The Management of Diabetic Neuropathy and Glycemic Control in Long-Term Care Facilities (Part II of III)

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Citation: 

Pages 4 - 9

Authors: 

Richard Bedlack, MD, PhD
Activity Medical Director
Associate Professor of Neurology
Duke University School of Medicine
Durham, NC

The Diabetes Control and Complications Trial (DCCT) demonstrated that tight control of glycemia may result in a greater than 60% reduction in the risk of developing clinical neuropathy in patients with type 1 diabetes.3,35 A follow-up study to DCCT, Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC), demonstrated a lower prevalence of neuropathy in the intensively treated group when assessed either by questionnaire (1.8% vs 4.7%; P < 0.0001) or examination (17.8% vs 28.0%; P < 0.0001).36

The UK Prospective Diabetes Study (UKPDS) 33 obtained similar findings in patients with type 2 diabetes, reporting significant reductions in microvascular and neuropathic complications with intensive glucose-lowering therapy.37

Both the DCCT and UKPDS demonstrated that long-term intensive glucose control improved measures of autonomic function in both DPN and diabetic autonomic neuropathy.35,37 Acute sensory neuropathy has a strong association with blood glucose levels maintaining euglycemia, and often results in the resolution of painful symptoms.3

Controlling Blood Glucose, Blood Pressure, and Cholesterol Reduces Risk of Diabetic Neuropathy

Several studies also confirm how intensive therapy combining tight control of blood glucose, blood pressure, and cholesterol can benefit diabetic neuropathy. In the Steno-2 study published in 2008, Gæde and colleagues randomly assigned 160 patients with type 2 diabetes and persistent microalbuminuria to receive either intensive therapy or conventional therapy over a mean treatment period of 7.8 years.38 Intensive combined therapy was associated with a lower risk of death from cardiovascular causes (hazard ratio [HR] 0.43; 95% confidence interval [CI], 0.19-0.94; P = 0.04) and a lower risk of cardiovascular events (HR 0.41; 95% CI, 0.25-0.67; P < 0.001). Intensive therapy also reduced the relative risk of autonomic neuropathy to 0.53 (P = 0.004), but the relative risk of peripheral neuropathy was 0.97 (P = 0.89).

Another 2008 study conducted by the Action in Diabetes and Vascular Disease (ADVANCE) Collaborative Group revealed that intensive glucose and blood pressure control significantly reduced microvascular events.39 However, the effect was primarily due to a reduction in nephropathy; new or worsening neuropathy was unchanged by intensive treatment (2353 with intensive treatment vs 2311 with standard treatment). Stratton and colleagues showed that the incidence of clinical complications was significantly tied to glycemic control.40 In their 2000 study (UKPDS 35) in nearly 4600 patients, the authors concluded that each 1% reduction in updated mean A1C was associated with risk reductions of 21% for any endpoint related to diabetes (95% CI, 17-24; P < 0.0001), 21% for deaths related to diabetes (95% CI, 15-27; P < 0.0001), 14% for myocardial infarction (95% CI, 8-21; P < 0.0001), and 37% for microvascular complications (95% CI, 33-41; P < 0.0001).

Tight Glycemic Control Is Key When Managing the Elderly

Approximately 1 in 5 nursing home residents has diabetes.41 Of these patients, 90% have shown signs of coronary artery disease, stroke, and/or peripheral vascular disease. Elderly patients suffer from higher rates of all complications of diabetes, including autonomic neuropathy, nephropathy, retinopathy, erectile dysfunction, and foot ulcers.42

References: 


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