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Neuropatia Diabetica
Neuropatia Diabetica
NEUROPATHY
Polyradiculoneuropathy
Diabetic neuropathic cachexia
DISTAL SYMMETRICAL POLYNEUROPATHY
Small-fiber neuropathy
Deep, burning, stinging, aching pain ;allodynia to light touch.
Pain & temp impaired, relative preservation of vibration & JPS & DTR
Often accompanied by autonomic neuropathy
May develop soon after onset of IDDM.
Distal joint destruction (acrodystrophic neuropathy).
Chronic foot ulceration (4% to 10%) due to unnoticed tissue damage, vascular
insufficiency, secondary infection
Neuropathic arthropathy(Charcot joint ) in patients with foot ulcers &
autonomic impairment,
Small joints of feet.
Diabetic pseudotabes - lancinating pains, loss of JPS , diabetic pupillary
abnormalities (pseudo-Argyll Robertson pupils).
EDX studies
Absent or decreased amplitudes of sural SNAPs
Low amplitude or absent tibial H-reflexes .
Active denervation in intrinsic foot muscles or decreased amplitudes of
CMAPs
Slowing of motor conduction velocities, in 2/3 rd patients.
DIABETIC NEUROPATHY & CIDP
CIDP, MGUS, circulating GM1 antibodies and antibodies to
neuronal cells, and inflammatory vasculitis .
Vinik et al - half of patients with proximal neuropathies have a
vasculitis,
9% have CIDP, MGUS, ganglioside antibody syndrome
Sharma et al- CIDP 11 times more frequent among diabetics
If demyelinating, CIDP should be considered.
CIDP responds to intervention
Sharma K, Cross J, Farronay O, et al. Demyelinating neuropathy in diabetes mellitus. Arch Neurol
2002;59:758–65
EDX and nerve biopsy suggest diabetes contributes to an
axonal damage, with demyelination in CIDP.
Difficulties in distinguishing between diabetic
polyneuropathy and CIDP
1) Overlap of the clinical features
2) CSF protein often elevated in DM
3) EDX may show demyelination in DM
4) Nerve biopsies show varying axonal and demyelinating
changes in both conditions.
DIABETIC AUTONOMIC
NEUROPATHY
May develop with long-standing NIDDM during poor metabolic control and
weight loss, but can occur in mild and well-controlled diabetics or be
presenting feature.
Unilateral severe pain in the lower back, hip, and anterior thigh heralds onset
Vinik et al , Diabetic Neuropathy in Older Adults. Clin Geriatr Med 24 (2008) 407–
435
IS IT ‘‘DIABETIC NEUROPATHY’’ OR
‘‘NEUROPATHY IN A DIABETIC
PATIENT’’?
Think if-
Rapidly progressive
Prominent motor abnormality or cranial nerve involvement
Disproportionate large fiber abnormalities.
Involvement of the entire lower limbs without neuropathy of the
distal upper limb.
More often sensory symptoms and findings in the hands
SIGNS
Scores to assess clinical signs pioneered by Dyck , who first
described the NDS and later the Neuropathy Impairment Score
(NIS).
A modified NDS used in several studies , can be used in
community
Shown to be best predictor of foot ulceration and best neuropathic
end point in a large prospective community study
The maximum NDS is 10, with a score of 6 or more being
predictive of foot ulcer risk.
THE MODIFIED NEUROPATHIC
DISABILITY SCORE.
DEVICES FOR CLINICAL
SCREENING.
Semmes-Weinstein monofilament
Assesses pressure perception when gentle pressure is applied to the handle
sufficient to buckle the nylon filament.
One that exerts 10 g pressure, is most commonly used
Tricyclic drugs
Several RCTs supported these agents in neuropathic pains.
Mechanisms
Inhibition of NE &/or 5-HT reuptake at synapses of central descending pain
control systems
Antagonism of NMDA rec mediating hyperalgesia & allodynia .
Rapid onset, suggests a mode of action not primarily relief of depression.
use is restricted because of the frequency and severity of side effects.
Most experience with amitriptyline and imipramine.
Can be taken once a day in the evening.
Desipramine also useful drug ,better tolerated than amitriptyline
Side effects
Drowsiness and lethargy
Anticholinergic side effects, particularly dry mouth
In cases of painful neuropathy resistant to tricyclic drugs, combination with
major tranquilizers
Amitriptyline and transcutaneous electrotherapy described in failed
monotherapy.
