For many years proximal neuropathy has been considered a component of DN. Its pathogenesis was ill understood (46), and its treatment was neglected with the anticipation that the patient would eventually recover, albeit over a period of some 1-2 years and after suffering considerable pain, weakness and disability. The condition has a number of synonyms including diabetic amyotrophy and femoral neuropathy. It can be clinically identified based on the occurrence of these common features: 1) primarily affects the elderly (50 to 60 years old) with type 2 diabetes; 2) onset can be gradual or abrupt; 3) presents with severe pain in the thighs, hips and buttocks, followed by significant weakness of the proximal muscles of the lower limbs with inability to rise from the sitting position (positive Gower's maneuver); 4) can start unilaterally and then spread bilaterally; 5) often coexists with distal symmetric polyneuropathy; and 6) is characterized by muscle fasciculation, either spontaneous or provoked by percussion. Pathogenesis is not yet clearly understood although immune-mediated epineurial microvasculitis has been demonstrated in some cases. Immunosuppressive therapy is recommended using high dose steroids or intravenous immunoglobulin (47). The condition is now recognized as being secondary to a variety of causes unrelated to diabetes, but which have a greater frequency in patients with diabetes than the general population. It includes patients with chronic inflammatory demyelinating polyneuropathy (CIDP), monoclonal gammopathy, circulating GM1 antibodies, and inflammatory vasculitis (48) (49) (43) (44).
Ensuring the optimal care of the many people with diabetes who fast during Ramadan is crucial. The International Diabetes Federation (IDF) and the Diabetes and Ramadan (DAR) International Alliance have therefore come together to deliver comprehensive guidance on this subject. The IDF-DAR Practical Guidelines provide healthcare professionals (HCPs) with relevant background information and practical recommendations to enable them to help people with diabetes participate in fasting during Ramadan while minimising the risk of complications.
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