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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Best Practices in Podiatry: Improving Screening and Management Strategies for Diabetic Peripheral Neuropathy


GOAL
To discuss strategies for screening and diagnosing diabetic peripheral neuropathy (DPN) and review current and emerging trends in DPN treatment, with emphasis on the interdisciplinary approach to the care of a patient with DPN.

TARGET AUDIENCE
This activity is designed for podiatrists, endocrinologists, diabetologists, and primary care clinicians.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, participants should be able to:

  • Outline protocols for the screening and diagnosis of diabetic peripheral neuropathy.
  • Identify the symptoms related to diabetic peripheral neuropathy.
  • Describe an appropriate clinical examination of motor, sensory, and reflex function in the extremities.
  • Evaluate current and emerging targeted strategies for the treatment of diabetic peripheral neuropathy, with specific focus on the protein kinase C (PKC) ß enzyme.
  • Explain the rationale for existing and emerging treatment options for diabetic peripheral neuropathy.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity. The estimated time to complete this educational activity: 2 hours.

Release date: December 15, 2005.
Expiration date: December 15, 2007.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Eli Lilly and Company.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Directors and Participating Faculty reported the following:

PROGRAM DIRECTOR

Christopher D. Saudek, MD
Past President
American Diabetes Association
Hugh P. McCormick Family Professor of Endocrinology and Metabolism
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Saudek reports no financial or advisory relationships with corporate organizations related to this activity.

PARTICIPATING FACULTY

David G. Armstrong, DPM, MSc, PhD
Professor of Surgery
Chair of Research
Director
Center for Lower Extremity Ambulatory Research (CLEAR)
Assistant Dean
Dr William M Scholl College of Podiatric Medicine
Rosalind Franklin University of Medicine and Science
North Chicago, Illinois
Dr Armstrong reports that he is a consultant for Xilas Medical Inc.

Andrew J. M. Boulton, MD, DSc(Hon), FRCP
Professor of Medicine
University of Manchester
Manchester, United Kingdom
University of Miami
Miami, Florida
Chairman
Diabetic Foot Study Group, Postgraduate Education
European Association for the Study of Diabetes
North Chicago, Illinois
Dr Boulton reports serving as a consultant and receiving honoraria from Eli Lilly and Company and Pfizer Inc.

Lee J. Sanders, DPM
Chief of Podiatry
Department of Veterans Affairs
Medical Center in Lebanon
Lebanon, Pennsylvania
Dr Sanders reports he is a consultant for and serves on the advisory panel of Eli Lilly and Company.

Notice: The audience is advised that articles in this CME activity contain no reference(s) to unlabeled or unapproved uses of drugs or devices.

Dr Boulton—advanced glycation end-product (AGE) receptor blockers, aldose reductase inhibitors (ARIs), benfotiamine, a-lipoic acid, poly (ADP-ribose) polymerase (PARP) inhibitors, and protein kinase C (PKC) ß inhibitors for treatment of diabetic microvascular complications.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Best Practices in Podiatry: Improving Screening and Management Strategies for Diabetic Peripheral Neuropathy
Christopher D. Saudek, MD*

Diabetes mellitus has reached epidemic proportions in the United States and around the globe. According to the most recent statistics available from the Centers for Disease Control and Prevention, 20.8 million individuals in the United States—7.0% of the population—have diabetes, with 1.5 million new cases of diabetes diagnosed each year.1 The World Health Organization estimates there are currently 171 million people worldwide who have this chronic condition, and it is projected that by the year 2030 the prevalence will escalate to 366 million.2

Diabetes is responsible for significant morbidity and mortality resulting from a variety of metabolic, macrovascular, and microvascular complications. Specifically, diabetic peripheral neuropathy (DPN) is a serious complication of diabetes that affects up to half of patients with diabetes. The highest rates of neuropathy are among people who have had the disease for at least 25 years (particularly those over age 40), who have poorly controlled glycemic levels, and who have other cardiovascular risk factors such as obesity and hypertension.3

The most common type of diabetic neuropathy is peripheral neuropathy, also called distal symmetric neuropathy, which affects the arms and legs. Damaged nerves can cause pain, burning, numbness, tingling, and weakness in the feet and hands, as well as imbalance or unsteadiness of the feet. Lacking warning symptoms or cues to danger, these patients are at high risk for developing neuropathic foot ulcers that may lead to the need for amputation.

Indeed, 15% of individuals with diabetes (2 million patients) may develop foot ulcers; patients with diabetes are 12 times more likely to undergo amputation than those without diabetes; 86 000 lower-limb amputations are performed every year on patients with this chronic condition. Thus, the effects of DPN can significantly impact quality of life for all individuals with diabetes, yet it is estimated that nearly half of these may be preventable with proper care and treatment.3-5

Clinicians play a pivotal role in the prevention and early diagnosis of diabetic peripheral neuropathy. Unfortunately, DPN often is underdiagnosed, resulting in devastating complications. Signs and symptoms of DPN can be detected through early, thorough, and frequent physical examinations, including specific neurologic testing such as tuning fork and monofilament testing.

In this Advanced Studies in Medicine monograph, which is based upon proceedings of a satellite symposium that took place on August 6, 2005, specific aspects of patient education, screening, and diagnostic testing for DPN as well as proper management and the potential role of emerging therapies are discussed.

REFERENCES

1. Centers for Disease Control and Prevention. National diabetes fact sheet. Available at: www.cdc.gov/diabetes/ pubs/estimates.htm. Last accessed September 7, 2005.
2. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27:1047-1053.
3. National Diabetes Information Clearinghouse. Diabetic neuropathies: the nerve damage of diabetes. Available at: http://diabetes.niddk.nih.gov/dm/pubs/neuropathies. Last accessed September 7, 2005.
4. Foot and Ankle Institute. Diabetes statistics. Available at: www.feetnet.com/statistics.php. Last accessed September 7, 2005.
5. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977-986.

*Past President, American Diabetes Association; Hugh P. McCormick Family Professor of Endocrinology and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Address correspondence to: Christopher D. Saudek, MD, Osler 576, 600 N Wolfe St, Baltimore, MD 21287. E-mail: csaudek@jhu.edu.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.