Diabetic Neuropathy

Download Report

Transcript Diabetic Neuropathy

Diabetic Neuropathy
Diabetic Neuropathy
 About 60-70% of people with
diabetes have mild to severe
forms of nervous system damage,
 Impaired sensation or pain in the feet
or hands
 Slowed digestion of food in the
 Carpal tunnel syndrome
 Other nerve problems
 More than 60% of nontraumatic
lower-limb amputations in the
United States occur among people
with diabetes.
Risk Factors
Glucose control
Duration of diabetes
Damage to blood vessels
Mechanical injury to nerves
Autoimmune factors
Genetic susceptibility
Lifestyle factors
– Smoking
– Diet
Pathogenesis of Diabetic
• 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
Classification of Diabetic
Symmetric polyneuropathy
Autonomic neuropathy
Symmetric Polyneuropathy
• Most common form of diabetic
• Affects distal lower extremities and
hands (“stocking-glove” sensory
• Symptoms/Signs
– Pain
– Paresthesia/dysesthesia
– Loss of vibratory sensation
Complications of Polyneuropathy
Charcot arthropathy
Dislocation and stress fractures
Amputation - Risk factors include:
– Peripheral neuropathy with loss of protective
– Altered biomechanics (with neuropathy)
– Evidence of increased pressure (callus)
– Peripheral vascular disease
– History of ulcers or amputation
– Severe nail pathology
Treatment of Symmetric
• 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
Peripheral Autonomic
• Contributes to the following
– Neuropathic arthropathy (Charcot foot)
– Aching, pulsation, tightness, cramping, dry skin,
pruritus, edema, sweating abnormalities
– Weakening of the bones in the foot leading to
• 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
Bladder dysfunction
Voluntary urination;
Retrograde ejaculation
Erectile dysfunction
Sildenafil, tadalafil
Lubricants; estrogen
Gastrointestinal Autonomic
• Symptoms/Signs
– Gastroparesis resulting in anorexia, nausea,
vomiting, and early satiety
– Diabetic enteropathy resulting in diarrhea and
• 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
• Symptoms/Signs
– Exercise intolerance
– Postural hypotension
• Treatment
– Discontinue aggravating drugs
– Change posture (make postural
changes slowly, elevate bed)
– Increase plasma volume
• Lumbar polyradiculopathy (diabetic
– 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
Polyradiculopathy, cont.
• Polyradiculopathies are diagnosed
by electromyographic (EMG) studies
• Treatment
– Foot care
– Glucose control
– Pain control
• Peripheral mononeuropathy
– Single nerve damage due to compression
or ischemia
– Occurs in wrist (carpal tunnel syndrome),
elbow, or foot (unilateral foot drop)
– Symptoms/Signs
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
American Diabetes Association: Preventive Foot Care in Diabetes
(Position Statement). Diabetes Care 27 (Suppl.1): S63-S64, 2004
Feldman, EL: Classification of diabetic neuropathy. In UpToDate.
Wellesley, MA, UpToDate, 2003
National Diabetes Information Clearinghouse. Diabetic Neuropathies:
The Nerve Damage of Diabetes. Bethesda, MD: National Institute of
Diabetes and Digestive and Kidney Diseases, National Institutes of
Health (NIH), DHHS; 2002
National Diabetes Information Clearinghouse. Prevent Diabetes
Problems: Keep Your Feet and Skin Healthy. Bethesda, MD: National
Institute of Diabetes and Digestive and Kidney Diseases, National
Institutes of Health (NIH), DHHS; 2003
References, cont.
Feldman, EL: Pathogenesis and prevention of diabetic
polyneuropathy. In UpToDate. Wellesley, MA, UpToDate, 2003.
Feldman, EL, McCulloch, DK: Treatment of diabetic neuropathy. In
UpToDate. Wellesley, MA, UpToDate, 2003.
Stevens, MJ: Diabetic autonomic neuropathy. In UpToDate.
Wellesley, MA, UpToDate, 2003.
Feldman, EL: Clinical manifestations and diagnosis of diabetic
polyneuropathy. In UpToDate. Wellesley, MA, UpToDate, 2003.