Pekerjaan:

Dokter IDT Puskesmas Belang, Kab. Minahasa, 1994.

Dokter Ka. Puskesmas Tolinggula, Kab Gorontalo, 1995-1998
Staf di Bagian Saraf RSU Prof.dr. RD Kandou, Manado 2000-2002
Dokter PNS RSUD dr. M. Haulussy Ambon, 1999 -.

Pendidikan:
Dokter Umum : FK Universitas Sam Ratulangi 1994
Spesialis Saraf (SpS) : FK Universitas Indonesia 2008
Magister Kedokteran : FK Universitas Indonesia 2008
Ketua Komite Mutu RS & Patient Safety dr. M. Haulussy : 2009-
2013
Surveyor Internal Akreditasi RS dr. M. Haulussy : 2014-
Pengurus TAGANA RBV Maluku : 2014-
Ketua PDGBI (Persekutuan Dokter GBI) Ambon : 2014-
Pengurus IDI Cab. Ambon : 2014-
dr. Semuel A. Wagiu, SpS.
RSUD dr. M. Haulussy Ambon

Saumlaki, 9 Mei 2015

 Common complication of diabetes, is
damage to the nerves that allow you to feel
sensations such as pain.
There are a number of ways that diabetes
damages the nerves, but they all seem
related to blood sugar being too high for a
long period of time.
Neuropathy:nerve disorder that results in
distortion of nerve function.
 About 60-70% of people with diabetes
have mild to severe forms of nervous
system damage, including:
Impaired sensation or pain in the feet or
hands
Slowed digestion of food in the stomach
Carpal tunnel syndrome
Other nerve problems
More than 60% of nontraumatic lower-
limb amputations in the United States
occur among people with diabetes.
 Most common form of neuropathy
Affects approximately 50% after 15 years
Affects long nerves (feet and legs) first
Glove and stocking distribution
Bilateral
Equal symptoms in both limbs
 Poor glycaemic control
Long duration
Age
Height
Dyslipidemia
Hypertension
Alcohol
Smoking
Nerves of the Foot
 Metabolic factors
High blood glucose
Advanced glycation end products
Sorbitol
Abnormal blood fat levels
Ischemia
Nerve fiber repair mechanisms
 Classified based on the affected nerves:-
Peripheral neuropathy
Autonomic neuropathy
Focal neuropathy
Proximal neuropathy
 The areas of the body most commonly
affected are the feet and legs.
Nerve damage in the feet ;result in a loss of
foot sensation (foot problem).
Injuries and sores on the feet may go
unrecognized due to lack of sensation.
Should practice proper skin and foot care.
Regions of the body
affected by peripheral
neuropathy
 Symptoms:
burning
pins and needles
pain
No symptoms
 Affects the autonomic nerves controlling
internal organs
Peripheral
Genitourinary
Gastrointestinal
Cardiovascular
Regions of the body
affected by autonomic
neuropathy
 Bloating Decrease in vaginal
Diarrheal lubrication
Decrease in number of
Constipation
orgasms or lack of orgasm
Heartburn Unable to completely
Nausea empty bladder
Vomiting Incontinence (leaking
Feeling full after small urine)
meals Increased urination at night
Nausea
Blacking out when you Vomiting
stand up quickly Early fullness
Increased heart rate Erectile dysfunction
Dizziness
Low blood pressure
Dry skin mainly from decreased
Sweating due to autonomic
neuropathy
 Appear suddenly and affect specific nerves,
most often in the head, torso, or leg, causing
muscle weakness or pain.
Symptoms may include:
double vision
eye pain
paralysis on one side of the face (Bell's palsy)
severe pain in a certain area, such as the lower back or
leg(s)
chest or abdominal pain that is sometimes mistaken
for another condition such as heart attack or
appendicitis
 Causes pain (usually on one side) in the
thighs, hips, or buttocks.
Also lead to weakness in the legs.
Treatment for weakness or pain is usually
needed and may include medication and
physical therapy.
The recovery varies, depending on the type of
nerve damage.
Definition:
Infection, ulceration or destruction of
deep tissues associated with
neurological abnormalities & various
degrees of peripheral vascular
diseases in the lower limb

(based on WHO definition)

 GTT/OGTT
Foot examto assess sensation in the foot
Nerve conduction studiesto test nerve activity
Electromyographyto determine how muscles
respond to nerve signals
Quantitative sensory testingthe use of stimuli
(eg, vibration) to check for neuropathy
QSART (quantitative sudomotor axon reflex
test) a test which evaluates the inervation of
sweat glands.
 Heart rate teststo determine how the heart
responds to changes
Ultrasoundto view internal organs
Biopsyto remove a sample of nerve or skin
tissue for examination
 Monofilament (cutaneous touch)
Proprioception (rhomberg)
Test of motion and orientation
Sharp/Dull Perception
Pin Prick Test
Temperature sensation
(test tubes with water)
Tuning fork
(vibratory sense 128 Hz tuning fork )
Gait, muscle strength, reflexes
 Ulcers
Charcot arthropathy
Dislocation and stress fractures
Amputation - Risk factors include:
Peripheral neuropathy with loss of protective
sensation
Altered biomechanics (with neuropathy)
Evidence of increased pressure (callus)
Peripheral vascular disease
History of ulcers or amputation
Severe nail pathology
 Tighter control of blood glucose
Pain relief (amitriptyline, nortriptyline etc)
Regular exercise
Avoiding smoking
Medications to treat autonomic problems
and prevent bladder infections
Physical therapy
Foot care
Weight control
 Insulin Resistance
Hyperinsulinemia

