Monday, December 19, 2011

A Patient with Diabetic Neuropathy

I was seeing patients in my hepatitis clinic when I went into see a new patient who had been referred over for possible treatment of his viral hepatitis C infection.  As I was going over his past medical history he mentioned that he had recently noticed some tingling in his feet  with some loss of feeling.  The patient’s name was John, he was in his late 40s, had a slightly balding head, and was probably about 20-30 pounds overweight.  He was a married hispanic, 5’6” in height.   And he was probably anxious, his hands didn’t stop fidgeting the whole time I was seeing him.
“Well, John I see a part of your past medical history is that you have type two diabetes.  How long have you had it?”
“About 5 years.”
“Have you kept your blood sugars in the normal range as well  as your HgbA1c levels around the 7 range?”
“No, not really.  I tried to stay on the diet my primary care physician gave me, but I like my Mexican food too much.  I know it’s not good for you, but it’s what I like to eat.  My primary care physician has told me that he’s going to start me on insulin injections if I don’t start working on getting my extra weight off with exercise and eating right.  If he puts me on insulin, then that will be three medications that I will have to take for my diabetes.  That’s not good, is it?”
“No, it doesn’t sound like it is.  But you’re having tingling in your feet with some numbness is probably related to your diabetes.  But because it can also be related to your hepatitis C infection, I’ll have to send you over to the neurology clinic and have them assess you for the cause of your problem with your feet.  Meanwhile, you do indeed need to work on those ideas that your primary care physician gave you regarding how to control your diabetes.  If this is indeed diabetic neuropathy starting up in your feet, the better your control your diabetes the better your neuropathy can get.  Okay?”
“I’ll try.” 
“Okay, well then let me finish up with your history, I’ll do a quick exam, check the size of your liver, things like that and then I’m going to send you off for blood work and an ultrasound of your liver.”
With that, I finished taking his history and doing his physical exam.  After that I sent him off for all of the blood work that would be needed as well as his ultrasound.  I also handed him the referral form so he could get into to see the neurology service. 

Diabetes can cause nerve damage and it can occur in several different areas.  Patients can have gastric neuropathy, where they have problems with rhythmic passage of food through the GI tract, or they can have nerve problems with their GU tract (kidney, urinary bladder, erectile dysfunction).  They also can have problems with nerve damage to their peripheral nerves (legs, feet, hands). 

Sometimes diabetic neuropathy can just show up as a loss of feeling with no parasthesias (i.e. tingling, burning or pain associated with it).  But if the patient has parasthesias, then they need to be treated medically. 

Both type 1 diabetics (what used to be called juvenile diabetes) and type 2 diabetics (which used to be called adult onset diabetes) can have neuropathy.  In the type 2 patients they can have neuropathy when they are initially diagnosed with diabetes.  With the type 1 diabetic, their neuroapthy problems can begin as soon as five years into their disease. 

I saw John back in the clinic several weeks later after he had gotten all of his lab work done, had his ultrasound and had been seen by the neurology service.  I read the neurology note and even though they were going to see him back in clinic they believed his peripheral neuropathy was due to his diabetes and not his chronic hepatitis C disease.  They wrote he was supposed to get his diabetes under better control and they wanted him seen by his primary care again to address this.  He was also supposed to see the podiatrist to teach him how to do appropriate foot care for his diabetes. 

I knocked on the exam room door and went in.  John was sitting on the exam room table, fidgeting with his hands again.  “Hi, John, how are you?”
“I’m okay, I guess. I’m trying to address my diabetes like the neurology service wants me to do.  But it’s not easy.”
“That’s understandable.  Anything that is worth doing, can sometimes be hard.  But keep it up, don’t give up with your addressing your diabetes every day.  It will pay off.”
“I’ll keep trying.”
“Good, I have your lab results and your ultrasound.  If you come over her to the computer I can show you the results and explain them to you.   So why don’t you sit right here, and I’ll go through them.”
“Alright.”
I explained all of John’s test results to him and after answering his questions, I set him up for a liver biopsy. 
He returned after his liver biopsy and I noticed he had seen his primary care regarding his diabetic care and was doing better with his daily blood sugars.  He had also seen neurology for his follow-up appointment and their testing had shown his neuropathy was indeed due to his diabetes.  The neurology service had started him on Elavil to take at night to help with his foot tingling.  He had an appointment to see them in follow-up so as to make sure that the medication was working. 
I knocked on the exam room door and went into see John again.  As usual, he was fidgeting again sitting on the exam room table.  He always reminded me of a person who didn’t like to be seen for any medical needs.  Being a patient probably made him uncomfortable, no doubt.

Treatment for diabetic neuropathy consists of having the patient acquire better control of their diabetes, this means they need to have their daily blood sugars as close to the normal range as possible, they need to have their HgbA1c  levels below 7.0 (which is a test for chronic control of diabetes).  Patients who have neuropathy also need to make sure they are doing appropriate foot care, i.e. they are looking at their feet every day, making sure they don’t have any ulcers, or blisters.  The third part of medical therapy for diabetic neuropathy is controlling the parasthesias.  Patients who are having the tingling, burning or pain with their neuropathy need to be treated with medication.  They can be treated with anti-depressants, anti-seizure medications, or sometimes even pain medications. 

“Hi, John,” I said.  I have your liver biopsy results here.  You don’t have a lot of damage to your liver, you’re a stage two, (liver biopsies go from stage 0-4, 4 being a cirrhotic liver, or end stage liver) so if you want to wait until after you get your diabetic neuropathy under control , you could do it without a problem.  In fact you probably won’t need treatment for your hepatitis C for several years.  By then there will probably be new medications out for it which will work better.  Maybe the new medications coming out will not be interferon based, I don’t know at this point.  But if interferon is not a part of the treatment program, that would be good for you, seeing that one of the possible side effects to interferon is parasthesia, which is very similar to the tingling going on in your feet right now.”
I noticed after I told him he could wait to receive his treatment for his hepatitis C, that his fidgeting hands calmed down. 
“Really, I don’t need to start right now?” John asked.
“That’s what I said, your liver biopsy shows only a limited amount of damage to it, so you don’t have to start right away.  You can wait a few years.  That will give you time to get your diabetes under control and hopefully your diabetic neuropathy will be better with your being on medications for it.  So is that okay with you?”
With this news, John became somewhat animated.  “Yeah, that’s sounds great!  Thanks.”
“Okay, well for those patients who are wanting to wait, I see them once a year just to get their labs re-drawn, viral load re-done and let you know of any changes in the treatment regimens.  Is that okay?”
“Yeah, that’s okay with me.” John said rather excitedly.
“Alright, well then I’ll see you a year from now.” 

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