Diabetes: Dealing with the Complications

WebMD Live Events Transcript

From eyes to feet, heart to kidneys, complications from poorly managed or long-term diabetes can cause a variety of dangerous problems. Whether you're battling complications or want to avoid any future problems, join us to discuss prevention and treatment with endocrinologist Robert Zimmerman, MD, FACE, and foot specialist Peter Cavanagh, PhD, from the Cleveland Clinic.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MEMBER QUESTION:
Doctors, can the use of Lantus and NovoLog cause organ or nerve damage?

ZIMMERMAN:
I have not seen any data to suggest they would cause any problems to the body. They're both good medicines.

MEMBER QUESTION:
Dr. Cavanaugh, I have seen a podiatrist for treatment of plantar fasciitis. He advised me to wear only cross-trainer shoes and to stay away from heels of more than 1/2 inch. Is this also a good rule of thumb for diabetes foot care?

CAVANAGH:
No. There's no real association between diabetes and plantar fasciitis. There's no evidence to suggest that people with diabetes get more or less plantar fasciitis than those who do not. The requirements for footwear for people with diabetes are quite specific to the status of the patient.

MEMBER QUESTION:
My heel started hurting about three days ago -- is that a sign of nerve-ending damage? Also, many times a day I'm sweating very hard. What can I do about it? (I'm on Metformin, 1,000 mg two times per day.)

CAVANAGH:
Such sudden onset of heel pain is unlikely to be neuropathy-related if there have not been prior symptoms. Heel pain can be related to many causes and most often is mechanical in nature.

ZIMMERMAN:
Sweats in patients with diabetes can sometimes be related to low blood sugar caused by medication. The medication that you are taking, however, does not generally cause low blood sugar.

Other endocrine causes of increased sweats include problems with hyperthyroidism, so you need to make sure that this is not one of your problems. In addition, people going through menopause also have increased sweats. In patients with diabetes, sometimes there can be autonomic abnormalities associated with sweats; sometimes these occur after eating.

MEMBER QUESTION:
Can you have complications from simply having diabetes long-term?

ZIMMERMAN:
Studies have shown that well-managed diabetes can decrease long-term microvascular complications; unfortunately, even with excellent control, there is no guarantee that some complications won't occur. So though the risk is certainly much higher in patients with poorly controlled diabetes, it is not completely absent, and the risk does increase related to how long a person has had diabetes.

MEMBER QUESTION:
When you say complications can occur with long-term diabetes, please define "long term."

ZIMMERMAN:
It's difficult to actually know how long somebody has diabetes, especially someone with type 2. Often they may have had diabetes for awhile before it was diagnosed. But I would say long term may be, as a guess, 10 years or more. Sometimes people with type 2 diabetes have complications when they first get their diagnosis.

"Well-managed diabetes can decrease long-term microvascular complications; unfortunately...there is no guarantee that some complications won't occur."

MEMBER QUESTION:
Is there an association between celiac disease and diabetes?

ZIMMERMAN:
Both are autoimmune-mediated diseases, so there can be some increased risk of diabetes in patients with celiac disease.

MEMBER QUESTION:
What is the connection between diabetes and kidney disease?

ZIMMERMAN:
One of the microvascular complications of diabetes can be kidney disease, which is termed nephropathy. Initially patients develop increased excretion of protein in the urine. This often is complicated by high blood pressure and in some instances, renal insufficiency can develop, and ultimately this can lead to a need for dialysis in some patients.

MEMBER QUESTION:
Is occasional shooting pains in my big toes indicative of neuropathy?

CAVANAGH:
It may be the first early signs of peripheral neuropathy, what we call paresthesias, unusual pains or feelings that are not related to any external stimulus. Shooting pains or sensations are quite typical of the early signs in peripheral neuropathy.

ZIMMERMAN:
The pain in the foot is not necessarily neuropathy, especially in the big toe. Something like gout might be a consideration.

MEMBER QUESTION:
Are the increased numbness in my toes, as well as leg and foot cramps diabetes complications?

CAVANAGH:
These certainly need investigation. One thing we worry about in leg cramping is an ischemic problem, which can be the issue with some people with diabetes. However, this can easily be ruled out, and there are many other reasons why cramping, particularly in other parts of the lower extremity, could occur.

