DIABETIC FOOT PROBLEM: SYMPTOMS,CAUSES AND TREATMENT

Hi today we are going to discuss about the different kinds of foot problems can occur in people with diabetes. There are a number of problem that a diabetic may face:

• Two main conditions are  
• Peripheral artery disease (PAD) and Peripheral neuropathy, are responsible for the increased risk of foot problems in people with diabetes.
• Symptoms and signs of diabetic foot problems arise due to the decreased sensation from nerve damage as well as the lack of oxygen delivery to the feet caused by vascular disease.
• People with diabetes have an increased risk of ulcers and damage to the feet.
• Diabetic foot problems also include bunions, corns, calluses, hammertoes, fungal infections, dryness of the skin, and ingrown toenails. These problems are not specific to diabetes, but may occur more commonly due to the nerve and vascular damage caused by diabetes.
• Treatment depends on the exact type of foot problem. Surgery or even amputation may be required for some cases.
• Gangrene (dry gangrene) is tissue death due to absence of blood circulation. It can be life threatening if bacterial infection develops (wet gangrene).
• Many diabetes-related foot problems can be prevented by good control of blood sugar levels combined with appropriate care of the feet.

How can diabetes cause foot problems?

Both type 1 and type 2 diabetes cause damage to blood vessels and peripheral nerves that can result in problems in the legs and feet. Two main conditions, 1) peripheral artery disease (PAD), and 2) peripheral neuropathy are responsible for the increased risk of foot problems in people with diabetes.

• Peripheral artery disease (PAD), sometimes referred to as peripheral vascular disease (PVD), means that there is narrowing or occlusion by atherosclerotic plaques of arteries outside of the heart and brain. This is sometimes referred to as "hardening" of the arteries. Diabetes is a known risk factor for developing peripheral artery disease. In addition to pain in the calves during exercise (medically known as intermittent claudication), the signs and symptoms of peripheral artery disease relate to a decreased delivery of oxygen to the lower legs and feet. In severe cases, the lack of oxygen delivery to tissues can result in ulcers and even gangrene (tissue death).
• Peripheral neuropathy refers to damage to the peripheral nerves directly as a result of diabetes. Symptoms of peripheral neuropathy include decreased sensation in the nerves of the legs and feet, making it difficult to perceive injuries due to lack of feeling. Peripheral neuropathy also causes a tingling, pain, or burning in the involved areas. It can also cause the muscles of the feet to work improperly, leading to misalignment of the foot that can put pressure on certain areas of the foot.

Peripheral Artery Disease (PAD or PVD) Symptoms

Peripheral artery disease (or peripheral vascular disease) symptoms include:

·        Intermittent claudication

·        Numbness in the extremities

·        Weakness of the calf muscle

·        Pain at rest

·        Hair loss

·        Coldness in the legs or feet

What are the symptoms of foot problems caused by diabetes?

In the most severe case, as mentioned above, due to a combination of decreased sensation and reduced blood flow to the feet, ulcers may develop. If the tissues continue to receive insufficient oxygen, tissue death (gangrene) occurs. Gangrene is a serious and potentially life-threatening condition. Other potentially serious problems that may develop include cellulitis (infection of the tissues beneath the skin) and osteomyelitis (infection of the bone); sepsis (the infection spreads to the bloodstream) also is possible.

People with diabetes are at increased risk for milder problems with the feet that are not specific to diabetes but may occur more frequently due to problems with the nerves and circulation to the feet.

Some of these conditions are:

Calluses and corns, that may develop due to abnormal alignment of the feet or abnormal gait

• Fungal infections of the nails, which can appear as thickened, discolored, and at times brittle nails
• Tinea pedis, or athlete's foot, a fungal infection of the skin of the feet
• Hammertoes, or bent toes due to muscle weakness.
• Bunions, or the angling of the big toe toward the second toe. The area of the bunion may become reddened and irritated, leading to callus formation.
• Ingrown toenails
• Cracking of the skin of the feet, especially the heels, due to dry skin

How are foot problems caused by diabetes treated?

Treatment depends upon the type of foot problem. For example, some problems such as corns may require wearing corrective shoes, while others such as mild infections may be treated with antibiotics or antifungals. Other problems may need surgical debridement and antibiotics. Gangrene, or tissue death, cannot be reversed, but treatments are available to prevent gangrene (often termed dry gangrene) from spreading or becoming infected (dry gangrene becomes infected and develops into wet gangrene). Surgical removal of the dead tissue is typically required, and antibiotics are given to prevent the development of life-threatening infections in the dead tissue. In severe cases of gangrene, amputation of the affected part may be necessary.

