medications you have been prescribed, either pills and/or insulin.) Do not smoke. Smoking increases the rate of illness and death for diabetic patients.

Have a flu shot each fall and have the pneumonia vaccine once and repeated once if your doctor determines you need a second vaccination. Have regular check-ups with your doctor, dentist and eye specialist. Learn about diabetes through a diabetes education program.

Ask your doctor about medications that can help prevent damage to your heart and kidneys.

Become a knowledgeable health care consumer. Ask questions and get a second opinion if you have any concerns. Wear a MedicAlert bracelet or other diabetes identification at all times.

Low Blood Sugar (Hypoglycemia) — What You Need to Know What is hypoglycemia?

Hypoglycemia occurs when a person's blood sugar level is too low. It can be a serious condition, especially for people who have diabetes. If you are using medications (pills or insulin), you are at risk for hypoglycemia.

What are the signs of hypoglycemia?

Early signs of hypoglycemia include sweating, hunger, shakiness, heart palpitations (heavy, fast heartbeats), anxiety, feeling irritable, mood or behaviour changes, numb lips or tongue and headache.

Tips to manage hypoglycemia:

Always carry a source of fast sugar (such as glucose tablets, juice box or regular soft drink) and a snack (such as 6 crackers and cheese or peanut butter). At the first sign(s) of low blood sugar, check your blood glucose value if you have a meter and eat one of the following fast sugar (carbohydrate) sources right away: 15 grams glucose (glucose tablets) 3/4 cup of orange juice

6 Life Savers candies (chewed)

15 mL or 3 packets of sugar dissolved in water or 15 mL (3 teaspoonfuls) of honey 3/4 cup regular soft drink

After 10–15 minutes, if you don't feel better or your blood glucose level is less than 4 mmol/L, take one of the items listed above again. If your blood sugar level is still low after another 10–15 minutes, be taken to the nearest emergency department.

If the hypoglycemia is severe (blood glucose less than 2.8 mmol/L), eat 20 grams of carbohydrate (for example, 4 packets or teaspoons of sugar). Wait 15 minutes, retest blood glucose and if below 4 mmol/L, take 15 grams of carbohydrate. If your blood sugar is over 4 mmol/L but your next meal or snack is 30 minutes or more away, immediately eat a snack of 6 crackers and 1 ounce of cheese or 1 slice of bread and a tablespoonful of peanut butter or equivalent.

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https://www.e-therapeutics.ca/print/new/documents/MA_CHAPTER/en/... If you are having a hypoglycemic reaction and are not able to swallow, a support person should get medical attention for you as soon as possible. Families and friends should be taught how to give glucagon if you are unconscious and should call 911 as soon as possible.

If you are taking the medication acarbose (Prandase/Glucobay) and have a hypoglycemic reaction, you must take a commercially available source of glucose such as glucose tablets, milk or honey. Acarbose prevents other sugars from being quickly absorbed. Teach family members and friends, or have your diabetes health care provider help teach them, how to administer glucagon in situations when your hypoglycemia does not respond to any of the above treatments. The package insert for glucagon also gives specific directions about how to use it.

Foot Care for People with Diabetes — What You Need to Know

People who have diabetes must take good care of their feet. Although not all individuals with diabetes suffer from circulation or nerve defects in their feet, everyone with diabetes should be knowledgeable about foot care and should be vigilant for changes in the condition of their feet. Here are some tips to help you keep your feet in good condition: 1. Inspect

Check your feet every day. Look for scratches, cracks between the toes, blisters, corns and other sores. Watch for swelling and changes in the temperature or colour of your feet and legs. If you cannot see all parts of your feet, use a mirror. Another person can also help you inspect your feet. Your doctor should check your feet at each appointment. Other health care professionals involved in managing your diabetes (e.g., an endocrinologist) may also check your feet during your appointments.

2. Bathe

Wash your feet daily with warm—not hot—soapy water. Check the water temperature with your elbow. Your hands and feet may not be able to tell you how hot the water is. Do not soak your feet. Dry your feet well, especially between the toes. Do not scrub with abrasive cloths or loofas.

3. Moisturize

4. Trim

Apply moisturizer to the tops and bottoms of your feet. Do not apply lotion, cream or oil between the toes. You can use a small amount of foot powder on your feet. Avoid putting it in your shoes or in between toes as it may cake and rub against the foot. Cut your toenails straight across. File any sharp edges with an emery board. Have a professional cut your nails, especially if you have vision problems, if the nails are thick or if you have poor circulation or nerve defects in your feet. Do not cut calluses or corns with razor blades, scissors or any other sharp object. Do not use chemical corn and callus removers; they may damage your skin. See a professional trained in foot care if you have corns or calluses.

5. Shoes and Socks

Always wear shoes and breathable, clean, soft socks or nylons. Do not wear socks that have been mended, have holes or seams that may irritate your feet or that are too tight.

Select shoes that fit well, preferably made of breathable material (e.g., leather). Avoid sandals, plastic shoes, pointed toes and high heels. Check the inside of your shoes for sharp objects or rough spots before you wear them.

Break in new shoes slowly (e.g., wear them for 30 minutes the first day, 60 minutes the next day, and so on). Protect your feet at the beach. Sand, shells and rocks can damage your feet. Wear protective shoes.

6. Keep Feet Warm

Wear socks to bed if your feet are cold.

Do not use heating pads or hot water bottles and do not warm your feet by a fireplace.

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7. Circulation

Avoid anything that puts pressure on your feet and legs (such as tight socks or stockings, girdles and pantyhose). They may reduce circulation to the legs and feet. Avoid smoking and drinking alcohol. Maintain a healthy body weight.

Do not cross your legs when you are sitting.

8. Injuries/Infections

See your doctor as soon as possible if you injure your feet or legs or you see changes in their condition. If you need treatment, it should be started as soon as possible. Treat athlete's foot at the first sign of infection.

9. Exercise

Ask your doctor to recommend safe exercises to improve circulation. Perform your exercises every day.

10. Control

Follow your doctor's advice to control your blood glucose, cholesterol and blood pressure.

CPhA assumes no responsibility for or liability in connection with the use of this information. For clinical use only and not intended for for use by patients. Once printed there is no quarantee the information is up-to-date. [Printed on: 03-03-2016 05:40 AM] RxTx, Compendium of Therapeutics for Minor Ailments © Canadian Pharmacists Association, 2016. All rights reserved

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