Superior to that of tricyclic monotherapy plus sham electrotherapy
SSRIs
inhibit presynaptic reuptake of 5HT, not NE.
Paroxetine but not fluoxetine associated with significant pain relief.
Citalopram 40 mg/day was confirmed to be efficacious in relieving
neuropathic pain, but less effective than imipramine
Side effects are less common with SSRIs.
Anticonvulsants.
Used for many years
Limited evidence for phenytoin and carbamazepine in DN
Gabapentin now widely used
In a large controlled trial, significant pain relief with reduced sleep
disturbance was reported using dosages of 900–3,600 mg daily.
In a recent review of all the trials of gabapentin for neuropathic pain, it was
concluded that dosages of 1,800–3,600 mg per day of this agent were
effective
Lamotrigine - antiepileptic agent with at least two antinociceptive properties.
In a randomized placebo controlled study, Eisenberg et al confirmed
Capsaicin
Alkaloid, in red pepper, depletes substance P and reduces
chemically induced pain.
Several controlled studies combined in meta-analyses seem to
provide some evidence of efficacy in diabetic neuropathic pain
Only recommended for up to 8 weeks of treatment
Useful in localized discomfort.
Acupuncture.
Unmasked studies support its use .
In recent report, benefits lasted 6 months, reduced use of other analgesics
Conduct of potential blinded studies of acupuncture is problematic; although a
placebo response is possible with acupuncture
Other physical therapies.
Percutaneous nerve stimulation
Static magnetic field therapy .
Electrical spinal cord stimulation.
A case series of patients with severe painful neuropathy unresponsive to
conventional therapy suggested efficacy of using an implanted spinal cord
stimulator.
EVIDENCE-BASED GUIDELINE:
TREATMENT OF
PAINFUL DIABETIC
NEUROPATHY
Anticonvulsants
If clinically appropriate, pregabalin should be offered for the treatment of PDN
(Level A).
Gabapentin and sodium valproate should be considered for the treatment of PDN
(Level B).
There is insufficient evidence to support or refute the use of topiramate for the
treatment of PDN (Level U).
Valproate may is potentially teratogenic, be avoided in women of childbearing age. Due to weight gain and
potential worsening of glycemic control, this drug is unlikely to be the first treatment choice for PDN.
Antidepressants.
The Lidoderm patch may be considered for the treatment of PDN (Level C).
Although capsaicin has been effective in reducing pain in PDN clinical trials,
many patients are intolerant of the side effects, mainly burning pain on contact
with warm/hot water or in hot weather.
NONPHARMACOLOGIC
MODALITIES ?
V. Bril, J. England, G.M. Franklin, et al. Evidence-based guideline: Treatment of painful diabeticneuropathy : Report of
the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine,
and the American Academy of Physical Medicine and Rehabilitation .Neurology 76 May 17, 2011
AUTONOMIC NEUROPATHY
Head of bed elevated 6 to 10 inches.
Prevents salt & water losses during night and combat supine hypertension.
Two cups of strong coffee or tea with meals
Frequent small meals
Daily fluid intake (>20 oz/day) and salt ingestion (10-20 g/day).
Elastic body stockings may be beneficial by reducing the venous capacitance in
bed but poorly tolerated.
Plasma volume expansion can by fludrocortisone (0.1-0.6 mg/day).
NSAlDs, which inhibit prostaglandin synthesis, ibuprofen, 400 mg QID
Phenylpropanolamine (25-50 mg TDS), once used to manage OH
Midodrine, an α1-adrenergic agonist,causes vasoconstriction, also effective.
Subcutaneous recombinant human erythropoietin effective in some patients
with OH & anemia.
Octreotide may improve OH by splanchnic vasoconstriction.
Delayed gastric emptying relieved with metoclopramide
Diabetic diarrhea treated with short courses of tetracycline or erythromycin
Clonidine reported to reduce troublesome diarrhea.
PATHOGENETIC TREATMENTS AND
PREVENTION
Aldose Reductase Inhibitors.
The first clinical trials of ARIs in DN took place 25 years ago, and
currently only one agent is available in one country (Epalrestat in
Japan) .
Most of the early trials can be summarized as: