What is the best assessment and treatment plan for a patient in their late 40s with a history of poorly controlled Diabetes Mellitus (DM), presenting with worsening peripheral neuropathy in their feet and a recent Hemoglobin A1c (HbA1c) level of 7.4%, who is unwilling to start medication?

Management of Worsening Diabetic Neuropathy with Patient Refusing Medication

This patient requires immediate comprehensive foot examination with risk stratification, aggressive non-pharmacologic glycemic interventions, and urgent podiatry referral—the HbA1c of 7.4% is inadequate to prevent neuropathy progression, and medication refusal necessitates intensive lifestyle modification while simultaneously addressing the high amputation risk from existing neuropathy. 1, 2

Immediate Assessment Required

Comprehensive Foot Examination

• Perform monofilament testing (10-g Semmes-Weinstein) at multiple plantar sites to confirm loss of protective sensation (LOPS)—inability to perceive the monofilament at any site confirms high-risk status. 1, 2
• Test vibration sense using 128-Hz tuning fork at the dorsum of the great toe to assess large fiber function. 2
• Check ankle reflexes, which are typically diminished or absent in diabetic peripheral neuropathy. 2
• Inspect feet thoroughly for skin integrity, calluses, deformities, pre-ulcerative signs (erythema, warmth, hemorrhage under callus), and any existing ulceration. 1

Vascular Assessment

• Palpate dorsalis pedis and posterior tibial pulses bilaterally—peripheral artery disease is present in up to 50% of diabetic foot complications and dramatically increases amputation risk. 1, 2
• Measure ankle-brachial index (ABI) to determine arterial perfusion status, as ABI <0.6 indicates critical limb ischemia requiring urgent vascular evaluation. 3
• Assess capillary refill time and look for dependent rubor or pallor on elevation. 2

Risk Stratification

This patient falls into IWGDF Risk Category 1 (peripheral neuropathy alone) at minimum, requiring screening every 6 months—if foot deformity or peripheral artery disease is present, they escalate to Category 2 (requiring screening every 3-6 months). 1, 2

Addressing Glycemic Control Without Medication

The HbA1c Reality

An HbA1c of 7.4% is insufficient to prevent neuropathy progression—elevated HbA1c is the most important predictor of subclinical neuropathy (adjusted odds ratio 10.71), and this patient already has symptomatic worsening neuropathy. 4

However, a critical caveat exists: Rapid glycemic improvement can paradoxically cause treatment-induced neuropathy of diabetes (TIND), manifesting as acute painful sensory neuropathy within 6-8 weeks of aggressive glucose lowering. 5, 6 This means any glycemic intervention must be gradual.

Non-Pharmacologic Interventions (Since Medication Refused)

• Implement structured medical nutrition therapy with a registered dietitian specializing in diabetes—carbohydrate counting, portion control, and meal timing are essential. 1
• Prescribe supervised exercise training program: 150 minutes per week of moderate-intensity aerobic activity plus resistance training 2-3 times weekly. 1
• Achieve gradual weight loss of 5-10% if overweight, as this significantly improves insulin sensitivity. 1
• Monitor glucose with continuous glucose monitoring or frequent self-monitoring to track response to lifestyle changes. 1

Counseling About Medication

While respecting patient autonomy, explicitly document that you have informed the patient that lifestyle modification alone is unlikely to achieve HbA1c <7% needed to prevent microvascular complications, and that metformin is first-line therapy with proven benefits on mortality and neuropathy prevention. 1 Note that metformin use is associated with vitamin B12 deficiency that can worsen neuropathy symptoms, requiring periodic B12 testing if eventually started. 1

Immediate Neuropathy-Specific Management

Foot Protection (Non-Negotiable)

• Instruct patient to NEVER walk barefoot, in socks only, or in thin-soled slippers—whether at home or outside. 1, 2
• Prescribe therapeutic footwear with adequate cushioning and depth to accommodate any deformities and redistribute plantar pressures by at least 30% compared to standard footwear. 1, 2
• Check inside shoes before wearing for foreign objects. 2

Daily Self-Care Protocol

• Inspect feet daily using a mirror to examine plantar surfaces for cuts, blisters, redness, or calluses. 1, 2
• Wash feet daily with careful drying between toes, using lukewarm water (test with elbow, not foot). 1, 2
• Apply emollients to lubricate dry skin but not between toes. 1
• Cut toenails straight across, not too short. 1, 2
• Report any skin breaks, color changes, swelling, or warmth immediately—these are pre-ulcerative emergencies. 2

Pre-Ulcerative Sign Management

Any callus must be debrided by a foot care specialist—callus increases plantar pressure and leads to subcutaneous hemorrhage and ulceration. 1 Patients should never use chemical agents or plasters to remove callus themselves. 1

Specialist Referrals

Podiatry (Urgent)

Refer immediately to podiatry or foot care specialist for ongoing preventive care and life-long surveillance—patients with neuropathy and unwillingness to optimize medical therapy are at extremely high risk. 1, 2 Podiatry should provide integrated foot care including professional foot treatment, custom therapeutic footwear, and reinforced education every 1-3 months. 1

Vascular Surgery (If Indicated)

If ABI is abnormal (<0.9) or pulses are diminished/absent, refer for vascular assessment to evaluate for revascularization options. 1, 3

Cardiovascular Risk Factor Management

Blood Pressure

Target blood pressure <130/80 mmHg in diabetes—this slows retinopathy and likely neuropathy progression. 2 Beta-blockers are not contraindicated in peripheral artery disease. 1

Lipids

Initiate statin therapy to achieve LDL <100 mg/dL (or <70 mg/dL if very high cardiovascular risk)—this is indicated for all patients with peripheral artery disease regardless of baseline LDL. 1

Smoking

If patient smokes, provide intensive smoking cessation counseling at every visit with pharmacotherapy (varenicline, bupropion, or nicotine replacement)—smoking dramatically increases amputation risk. 1, 2

Monitoring for Complications

Autonomic Neuropathy Screening

Screen for cardiac autonomic neuropathy (resting tachycardia >100 bpm) and orthostatic hypotension, as these often coexist with peripheral neuropathy. 2

Charcot Foot Surveillance

Watch for unilateral red, warm, swollen foot with intact skin—this represents Charcot neuro-osteoarthropathy requiring immediate knee-high immobilization and urgent imaging. 2

Infection Vigilance

Maintain extremely high suspicion for infection even without pain—peripheral neuropathy and peripheral artery disease mask typical presentations, and delayed recognition increases amputation risk nearly 3-fold. 3

Critical Pitfalls to Avoid

• Never delay foot care referral hoping the patient will eventually accept medication—neuropathy complications progress independently and require immediate preventive intervention. 1, 2
• Never assume stable neuropathy means stable risk—motor dysfunction causes foot deformities and altered biomechanics that increase ulceration risk over time. 7
• Never apply compression therapy without first checking ABI—this can precipitate gangrene in patients with unrecognized peripheral artery disease. 3
• If patient eventually agrees to medication, avoid excessively rapid HbA1c reduction (>2% drop in 3 months)—this can cause treatment-induced neuropathy with severe acute pain. 5, 6

Documentation

Document the patient's refusal of pharmacologic therapy, your counseling about risks of inadequate glycemic control, and the specific non-pharmacologic interventions prescribed. Note that you have explained the high risk of foot ulceration and amputation with current neuropathy status and suboptimal glucose control. 1, 2