Hyperlipidemia Hyperglycemia
LDL goal < 100 mg/dl (< 70 mg/dl) HbA1C < 7%
HDL goal > 40 in men and 50 in women FPG 90-130 mg/dl
Triglycerides < 150 mg/dl PPPG < 180 mg/dl

Hypertension Hypercoagulable/
Inflammatory State
< 130/80 mm Hg Low dose Aspirin daily
 Pharmacotherapy
Nonopioid
Opioid
Adjuvant analgesics
Interventional
Neural blockade (eg, sympathetic nerve blocks)
Neurostimulatory techniques (eg, spinal cord stimulation)
Intraspinal infusion
 Pregabalin, Gabapentin, carbamazepine,
lamotrigine, and newer AEDs
Antidepressants (TCA)
Opioid analgesics
Lidocaine (transdermal, intravenous [IV]),
mexiletine
Alpha lipoic acid
Neurotropic vitamin
 Rehabilitative approaches
Psychologic interventions
Obat Golongan Dosis Efek Samping
HIPOTENSI ORTOSTATIK
9 Fluorohydrocortisone Mineralocorticoid 0.5-2 mg/hari Gagal jantung
kongestif,hipertensi

Clonidine 2-Adrenergic agonist 0.1-0.5 mg (malam) Hipotensi, sedasi, mulut

kering

Octreotide Analog Somatostatin 0.1-0.5 g/kg/hari Nyeri tempat suntikan, diare

GASTROPARESIS
Metoclopromide D2-Receptor antagonist 10 mg 30-60 mnt sebelum Galactorrhea, extrapiramidal
makan dan tidur

Domperidon D2-Receptor antagonist 10-20 mg 30-60 menit Galactorrhea

sblm makan dan tidur

Erythromycin Motilin receptor agonist 250 mg 30 menit sebelum Kram perut, mual, diare, rash
makan

Levosulfide D2-Receptor antagonist 25 mg tid Galactorrhea

 DIARE DIABETIK
Metranidazole Antibiotik spektrum luas 250 mg tid, minimal 3 Hipotensi ortostatik
minggu

Clonidine 2-Adrenergic agonist 0.1 mg bid atau tid Megakolon toksik

Cholestyramine Bile acid sequestrant 4 1-6 kali/hari Malabsorpsi nutrien (dosis
tinggi)

Loperamide Opiate-receptor agonists 2 mg qid

Octreotide Analog somatostatin 50 g tid
CYSTOPATHY
Bethanechol Acetylcholine receptor 10 mg, 4 kali/hari
agonist

Doxazosin 1-Adrenergic antagonist 1-2 mg, 2-3 kali/hari Hipotensi, sakit kepala,
palpitasi

DISFUNGSI EREKSI
Sildenafil GMP type-5 50 mg sebelum aktivitas Hipotensi dan kejadian
phosphodiesterase seksual, sekali sehari kardiak fatal, sakit kepala,
inhibitor flushing, kongesti hidung,
dispepsia, nyeri otot,
pandangan kabur.
 Well controlled diabetes.
Patient education about foot care.
Inspect their feet regularly by physician.
Avoid smoking.
DO
Check your feet every day for cuts, cracks, bruises, blisters, sores, infections, unusual
markings
Use a mirror to see the bottom of your feet if you can not lift them up
Check the colour of your legs & feet seek help if there is swelling, warmth or redness

Wash and dry your feet every day, especially between the toes

Apply a good skin lotion every day on your heels and soles. Wipe off excess

Change your socks every day

Trim your nails straight across
Clean a cut or scratch with mild soap and water and cover with dry dressing

Wear good supportive shoes or professionally fitted shoes with low heels (under 5cm)

Buy shoes in the late afternoon since your feet swell by then
Avoid extreme cold and heat (including the sun)
See a foot care specialist if you need advice or treatment
DO NOT
Cut your own corns or callouses

Treat your own in-growing toenails or slivers with a razor or scissors. See your
doctor or foot care specialist
Use over-the-counter medications to treat corns and warts

Apply heat with a hot water bottle or electric blanket may cause burns unknowingly

Soak your feet

Take very hot baths

Use lotion between your toes
Walk barefoot inside or outside

Wear tight socks, garter or elastics or knee highs

Wear over-the-counter insoles may cause blisters if not right for your feet
Sit for long periods of time
Smoke
semuel.wagiu@gmail.com
 Cardiovascular autonomic neuropathy can
cause death.
Peripheral neuropathy can lead to foot ulcers
and leg amputations.
Autonomic neuropathy is associated with
dizziness and falling with associated injuries,
nausea and vomiting, severe diarrhea, and
dehydration, all of which can lead to
hyperosmolar nonketotic diabetic coma or
diabetic ketoacidosis and, hence, to death.