By Tedler D. Depaynos, MD
The patient is a retired elementary head teacher. Actually, he has been assigned in several municipalities but when he had several years more before retiring, he preferred to be assigned to where he was born. He grew up as a farm boy and he wanted to go back to farming upon retirement. Throughout the years he expanded their family farm by investing mainly his retirement benefits.
It was more than a year ago when he felt slight numbness on his left foot. With time he felt it to be worsening. He did not seriously mind it at all because he could still walk and he just attributed it to “old age arthritis”. One day he slipped while going down to his farm and incurred a small wound on his left foot. It appeared minor but with time it failed to heal and it became bigger and bigger. It became a painless non-healing wound!
He was forced to consult their Municipal Health Officer (MHO) who inquired if the patient is diabetic because it may be due to uncontrolled Diabetis Mellitus. The patient admitted that his blood sugar was just always slightly elevated but he never felt anything. After cleaning the wound, the MHO referred him to a hospital for more extensive surgical debridement and for more work-up and treatment of his diabetis. He whispered to the patient’s relatives, however, the possibility of amputation because he felt no pulse in the lower part of the affected leg and appeared darker than the other one although he was not sure.
In the hospital, he was confirmed to be diabetic. The patient admitted that it was during his early years of teaching when he had a very “high blood sugar”. He was prescribed medications which he took regularly for years but because he was asymptomatic, he eventually took them on and off and later never returned for follow-up. He even shifted to “herbal medicines” which according to him made him feel good. He retired earlier from his medications, than from his profession..
The MD to whom he was referred to, saw him at the Emergency Room (ER) because due to the serious Covid 19 problem, all the MD clinics were forced to close.
Diabetis is a very insidious disease. It may be inherited. One does not feel anything until complications set in. They occur usually after 5 to 10 years of being diabetic and most of the time they are irreversible. The damage may already be done! They may be lessened but they would not completely disappear.
Diabetis is characterized by excess glucose in the blood. This is easily determined in the laboratory. The carbohydrates and sugar we take in are converted to glucose which is supposed to enter our cells to be used for energy with the aid of insulin. Insulin is secreted by our pancreas and the taking of food will automatically stimulate the production of insulin. Without insulin therefore, the sugar cannot enter our cells and will just be accumulated in our blood. Some will be excreted thru the kidneys making the urine highly colored and prone to infection. In Juvenile or Type 1 Diabetis, this is the main pathology. Due to a poorly understood auto immune mechanism, the cells in the pancreas secreting insulin are destroyed at a young age. Treatment obviously is insulin injection.
In Type 2 Diabetis which is developed later in life, insulin may be secreted by the pancreas but inadequate. It may also be abnormal so that it cannot do its function very well. Even if one reduces their sugar intake, the glucose manufactured and secreted by the liver will eventually become excessive because of lack or abnormal insulin making the blood sugar levels high. Of course the above mechanisms may all be present at the same time. The extent or degree of the defect and their concomitant presence will define the seriousness of the disease.
This is the type of diabetis mellitus found in the elderlies like in this patient.
With the above probable mechanisms, drugs acting on the different mechanisms may be prescribed. There are drugs that stimulate the pancreas to secrete enough insulin like oral Meglitinides. There are also drugs that aid the function of insulin in facilitating the entry of glucose into the cells (Thiazolidinediones) and there are drugs that control the liver function in manufacturing glucose (Metformin). To control the absorption of sugar in the intestine, various drugs like Alpha-glucosidase inhibitors are also prescribed. In short the different anti-diabetic drugs have different mechanisms of action. And this is the reason why multiple drugs are prescribed sometimes in treating diabetis.
With regards to the “herbal medicines” supposedly for diabetis, the attending MD admitted his ignorance
At present with intensive medical research, newer drugs are now available which are found to be more effective and with much lesser side effects. They are usually prescribed by doctors who took additional studies in diabetis. However, if the condition cannot be controlled adequately and the blood sugar is persistently high, these specialists usually go back to the basic in injecting insulin. It was emphasized, however, that most of the time one has to take his medications for life.
Of course, before and after anti-diabetic drugs are prescribed, patients are advised to change or improve their lifestyle that would result in weight reduction. It would enhance the response of the body to the anti diabetic drugs prescribed even with a 5 to 10 % weight reduction. Strict dieting like concentrating more on vegetables and low fat food and doing more exercises at least 3 hours per week are a must.
Change in lifestyle should also include control of alcoholic intake and cessation of smoking. Patients with these uncontrollable habits are more prone to the diabetic complications. Likewise stress reduction should be included in the new lifestyle. Constantly smiling is obviously better than frowning or seriousness.
The main objective in diagnosing and treating diabetis early is to prevent complications. The mechanism of their appearance is really complicated. It worsens the effect of other diseases and reduces one’s resistance making one look pale, sickly and prematurely old. Elderly diabetic with complications will then act and look much older.
In layman’s terms, one of the mechanisms of diabetic complications is the reduction or even obstruction of the lumen of the blood vessels. If the ones supplying the nerves are affected, numbness, tingling sensations and even pain especially in the lower extremities are felt. The blood vessels carry oxygen and if the tissues are devoid of oxygen, non-healing wounds and even gangrene results. This happens if the bigger blood vessels are affected. This may have happened to the patient so that the blood supply of his affected foot is diminished resulting in numbness and later making it appear darker than the other one. It is good that his coronary vessels are fortunately not involved otherwise he would have experienced ischemia or chest pains which may be severe. Likewise, his renal vessels most probably are still within normal or else renal failure with deceitful late manifestations may suddenly occur. Persistently very high blood pressure may be due to renal failure even if the renal function laboratory tests are normal. Since the patient could still see, his micro retinal blood vessels are still intact and not obstructed or else he would also be blind.
A more extensive debridement of the allegedly non-healing wound was done under local anesthesia at the ER because the operating rooms were reserved for emergency surgeries for the moment. Many of the staff were reassigned to control the Covid 19 problem.
Although the pulse was weak, there was blood oozing during debridement and the patient felt pain. Culture of the bacteria and tests for the best antibiotics (C and S) were done. Studies were supposed to be made on the blood supply of his affected leg but again because the hospital was giving priority to the prevention and control of the Covid 19 pandemic, this was rescheduled during his follow-up.
Extensive medications for his diabetis and possible infection were prescribed. Likewise medicines that may increase the blood supply of the leg and also to improve its numbness were added. The relatives were then taught how to clean the wound. Luckily, a nephew who accompanied him is a nursing student. The patient, however, was strictly advised to return for follow-up. He was warned of the possibility of amputation if the lessened blood supply would worsen and the wound would fail to heal.
Again, do not take diabetis for granted. One cannot do anything if one is destined to be diabetic. But the appearance could be delayed and the complications can be lessened or even prevented with early diagnosis and faithful treatment. **