ZIMMERMAN:
You can have progression of neuropathy even with improved glycemic control, and if it's increased pain sensation, sometimes as the nerves improve you actually have an increase in pain, which is a sign they're getting better.

CAVANAGH:
What people with neuropathy have to expect is they will have these unusual pains and when they go away, it does not necessarily mean the neuropathy is getting better. What it means is the neuropathy has progressed and that the inability to feel stimuli such as:

  • Touch

  • Hot

  • Cold

  • Pin pricks

will not return. In our studies, we have found many people have the misconception that if they no longer have pain that their neuropathy has resolved.

MEMBER QUESTION:
So there is no reversal of [neuropathy] damage, only a delay in further damage if caught and treated appropriately?

ZIMMERMAN:
In patients with neuropathy, there have been signs that sometimes diabetes control can make neuropathy better. But as I stated before, sometimes going from numbness to having a pain is actually an improvement, and going from pain to no pain would be an improvement if you then have normal sensation. There is sometimes improvement in neuropathy with good control.

CAVANAGH:
There have been several drugs that have shown promising results in animal studies. These drugs haven't reversed neuropathy, but have been able to halt the progression. Unfortunately, almost all of these drugs have proved to have damaging side effects in humans, although one or two are still in clinical trials in the U.S. and Europe.

MEMBER QUESTION:
When someone has ignored their neuropathy symptoms and has to have a partial foot amputation, how could that affect the rest of the body?

CAVANAGH:
Any amputation of a part of the foot carries with it an enormously high risk for a future injury or amputation. So although the cause of this particular amputation in the patient has not been mentioned, what it does mean is that he or she has all of the risk factors of amputation.

Now, most amputations start with an ulcer on the foot. So the critical thing for an individual with an amputation on one side or a partial amputation is to take extreme precautions, such they do not experience a skin injury, an ulcer that could progress to another amputation.

ZIMMERMAN:
If there's evidence of vascular problems with this patient, there could be vascular problems in other parts of the body, such as the heart. It would be reasonable to have some evaluation of cardiac function in this patient.

MEMBER QUESTION:
Do you recommend any particular kind of socks for diabetes patients?

CAVANAGH:
Yes. There have been studies to show that the kind of thick sport socks you can find in an athletic shoe store can reduce the pressure under the foot by as much as 20 percent. However, the danger is that patients will put thick socks into shoes where there isn't enough space. In many patients with neuropathy they simply would not feel the quite extreme foot pain. Thick socks can be helpful, as long as there is room in the shoes.

"Well-managed diabetes can decrease long-term microvascular complications; unfortunately...there is no guarantee that some complications won't occur."

MEMBER QUESTION:
I am on Metformin. I find that I have a numb feeling in the skin on my face and arms. Is this a problem?

ZIMMERMAN:
Yes, it can be a problem. I don't think that this is caused by Metformin. It could actually be another manifestation of neuropathy and should be evaluated by your physician.

MEMBER QUESTION:
Is Neurontin a good medication for diabetic neuropathy?

ZIMMERMAN:
Neurontin is one of a number of agents used for diabetic neuropathy pain management. Often a trial of different medications is necessary before one that helps the pain is found. Neurontin is one that does help a number of neuropathy patients.

MEMBER QUESTION:
Are there warning signs to watch for with eye damage? Annual exams are reassuring, but 12 months cans be a long time to wonder. I had a shoulder MRI recently, and I swear my 'floater' population has tripled!

ZIMMERMAN:
If you are having vision changes, ask for an eye exam in addition to your yearly eye exam. Often patients will have early signs of retinopathy before changes in visual acuity. If advanced retinopathy is observed, there are ophthalmological treatments that can be given to prevent vision loss.

MEMBER QUESTION:
Are eye 'floaters' indicative of diabetes-related eye problems?

ZIMMERMAN:
Not generally by themselves. Sometimes patients can develop floaters if you have a hemorrhage in the eye from proliferate diabetic retinopathy, but there are many more common problems of floaters.

MEMBER QUESTION:
Are nerve conduction studies worthwhile?