Other types of foot problems can be relieved by proper footwear, sometimes with orthotic devices, and splinting or bracing. For some conditions like hammertoes, bunions, and ingrown toenails; surgery may be necessary to correct severe cases.

Taking proper care of your feet (see Prevention section) can help prevent or relieve many common foot problems in people with diabetes.

Can diabetes-related foot problems be prevented?

Some diabetes foot-related problems can be prevented by taking careful steps to observe and care for your feet. Keeping blood sugar levels under control (in the ranges advised by your doctor), and following your recommended diet and exercise program are the best way to prevent all complications of diabetes, including foot problems. In addition to keeping your diabetes under control, you can take steps to care for your feet, including the following:

• Wear comfortable, closed-toe footwear at all times. Special shoes are available for people with bunions or foot deformities if these are necessary. Be sure no objects are trapped inside the shoes that could cut or injure your feet.
• Don't walk barefoot, even at home. Be sure your feet do not get burned by walking on very hot pavement in summer
• Always wash your feet with warm water and dry them well after washing.
• Check your feet daily for any sores or problems.
• Apply lotion to dry areas, especially heels, but don't use lotion between the toes. Corns and calluses can be lightly smoothed with a pumice stone. Never use scissors or razors to cut away corns or calluses.
• Trim toenails straight across, and do not cut the corners shorter than the rest of the nail.
• Be sure that your doctor checks your feet at every checkup.
• Stop smoking, if you are a smoker. Smoking further increases the risk of arteriosclerosis and poor circulation to the feet.

If left with any doubt or query you can comment in the comment section below.

ALL ABOUT INSULIN DELIVERY DEVICES- SYRINGE, PEN, PUMP.....

Hi today we are going to discuss about the various devices through which we can inject insulin in our body.

So let’s begin:

Insulin is a necessary part of the treatment plan for all people with Type 1 diabetes and many with Type 2. Insulin helps get glucose from the bloodstream into the muscle and fat cells to be used for fuel. It cannot be taken as a pill or a swallowed liquid, because it would be broken down by the digestive system before it reached the bloodstream, where insulin does its work. Instead, insulin is injected or infused into the fatty tissue under the skin.

There are a number of devices that can be used to deliver insulin, including syringes, insulin pens, jet injectors, and insulin pumps. No single device or type of device works well for everyone. The decision of which to use may be based on a person’s insulin regimen, ability to manipulate or operate a particular device, visual ability, insurance coverage or ability to afford a particular device and related supplies, occupation, and daily schedule or leisure-time activities. Discussing your needs and preferences with your diabetes care team is the best way to pick the device that will work well for you and get the training you need to use it correctly.

Syringes

The most common method of insulin delivery is by syringe. Medical syringes are relatively small, are disposable, and have fine needles with special coatings that make injecting as easy and painless as possible. To take insulin with a syringe, the user first pulls back on the plunger to draw in air equal to the amount of insulin to be drawn, inserts the syringe needle into a vial of insulin, pushes the air into the vial, pulls back on the plunger until the correct dose is drawn into the syringe barrel, then inserts the needle through the skin and presses down on the plunger until the barrel is emptied.

Syringes come in a variety of sizes, with different-size barrels, different needle gauges (thicknesses), and different needle lengths. The higher the gauge, the finer (thinner) the needle. Your diabetes care team will help choose the appropriate syringe for you based on the sizes of your insulin doses and your personal preference for needle gauge and length. While some people may prefer a shorter needle, insulin leakage at the injection site or worsening blood glucose control are signs that a longer needle may be necessary to deliver the insulin properly.

Reusing syringes is not recommended due to potential complications such as more painful injections as the needle dulls with use, infection, or tissue damage. The best practice is to use a new syringe for each injection.

It is important to be aware that insulin is manufactured in different strengths; however, U-100 (100 units of insulin per milliliter [ml] of fluid) is the most common strength. The syringes for administering insulin are specifically designed for each different strength. Therefore, a U-100 syringe should normally only be used with U-100 insulin.

While most insulin sold are U-100, people who are severely insulin resistant may use U-500 (500 units of insulin per ml). However, no U-500 syringes are manufactured, so people who are prescribed U-500 insulin must work with their diabetes care team to learn how to draw up the correct dose in a U-100 syringe.

