Management and treatment of peripheral neuropathy

An older patient with type 2 diabetes expresses concern about potential peripheral neuropathy.

The patient, aged 76 years, was diagnosed with type 2 diabetes about 25 years ago. She was originally managed with oral agents but was switched to a multiple daily injection insulin program involving Lantus and NovoLog insulins 10 years ago. In the last 5 years, her hemoglobin A1c levels have ranged between 7.6% and 9.5%.

During her current visit, this patient's hemoglobin A1c is 8.5%. She is currently using Lantus insulin 55 units once daily and NovoLog insulin 15 units with meals. She admits to occasionally forgetting to take NovoLog insulin doses about two to three times per month. She uses a correction dose at meal times starting at 150 mg/dL to 199 mg/dL, adding three units and then adding three units for every 50-point incremental rise thereafter.

The patient admits to occasionally forgetting to meter her glucose values. Upon review of downloaded meter, she is metering two to four times per day, attempting to meter prior to each meal and at bedtime. Review of downloaded meter information reveals 72 values in a 1-month time. Her average is 198 mg/dL. The majority of the patient's readings throughout the day are between 180 mg/dL and 230 mg/dL with no hypoglycemia in recent months.

Her primary concern at this appointment is a burning sensation in her lower extremities.

The patient receives annual eye exams and has a history of bilateral proliferative retinopathy.

Blood pressure is controlled at 120/75 on 2 agents. Her most recent cholesterol panel, taken in the past year, revealed her total cholesterol was 209; triglycerides 155; HDL 45; LDL 122. She has been prescribed simvastatin but reports that she often misses doses of this medication.

The patient notes increased feelings of neuropathy in bilateral lower extremities in the last 3 months. She has tried topical capsaicin cream at the recommendation of her pharmacist to minimal benefit. She denies issues with lower extremity ulcerations, states that she assesses her feet for open areas on a daily basis, and uses lotion daily due to issues with dry skin.

Creatinine is 1.0 with an estimated glomerular filtration rate of 53. Her microalbumin level is 15.

Weight today is 103.2 kg with a body mass index of 35. Weight is up from previous visit value of 101 kg, and she admits to not exercising and eating more carbohydrate-containing snacks over the holiday months.

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