Diabetic Polyneuropathy

Kursk-2020.
 Diabetic Neuropathy
• Diabetic neuropathies are neuropathic disorders that are
associated with diabetes mellitus. These conditions are thought
to result from diabetic microvascular injury involving small blood
vessels that supply nerves (vasa nervorum) in addition to
macrovascular conditions that can culminate in diabetic
neuropathy. Relatively common conditions which may be
associated with diabetic neuropathy include third nerve
palsy; mononeuropathy; mononeuropathy multiplex;
diabetic amyotrophy; a painful polyneuropathy;autonomic
neuropathy; and thoracoabdominal neuropathy.
Symptoms
• Depends on part of body
being affected.
• Diffuse Peripheral
– Pain
– Numbness and tingling in
the limbs
– Sensitivity to touch
– More susceptible to feet
injury and infections
– Loss of Balance and
Control
– Loss of sensation
• Diffuse Autonomic
– Bladder infections
– Stomach disorders
– dizziness
Symptoms Continued
• Localized neuropathy
– Pain in front of thigh,
lower back, chest
stomach and behind
eyes
– Double vision
– Paralysis of one side of
the face
www.plymouthdiabetes.org.uk/
pathophysiology
 Risk Factors
• Glycaemic control-DCCT
•  with age: 5% 20-29 years, 44.2% 70-79 years
• > 50% T2DM >60 years of age
•  with duration of diabetes: 20.8% < 5years, 36.8%>10 years
•  Smoking
•  Microalbuminuria
• Height
• Nutritional factors

www.plymouthdiabetes.org.uk/
 Pathogenesis of Diabetic
Neuropathy

• Metabolic factors
– High blood glucose
– Advanced glycation end products
– Sorbitol
– Abnormal blood fat levels
• Ischemia
• Nerve fiber repair mechanisms
 Diagnostic Tests
• Assess symptoms - muscle weakness, muscle
cramps, prickling, numbness or pain, vomiting,
diarrhea, poor bladder control and sexual
dysfunction
• Comprehensive foot exam
– Skin sensation and skin integrity
– Quantitative Sensory Testing (QST)
– X-ray
• Nerve conduction studies
• Electromyographic examination (EMG)
• Ultrasound
 Diagnosis
Annual review
• Enquire annually for:
· Painful neuropathy
· Loss of sensation
· Erectile impotence
• Note duration of DM, treatment,
complications & weight
• Ask about other manifestations of
autonomic neuropathy if:
· Other complications are present
· Anaesthesia is contemplated
· Blood glucose control is erratic

www.plymouthdiabetes.org.uk/
 Diagnosis
Examine:
• For evidence of peripheral neuropathy
annually
– LT
• OR if new symptoms
– Vibration
– LT
– ?Thermal thresholds
– ?Pain
– For postural hypotension if symptoms
of autonomic neuropathy
 Examination-ANS
Ewing’s battery
Abnormal results common
• Valsalva-expiration for 15 secs against 40
mmHg. Rest 1 min then repeatx2.
– Avoid in proliferative retinopathy.
– RR max : RR min>1.21 =Normal, <1.20 = abnormal.
• HR increase on standing
– RR 30:15 ratio > 1.04
– HR at max overshoot or 15 seconds  15bpm
(abnormal if<12)

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 Ewing’s battery
• HR variation during deep
breathing (6 breaths per minute)
– Max-min > 15bpm (<10 is
abnormal)
• Postural BP-2 mins after standing
– Fall< 10mmHg normal
– >30 mmHg abnormal

www.plymouthdiabetes.org.uk/
 Diagnosis
Consider differential diagnoses
• HSMN
• Ethanol
• B12/folate
• Malignancy
• Renal failure
• Drugs
• AI disease
• Cord problems
• Leprosy

www.plymouthdiabetes.org.uk/
 Doctors who see Diabetic Neuropathy

• General Physician
• Neurologist
• Urologist
• Gastroenterologist
• Podiatrists
Classification of Diabetic Neuropathy

• Symmetric polyneuropathy
• Autonomic neuropathy
• Polyradiculopathy
• Mononeuropathy
 Symmetric Polyneuropathy
• Most common form of diabetic neuropathy
• Affects distal lower extremities and hands
(“stocking-glove” sensory loss)
• Symptoms/Signs
– Pain
– Paresthesia/dysesthesia
– Loss of vibratory sensation
Complications of Polyneuropathy
• 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
 Treatment of Symmetric
Polyneuropathy