Insulin pens

Insulin pens look similar to oversized ink pens, making them a potentially convenient and discreet way of carrying insulin. To use an insulin pen, the pen cap is removed and a pen needle is attached. The pen is then “primed” by dialing in a very small dose (exactly how much depends on the particular pen) and expelling the insulin into the air. Priming is done to ensure that insulin is flowing through the pen properly and that there is no air in the cartridge or needle.

After priming is completed, the actual dose of insulin to be administered is dialed in using a dial or dose knob. The needle is inserted into the skin, and the dose is delivered by pressing on the dose knob until it is fully depressed. It is important to hold the pen in place and to continue pressing the dose knob while counting slowly to five before removing the needle from your skin to ensure that no insulin leaks out. Pen needles are intended for one use only and should be removed and discarded after an injection.

Insulin pens should never be stored with the needle still attached because doing so may allow insulin to leak out or air bubbles to form in the insulin cartridge. Between uses, the pen’s cap should be put on to protect the insulin cartridge. In-use pens or pen cartridges should not be stored in the refrigerator because of the possibility that condensation will form in the insulin container. (As soon as an insulin cartridge is placed in a pen, it is considered “in-use” and should no longer be stored in the refrigerator, even if the pen is not actually used for an injection for several days.)

Most pens hold 300 units (3 ml) of insulin and deliver doses in one-unit increments, with up to 60 to 80 units per dose. The NovoPen Junior and the HumaPen Luxura HD deliver insulin in half-unit increments. One of the biggest advantages of insulin pens is accurate dosing. Ease of use is another advantage of pens over syringes because they require less manual dexterity and coordination, and they may be easier to use for people with low vision.

Like syringes, pen needles also come in a variety of needle gauges and lengths. However, pen needles may be slightly thinner and in some cases shorter than syringe needles, so injections may be more comfortable.

Some pens are disposable, while others use replaceable cartridges of insulin that are inserted into the pen.

Prefilled pens. Prefilled, plastic, disposable insulin pens have a self-contained insulin cartridge. Several different types of insulin are sold in prefilled pens. Once you have used all of the insulin in the cartridge (or the insulin has reached its in-use expiration date), you dispose of the entire pen.

Durable pens. Insulin pens that use replaceable cartridges of insulin are also available. Most reusable pens are made of metal but otherwise have about the same features as disposable pens and a comparable cost.

Jet injectors

Another option that has been available for several years is insulin jet injectors. Jet injectors use a mechanism to produce high-pressure air to deliver a fine spray of insulin through the skin. Once the appropriate dose of insulin has been loaded into the injector, it is placed against the skin and the trigger, or button, is pushed. The high pressure causes the insulin to vaporize and penetrate the skin so that it reaches the subcutaneous tissue. Some bruising may occur from injections using a jet injector, but bruising can be minimized by adjusting the pressure (setting) of the spray. The pressure may have to be adjusted differently for different injection sites.

It is extremely important to follow the manufacturer’s guidelines on the care and cleaning of the device to maintain sterility. Jet injectors are generally not recommended for people who take blood thinners, are undergoing dialysis, or have hemophilia.

If you are interested in using a jet injector, work with your diabetes care team to learn the proper technique. In addition, check with your insurer to determine whether the cost of the device is covered.

Inhaled insulin

Inhaled insulin was approved by the Food and Drug Administration in January 2006, but the only inhaled insulin to reach the market so far — Exubera — was discontinued in October 2007. Other drug companies are working to gain approval of their products by the Food and Drug Administration.

External Insulin Pump

Insulin pumps are becoming more popular as the technology improves and additional features are added. Some pumps are now available that work in conjunction with continuous glucose monitors that can alert the user to high or low blood glucose levels if programmed to do so.

Insulin pumps have traditionally been used primarily by people with Type 1 diabetes, but they are becoming a treatment of choice for many with Type 2 diabetes, as well. Most insulin pumps are small devices about the size of a cell phone. (The exception is the OmniPod, which is even smaller and is attached directly to the skin, with no tubing necessary.) The pump itself can be clipped onto the waistband of your pants or skirt or placed in a pocket. A length of plastic tubing connects the insulin reservoir within the pump to the infusion set, which is taped onto the skin and contains a small catheter (often called a cannula), through which insulin enters the body. The catheter is commonly inserted into the abdomen or buttocks and needs to be changed every 48 hours.

The pump user programs the insulin pump to deliver insulin at a slow, continuous (basal) rate as well as in supplemental (bolus) doses before meals and to correct for high blood glucose. Basal and bolus dosing most closely resembles how the pancreas releases insulin in a person without diabetes.

Using an insulin pump requires commitment and frequent blood glucose monitoring. According to the American Diabetes Association, people who demonstrate the following characteristics are more likely to do well with pump therapy:
• Strongly motivated to improve glucose control
• Willing to work with their diabetes care team
• Willing to assume substantial responsibility for their day-to-day care
• Able to understand and demonstrate use of the insulin pump
• Willing and able to frequently perform self-monitoring of blood glucose
• Knowledgeable about using their blood glucose monitoring data to make dose adjustments

Many people are willing to put in the work necessary to use an insulin pump because it gives them more flexibility with respect to food choices and the timing of meals and activities, while helping to achieve tighter control of their blood glucose.

Disposal of needles

Most states require that used needles and other “sharps” (such as lancets) be disposed of in a way that reduces the risk of accidental needle sticks. Once you’ve used a needle or lancet, place it in a puncture-resistant container such as a liquid detergent bottle or a sharps container purchased at your local pharmacy. (When traveling, carry a small container with you.)

Some communities offer a sharps disposal program that allows you to drop off your sharps at particular locations such as hospitals or pharmacies. If your area does not have such a program, discard your puncture-resistant sharps containers by placing the lid securely onto the container, taping it shut, and marking it “USED SHARPS.” Place the container in the trash, not in a recycling container. Other options for disposing of sharps include sharps mail-back programs and home needle destruction devices.

Cost considerations

Always check with your insurance company to determine whether and which insulin injection devices and supplies are covered by your plan and what out-of-pocket costs are involved. If you do not have insurance coverage (or do not have prescription coverage), many pharmaceutical manufacturers offer patient assistance programs, which offer free or low-cost drugs and supplies to individuals who are unable to pay for their medicine.

Making your choice

The basic purpose of all insulin delivery devices is the same: to deliver the desired dose of insulin into the body to keep blood glucose levels under control. The device you choose should be one that’s easy for you to use and to afford. But picking one insulin delivery device now doesn’t mean you can’t switch to another — or to a combination of devices — in the future. If your needs, lifestyle, or fortunes change, you may decide that a different device might work better for you in your new situation.

So I think you all will be familiar with all types of devices which can be used for injecting insulin.

If left with any doubt or any query feel free to comment in comment section below.

DIFFERENT TYPES OF INSULIN AND THEIR USES

Today we are going to discuss about the different types of insulin available and what are there functions and uses.

Before discussing about different types of insulin we must know why is insulin important for a diabetic person.

So let’s start:-

Insulin for diabetes

Insulin is a hormone our body makes to keep our blood glucose levels within the normal range. It is made by beta cells in the pancreas. Insulin's main job is to move glucose from our bloodstream into the body's cells to make energy. If you don’t have enough insulin, the glucose builds up in your bloodstream instead of providing energy for your body. 

With type 1 diabetes, the body does not make any insulin and therefore insulin has to be injected regularly every day to stay alive. With type 2 diabetes, the body does not make enough insulin, or the insulin that is made does not work well. Insulin injections are sometimes needed to manage blood glucose levels.

Starting on insulin

People with type 1 diabetes must inject insulin every day, often up to four or five times per day. They may use a pump to deliver insulin which means they insert a new cannula (very fine plastic tube) under the skin every two to three days. Sometimes, people with type 2 diabetes also need to begin using insulin when diet, physical activity and tablets no longer effectively control their blood glucose levels.

Having to start injecting insulin can be frightening. However, injecting insulin is much easier than most people imagine. There are different devices that can be used to make insulin delivery easy. Pen needles are very fine and so are cannulas. Often people needing insulin feel much better once they start having insulin.

If you need to start using insulin, your doctor or diabetes nurse educator can help with education and support. They will teach you about:

·        the type and action of your insulin

·        how, where and when to inject insulin

·        how to rotate injection sites

·        where to get your insulin and how to store it safely

·        how to manage low blood glucose

·        how to keep a record of your blood glucose levels and insulin doses

·        who will help you to adjust insulin doses.

Insulin doses usually don’t stay the same as your starting dose. Your doctor will help you to adjust your insulin. An important part of insulin adjustment is regular blood glucose monitoring and recording. 

It may take some time to safely reach the right dose of insulin for you. And because your insulin needs won’t necessarily remain constant throughout your life, you will need to see your diabetes health care team regularly for review.

When you start using insulin it is important to have a review to understand how carbohydrates and insulin work together.