CAVANAGH:
Nerve conduction studies are generally not recommended in diabetes unless there are other reasons for the study. Much more common are the tests called quantitative sensory tests (QST). These tests allow the clinician to determine the functional effect of the neuropathy -- does the patient have protective sensation or not, for example. This is much more directly relevant than whether or not the nerve conduction velocity has slowed by 2 or 3 meters per second.

MEMBER QUESTION:
I have type 2 diabetes, very serious heart problem, and live in North Pole, Alaska, a place with very poor health care. What can I do?

ZIMMERMAN:
I think there might be a medical school in Alaska that would potentially be helpful. The type of specialist who takes care of diabetes patients is called an endocrinologist. See if you could find an endocrinologist.

MEMBER QUESTION:
Does having hypothyroidism (Hashimoto's) put me at an increased risk for type 2 diabetes?

ZIMMERMAN:
Hashimoto's is an autoimmune problem. Sometimes patients with one such problem are at risk for other autoimmune endocrine diseases. For Hashimoto's thyroiditis patients, the risk would more likely be in development of type 1 diabetes than type 2.

MEMBER QUESTION:
Are my very itchy hands, especially before bed, related to diabetes?

ZIMMERMAN:
Some patients with diabetes do develop problems with itching. It could be an early sign of neuropathy, but other causes of itching need to be ruled out, and a dermatologist would be the best physician to assess this particular problem.

MEMBER QUESTION:
My husband was diagnosed about 10 years ago. He is insulin dependent but has had his blood sugar levels under control for some time. He has diabetic neuropathy and is in constant extreme pain, with cramping in his arms and legs. His doctors just chalk it up to the diabetes. He is really at the edge with the pain and is very depressed. He has tried everything, but no relief. Could it be something else?

ZIMMERMAN:
Yes. He really should be assessed by a specialist in neuropathy and possibly diabetes. There are sometimes various treatments and drugs that may help. Some patients have compression on a nerve that can sometimes be managed with surgical intervention. There is a physician at the Cleveland Clinic, Dr. Siemionow, who assesses patients for that type of problem.

"The problem with trying to keep sugars absolutely low all the time is a marked increase in low blood sugar, which can have very significant complications."

MEMBER QUESTION:
I have peripheral neuropathy and starting two weeks ago began experiencing a loss of equilibrium when walking. I feel like I'm stepping right through the floor. Is this loss of equilibrium related to my diabetes?

CAVANAGH:
Many people with peripheral neuropathy experience postural instability. The reason for this is that the way we balance is by continual swaying forward and backwards and the receptors on the surface of our feet, the bottom surface of our feet, are able to sense where the body center of gravity is. People with neuropathy sway as much with their eyes open as people without neuropathy do with their eyes closed. However, there could be some other cause for the instability, and it would certainly be worth exploring if this is simply a neuropathic problem.

MEMBER QUESTION:
If I'm willing to do more injections, via smaller, more frequent meals or with all snacks, is it reasonable to aim to get my A1cs lower than 5.0 and 6.0?

ZIMMERMAN:
I think aiming for 7.0 or less is a good target. The problem with trying to keep sugars absolutely low all the time is a marked increase in low blood sugar, which can have very significant complications. Go with what the guidelines are recommending, rather than trying to achieve a hemoglobin A1c of 4.

MEMBER QUESTION:
I heal very slowly. If I do get a minor cut or injury on my foot, should I treat it myself, or go on to the doctor?

CAVANAGH:
We recommend that any time a patient with diabetes experiences a foot injury they always seek professional care.

MODERATOR:
Dr. Zimmerman, Dr. Cavanagh, do you have any final words of wisdom for us?

ZIMMERMAN:
Although diabetes is associated with a number of long-term complications, with improvement in blood sugar control these risks can be substantially reduced.

CAVANAGH:
The feeling among some people with diabetes that amputation is inevitable is absolutely wrong. With good care and good prevention, many foot injuries and conditions can be alleviated.

MODERATOR:
Thanks to our two guests from the Cleveland Clinic, Robert Zimmerman, MD, FACE, associate program director of the department of endocrinology, diabetes & metabolism, and Peter R. Cavanagh, PhD, academic director of the Diabetic Foot Care Program, for sharing their expertise with us.



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