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Intensive Insulin Therapy and Risk of Foot Ulcers.

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4 min read


This article reviews how the use of intensive insulin therapy in type 1 diabetes patients can lead to foot ulcers.

Medically reviewed by

Dr. Nagaraj

Published At September 30, 2022
Reviewed AtOctober 7, 2022

What Is Type I Diabetes?

It is a chronic condition in which the pancreas in the body produces insufficient or no insulin to maintain blood glucose levels. Insulin is a hormone with two primary functions-

  • Regulate Blood Sugar Levels- The carbohydrates that we consume get converted to simple sugars in our digestive system, which then enters the bloodstream. The pancreas responds to this increased blood glucose level by secreting insulin.

Insulin triggers and promotes glucose absorption by the skeletal system and the fat tissue from the bloodstream. The absorbed glucose is used for energy, protein, and fat synthesis.

  • Store Excess Glucose For Energy- Insulin also plays an important role in lowering the excess glucose in the blood. It stimulates the liver to convert and store the excess glucose into the form of glycogen. In between meals, when the blood sugar levels are low, the liver will convert the stored glycogen into glucose and release it into the blood with the help of another hormone called glucagon.

This process of converting glucose to glycogen by insulin and then the glycogen to glucose by glucagon keeps the blood sugar levels within the normal range, which is necessary for healthy physiological functions.

Type 1 diabetes is an autoimmune condition where the patient's own immune system attacks the cells in the pancreas that produce insulin. As a result, the pancreas will produce little to no insulin, thereby throwing off the blood sugar balance in the body, which is dangerous. Although type 1 diabetes often has an early onset, it can affect people at any age.

A few symptoms of type 1 diabetes are-

  • Increased thirst.

  • Frequent urination.

  • Extreme hunger and anger (hangry).

  • In children, it can cause unusual bed-wetting.

  • Unintended weight loss.

  • Fatigue and weakness.

  • Blurred vision.

  • Fruity breath.

If left untreated, type 1 diabetes will cause serious damage to different organs, including the heart, liver, eyes, kidneys, etc. Eventually, these complications turn into life-threatening conditions, including diabetic coma, brain damage, and death. Type 1 diabetes cannot be cured, but it can be treated. Treatment focuses on managing blood sugar levels with insulin therapy, diet, and lifestyle to prevent complications.

What Is Insulin Therapy?

In patients suffering from type 1 diabetes, insulin therapy makes up for the low or lack of insulin in the body. There are various types of insulin therapies, which makes it important for the clinician and the patient to communicate before deciding on the one that suits the patient’s needs.

A few key points to remember before choosing the therapy are-

  • The blood sugar level is not entirely dependent on the food-to-insulin ratio.

  • It also changes based on the drinks the patient consumes and on the amount of energy used during different physical activities.

  • The blood sugar level is different at different times of the day.

  • It also gets influenced if the patient has other unrelated medical conditions, hormonal changes, is on medication, etc.

So, it is important to know the patient's body and habits before finalizing the type of therapy. The different types of insulin therapy are-

Conventional Insulin Therapy-

  • It involves injecting insulin twice a day; it is often preferred for patients with a regular daily routine which makes it easy for them to inject insulin at the same time every day.

  • A mixture of pre-made short-acting and long-acting insulin is prescribed for patients on conventional insulin therapy. They will have to inject this mixture in the morning before breakfast and in the evening before their evening meal.

  • The amount of insulin is fixed and is based on the planned amount of food consumed over the course of the day. This leads to a regimented lifestyle; if the patient does choose to do any unplanned physical activity, they will have to balance the blood sugar with extra snacks between meals.

  • The downfall of conventional insulin therapy is that it does not effectively prevent the long-term complication of type 1 diabetes.

Intensive Insulin Therapy-

This type of insulin therapy is comparatively more effective at preventing type 1 diabetic complications than conventional insulin therapy. The principles behind intensive insulin therapy are constant monitoring and flexibility.

Two types of insulin are needed to complete the therapy. They are-

  • Basal Dose - This is the long-acting insulin that is given once or twice during the day; it covers the body’s basic insulin needs.

  • Bolus Dose - This is the short-acting insulin that is injected by the patient before every meal to process the carbohydrates. The patient will be given insulin to carbohydrate (I: CHO) ratio and the correction factor.

The I: CHO will tell the patient about the amount of carbohydrates that can be covered with one unit of short-acting insulin. The correction factor will let the patient know about the amount of blood sugar that will drop with one unit of short-acting insulin.

The I: CHO will help the patient to determine the amount of bolus dose that they will have to administer before the meal, and the correction factor will help them reduce their blood sugar level if it accidentally increases during one of their random monitoring sessions.

The goal of intensive insulin therapy is to maintain the blood sugar level at all times of the day so that the patient has greater flexibility in their daily life.

Why Do Diabetic Patients Suffer From Foot Ulcers?

Prolonged high blood sugar causes damage to the nerves, especially the peripheral nerves in the arm and the leg; this condition is known as diabetic neuropathy. This condition is common to both type 1 and type 2 diabetic patients.

Blood sugar levels in most diabetic patients are not constantly monitored; it is due to a lack of awareness of the condition. This results in prolonged excess glucose levels in the body, known as hyperglycemia.

