1. Peripheral neuropathy affects many patients with diabetes and causes nocturnal or constant pain, tingling and numbness and confers an increased risk for foot infections, foot ulcers, and amputation. 2. The feet should be evaluated regularly for sensation, pulses and sores. Semmes-Weinstein 10-g monofilament testing may be performed to accurately assess sensation. D. Autonomic neuropathy is found in many patients with long-standing diabetes. This problem can result in diarrhea, constipation, gastroparesis, vomiting, orthostatic hypotension, and erectile or ejaculatory dysfunction. Initial management of diarrhea consists of sugar-free psyllium [e.g., Metamucil, Sugar Free), loperamide (e.g., Imodium), 2.0 mg twice/day, or diphenoxylate/atropine sulfate (e.g., Lomotil)2.5 mg twice/day. Sildenafil (Viagra) is beneficial in patients with erectile dysfunction IV. Pharmacotherapy of diabetes A. Insulin

1. Insulin should be prescribed for all patients with type 1 diabetes and is beneficial in many individuals with type 2 diabetes. A general strategy is to provide long-acting insulin to meet basal requirements and supplement this regimen with rapid-acting insulin taken shortly before mealtimes.

2. NPH insulin is a long-acting insulin, which may be injected once per day at bedtime or twice per day, with about two-thirds of the daily dose given before breakfast and one-third given before the evening meal. Insulin therapy may be initiated in patients using oral agents by continuing the oral medications and adding 10 units of NPH insulin at 10 p.m. or bedtime.

3. Short-acting insulins include regular insulin and lispro insulin. Either of these agents may be used before meals to match insulin availability to glucose load. Lispro has a more rapid onset of action and is also more rapidly cleared; therefore, it can be injected immediately before eating.

Features of Insulin Therapy

Type of insulin

Onset of action

Peak action

Duration of action



10 minutes

One hour

Two hours

Inject immediately before meal


30 minutes

Two to four hours

Six to eight hours

Inject 15 to 30 minutes before meals


Two to four hours

Six to eight hours

Eight to 14 hours

Inject twice daily or at bedtime

Commonly Used Insulin Regimens

1. One shot per day: NPH at bedtime.

2. Two shots per day: NPH plus regular before breakfast and NPH plus regular before the evening meal.

3. Three shots per day: NPH plus regular before breakfast, regular before lunch and NPH plus regular before the evening meal.

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