• Glucose control
• Pain control
– Tricyclic antidepressants
– Topical creams
– Anticonvulsants
• Foot care
 Essentials of Foot Care
• Examination
– Annually for all patients
– Patients with neuropathy - visual inspection of feet at
every visit with a health care professional
• Advise patients to:
– Use lotion to prevent dryness and cracking
– File calluses with a pumice stone
– Cut toenails weekly or as needed
– Always wear socks and well-fitting shoes
– Notify their health care provider immediately if any foot
problems occur
 Autonomic neuropathy
• Affects the autonomic nerves controlling
internal organs
– Peripheral
– Genitourinary
– Gastrointestinal
– Cardiovascular
• Is classified as clinical or subclinical based on
the presence or absence of symptoms
www.plymouthdiabetes.org.uk/
Peripheral Autonomic Dysfunction
• Contributes to the following symptoms/signs:
– Neuropathic arthropathy (Charcot foot)
– Aching, pulsation, tightness, cramping, dry skin, pruritus,
edema, sweating abnormalities
– Weakening of the bones in the foot leading to fractures
• Testing
– Direct microelectrode recording of postglanglionic C fibers
– Galvanic skin responses
– Measurement of vascular responses
 Peripheral Autonomic Dysfunction,
cont.
• Treatment
– Foot care/elevate feet when sitting
– Eliminate aggravating drugs
– Reduce edema
• midodrine
• diuretics
– Support stockings
– Screen for CVD
 Genitourinary Autonomic
Neuropathy
Sign/Symptom Treatment
Bladder dysfunction Voluntary urination;
catheterization

Retrograde ejaculation Antihistamine

Erectile dysfunction Sildenafil, tadalafil

Dyspareunia Lubricants; estrogen

creams
 Gastrointestinal Autonomic
Neuropathy
• Symptoms/Signs
– Gastroparesis resulting in anorexia, nausea, vomiting,
and early satiety
– Diabetic enteropathy resulting in diarrhea and
constipation
• Treatment
– Other causes of gastroparesis or enteropathy should
first be ruled out
– Gastroparesis - Small, frequent meals,
metoclopramide, erythromycin
– Enteropathy - loperamide, antibiotics, stool softeners
or dietary fiber
 Cardiovascular Autonomic
Neuropathy
• Symptoms/Signs
– Exercise intolerance
– Postural hypotension
• Treatment
– Discontinue aggravating drugs
– Change posture (make postural changes slowly,
elevate bed)
– Increase plasma volume
 Polyradiculopathy
• Lumbar polyradiculopathy (diabetic
amyotrophy)
– Thigh pain followed by muscle weakness and
atrophy
• Thoracic polyradiculopathy
– Severe pain on one or both sides of the abdomen,
possibly in a band-like pattern
• Diabetic neuropathic cachexia
– Polyradiculopathy + peripheral neuropathy
– Associated with weight loss and depression
 Polyradiculopathy, cont.
• Polyradiculopathies are diagnosed by
electromyographic (EMG) studies
• Treatment
– Foot care
– Glucose control
– Pain control
Affected nerves
 Mononeuropathy
• Peripheral mononeuropathy
– Single nerve damage due to compression or
ischemia
– Occurs in wrist (carpal tunnel syndrome), elbow, or
foot (unilateral foot drop)
– Symptoms/Signs
• numbness
• edema
• pain
• prickling
 Mononeuropathy, cont.
• Cranial mononeuropathy
– Affects the 12 pairs of nerves that are connected
with the brain and control sight, eye movement,
hearing, and taste
– Symptoms/Signs
• unilateral pain near the affected eye
• paralysis of the eye muscle
• double vision
• Mononeuropathy multiplex
 Mononeuropathy, cont.

• Treatment
– Foot care
– Glucose control
– Pain control
 Other Treatment Options

• Aldose reductase inhibitors

• ACE inhibitors
• Weight control
• Exercise
How to Maintain a Healthy Lifestyle

• Manage Diabetes

• Don’t Drink Alcohol

• Avoid Cigarettes

• Check your feet

regularly
 references
• http://emedicine.medscape.com/article/11
70337-overview
• http://diabetes.niddk.nih.gov/dm/pubs/neu
ropathies/
• http://en.wikipedia.org/wiki/Diabetic_neur
opathy
• http://www.mayoclinic.org/diseases-
conditions/diabetic-
neuropathy/basics/definition/con-20033336
• http://www.webmd.com/diabetes/diabetes
-neuropathy