Hyperglycemia induces cellular hypoxia (state of oxygen deprivation) in different organs in the body; the blood vessels and the peripheral nerves are the first tissues to get affected by this phenomenon. If left untreated, hypoxia will cause the death of these tissues leading to diabetic neuropathy.

The nerves in the legs and the arms get affected early on due to their peripheral nature. Patients with diabetic nephropathy will develop the following symptoms-

  • Numbness.

  • Tingling.

  • Sharp pain or cramps.

  • Muscle weakness.

  • Extreme sensitivity to touch.

If the symptoms are left untreated, the patient will develop sores and breaks in the skin that will lead to ulcers in the affected limb. Ulcers formed due to diabetic neuropathy are difficult to heal and often become infected, leading to amputation of the limb. This can be prevented by-

  • Maintaining close to normal blood sugar levels and constantly monitoring them.

  • Cessation of smoking.

  • Regular check-ups with the podiatrist.

  • Good nail care.

  • Using moisturizing lotion.

  • Protecting the feet by wearing the right kind of shoes.


Modern diabetes management with intensive insulin therapy is all about self-management of blood sugar as effectively as possible. Living with diabetes, either type 1 or type 2, is stressful and overwhelming, but it is possible to manage it with patient education. People who are on intensive insulin therapy should learn a few skills, like adjusting their diet, physical activities, and stress-management techniques. Well-informed patients will follow the treatment plan and avoid complications giving themselves a flexible life similar to that of a non-diabetic person.

Frequently Asked Questions


What Are the Most Important Risk Factors for Diabetic Foot Ulcers?

The following are the most critical risk factors for diabetic foot ulcers:
- Poor glycemic control
- Calluses
- Foot deformities
- Inappropriate foot care
- Need to be more fitting footwear
- Underlying peripheral neuropathy
- Poor circulation
- Dry skin


What Causes Diabetic Patients to Get Foot Ulcers?

Diabetes ulcers are a dangerous consequence brought on by a confluence of poor circulation, infection susceptibility, and nerve damage from high blood sugar levels. The body has difficulty healing skin wounds with little blood supply to the injured region. As a result, these lesions turn into diabetic ulcers.


Why Are Diabetic Patients Considered to Be at High Risk for Ulcers?

Diabetes neuropathy, structural foot deformity, and peripheral artery occlusive disease are among the most prevalent risk factors contributing to ulcers in diabetic patients.


What Are the Different Types of Diabetic Foot Ulcers?

The three kinds of diabetic foot ulcers are:
- Neuropathic
- Neuroischaemic
- Ischaemic


Who Is Susceptible to Foot Ulcers?

Most cases of these ulcers occur in people with neuropathy with diabetes. The foot or toes may need to be amputated if an ulcer becomes infected.


What Are Three Things You Should Never Do to Someone With Diabetes’s Feet?

The following are the things that should be avoided with diabetes foot:
- Stay barefoot
- Wearing high heels and pointy toes is not advised
- Avoid socks with tight elastic bands because they impair circulation
- Spare feet in the bath


What Treatment Option Is Most Effective for Diabetic Foot Ulcers?

The best practices for treating diabetic foot ulcers include: 
- Debriding the lesion
- Treating if the wound has any infections
- Performing revascularization treatments
- Relieving pressure on the ulcer
A few more techniques that have been touted as useful adjunct therapies are:
- Negative-pressure wound treatment
- Hyperbaric oxygen therapy


What Is the Ideal Cream for Diabetic Foot Ulcers?

For both preventing and treating infections in diabetic foot ulcers, Clotrimazole is one of the most effective ointments. It is a member of a group of drugs known as Imidazoles.


Neuropathic Diabetic Foot Ulcers: What Are They?

When a person with impaired peripheral nervous system neurological function has pressure sites that induce ulceration through the epidermal and dermal tissue layers, this condition is known as a neuropathic ulcer. This typical ailment affects the foot and sporadically other body regions.


What Is the First Guideline for Treating Diabetic Feet?

The common procedures for managing diabetic foot ulcerations include surgical debridement, dressings to provide a moist wound environment and exudate control, wound off-loading, vascular evaluation, and infection and glucose control.


What Is the Most Effective Method of Treating Diabetic Foot Neuropathy?

Pregabalin is suggested as the first-line treatment for diabetic peripheral neuropathy in the AAN (American Academy of Neurology) recommendations due to its efficiency in lowering pain and pain-related sleep disruption.


What Stages of Diabetic Foot Ulcers Are There?

Grade 0 - Only foot symptoms such as discomfort.
Grade 1 - Superficial ulcers affecting the skin and subcutaneous tissue.
Grade 2 - Deep ulcers affecting ligaments, muscles, tendons, etc.
Grade 3 - Ulcer involving the bone.
Grade 4 - Gangrene of the forefoot.
Grade 5 - Complete foot gangrene.


Why Is Betadine Not Used in Patients With Diabetes?

Betadine should be avoided in diabetes individuals because it might interfere with wound healing.


Which New Medication Treats Diabetic Neuropathy?

Duloxetine (Cymbalta) has FDA clearance to treat the discomfort brought on by diabetic neuropathy among tricyclic antidepressants. It works on the central nervous system to assist in inhibiting pain signalstem.
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Dr. Nagaraj
Dr. Nagaraj



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