If you have type 1 diabetes, learning how to count carbohydrates and matching your insulin to the food you eat is the ideal way to manage it. Depending on what you eat, your mealtime insulin doses may therefore vary from meal to meal and day to day.

Types of insulin

Rapid- and short-acting insulin helps reduce blood glucose levels at mealtimes and intermediate or long-acting insulin helps with managing the body’s general needs. Both help manage blood glucose levels.

Insulin is grouped according to how long it works in the body. The five different types of insulin range from rapid- to long-acting. Some types of insulin look clear, while others are cloudy. Check with your pharmacist whether the insulin you are taking should be clear or cloudy.

Before injecting a cloudy insulin, the pen or vial needs to be gently rolled between your hands to make sure the insulin is evenly mixed (until it looks milky). Don't use clear insulin if it appears cloudy.

Often, people need both rapid- and longer-acting insulin. Everyone is different and needs different combinations.

The five types of insulin are:

·        rapid-acting insulin

·        short-acting insulin

·        intermediate-acting insulin

·        mixed insulin

·        long-acting insulin.

Rapid-acting insulin

Rapid-acting insulin starts working somewhere between 2.5 to 20 minutes after injection. Its action is at its greatest between one and three hours after injection and can last up to five hours. This type of insulin acts more quickly after a meal, similar to the body's natural insulin, reducing the risk of a low blood glucose (blood glucose below 4 mmol/L). When you use this type of insulin, you must eat immediately after you inject.

The three rapid-acting insulin types currently available are: 

·        Fiasp and NovoRapid (insulin aspart)

·        Humalog (insulin lispro)

·        Apidra (insulin glulisine).

Fiasp – released in Australia June 2019 – is a new, rapid acting insulin with faster onset of action. It is designed to improve blood glucose levels after a meal.

Short-acting insulin

Short-acting insulin takes longer to start working than the rapid-acting insulins.

Short-acting insulin begins to lower blood glucose levels within 30 minutes, so you need to have your injection 30 minutes before eating. It has its maximum effect two to five hours after injection and lasts for six to eight hours.

Short-acting insulins currently available in Australia are:

·        Actrapid

·        Humulin R.

Intermediate-acting insulin

Intermediate-acting and long-acting insulins are often termed background or basal insulins.

The intermediate-acting insulins are cloudy in nature and need to be mixed well.

These insulins begin to work about 60 to 90 minutes after injection, peak between 4 to 12 hours and last for between 16 to 24 hours.

Intermediate-acting insulins currently available are:

·               Protaphane (a human isophane insulin).

·        Humulin NPH (a human isophane insulin)

Long-acting insulin

The long-acting insulins currently available are:

·        Lantus (glargine insulin) – slow, steady release of insulin with no apparent peak action. One injection can last up to 24 hours. It is usually injected once a day but can be taken twice daily.

·        Toujeo (glargine insulin) – this insulin has a strength of 300 units per ml so is three times the concentration of other insulin in Australia. It is given once a day and lasts for at least 24 hours. It should not be confused with regular Lantus which has a strength of 100 units per ml. Toujeo is given for safety by a disposable pen only. Toujeo gives a slower, steadier glucose profile especially during the night. 

·        Levemir (detemir insulin) –slow, steady release of insulin with no apparent peak action and can last up to18 hours. It is usually injected twice daily. 

Although these insulins are long-acting, they are clear and do not need mixing before injecting.

Mixed insulin

Mixed insulin contains a pre-mixed combination of either very rapid-acting or short-acting insulin, together with intermediate-acting insulin.

The mixed insulins currently available are:

·        rapid-acting and intermediate-acting insulin  

o   Ryzodeg 70:30 (70% long acting Degludec, 30% rapid Aspart)

o   NovoMix 30 (30% rapid, 70% intermediate Protaphane)

o   Humalog Mix 25 (25% rapid, 75% intermediate Humulin NPH)

o   Humalog Mix 50 (50% rapid, 50% intermediate Humulin NPH)

·        short-acting and intermediate-acting insulin  

o   Mixtard 30/70 (30% short, 70% intermediate Protaphane)

o   Mixtard 50/50 (50% short, 50% intermediate Protaphane)

o   Humulin 30/70 (30% short, 70% intermediate Humulin NPH).

I have discussed about different types of insulin and in next article we will be discussing about various devices to inject the insulin. So make sure you follow us for more updates.

In case you have any doubt or query feel free to comment in comment section below.