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Clinical Care
Part II
NEUROPATHY
Commonest complication associated with diabetes.
| Clinical Classification of DIABETIC
NEUROPATHY |
Somatic Neuropathy
| GRADUAL ONSET |
| Type |
Type |
| Distal symmetrical polyneuropathy |
Chronic symmetrical symptoms affecting peripheral nerves with the
longest nerves usually affected first; Sensory and motor functions
affected in varying degrees, but may be predominantly sensory. Often
associated with autonomic dysfunction;
Signs and symptoms varies commonly presents with tingling or numbness
( with or without pain) pain usually bilateral beginning in the feet,
spreading proximally in stocking like fashion; Later the upper extremities
develop similar manifestations and progress upwards in a glove like
manner; Loss of balance, especially with the eyes closed, and painless
injuries due to loss of sensation are common. |
| ACUTE ONSET |
| Type |
Signs and Symptoms |
| Painful symmetric polyneuropathy |
As above but with an acute onset and associated with significant
burning, stabbing, crushing, aching, or cramplike symptoms, with increased
severity at night; |
| Mononeuropathy multiplex |
An individual nerve can be affected, such as the peroneal nerve,
resulting in footdrop, median neuropathy of the wrist, ulnar neuropathy
of the elbow
Symptoms usually comprise pain, tingling, numbnessand wasting and
weakness;
This might be in the form of solitary nerve involvement or in combination-mononeuropathy
or mononeuropathy multiplex. |
| Cranial mononeuropathy |
CN III, IV, and VI disease manifests as acute headache or eye pain
followed by diplopia developing over a few hours; Muscle weakness
is typically in the distribution of a single nerve, and pupillary
light reflexes are usually spared.
Facial neuropathy (CN VII) manifests as acute or subacute facial weakness
(taste is not normally involved) and can be recurrent or bilateral.
|
| Diabetic radiculoplexopathy Also known as Proximal motor neuropathy
(amyotrophy) |
Starts as sudden, severe, unilateral pain usually in the lower back,
hips, and thighs and may occur in the shoulder/neck;
Weakness and atrophy usually develop over a brief time. Reflexes in
the affected limb may be depressed. Numbness and paresthesias may
occur;
Accompanied with depression and significant ooss of appetite with
significant weight loss in more than 50% of the patients;
Usually seen on older people; |
| Diabetic radiculopathy and Diabetic polyradiculopathy |
Burning, stabbing, boring, belt-like, or deep aching pain in the
territory of a nerve root; usually begins unilaterally, may become
bilateral. Numbness is most prominent in distal distribution of nerve
roots. Skin hypersensitivity may occur;
Weakness presents in the distribution of the affected nerve root;
Coexisting diabetic distal symmetrical polyneuropathy often is present;
Single or more commonly multiple spinal roots are involved |
| Diabetic neuropathic cachexia |
Presents with severe weight loss usually in older subjects often
not diagnosed as having diabetes;
Followed by severe pain and signs and symptoms of autonomic neuropathy;
Muscle weakness is rare; |
Autonomic Neuropathy (AN)
| Clinical Manifestations
of Autonomic Neuropathy (AN) |
Screening
A) Careful History : Questions related to the sensory (tingling,
numbness, anaesthesia, parasthesias, inco-ordination), motor (wasting,
weakness, nocturnal muscle cramps) and autonomic (gastrointestinal and
bladder symptoms, sexual dysfunction, postural light-headedness) nervous
systems, etc.
B) Tests for Peripheral Sensation : Check for touch, pain (pinprick)
and vibration thresholds (calibrated tuning fork).
Although tests like nerve conduction studies and EMG can be done, in clinical
terms, the most simple test known as the Monofilament test. This allows
a very simple but clinically important study of the sensation in the feet
which, if often and correctly done can help in avoiding the most dreaded
of complications such as foot injuries and infections.
For a note on the use of the Monofilament Test see appendix 9a
C) Motor Involvement : Check for muscle weakness and wasting.
D) Reflexes
E) Detecting Autonomic Neuropathy
| Simple clinical tests for Detecting autonomic neuropathy |
| Tests for autonomic neuropathy |
Normal response |
Abnormal response |
| Resting heart rate |
|
>100/minute |
| Heart rate response to standing |
Measure R-R interval at beats 15 and 30 after the patient stands |
|
A 30:15 ratio of less than 1.03 is abnormal |
| Systolic blood pressure changes on standing |
Measure systolic blood pressure lying down then standing. |
Decrease < 10 mm Hg |
Decrease > 30 mm Hg |
| Heart rate response to deep breathing |
Measure heart rate response to deep breathing |
Increase rate > 15 beats /min |
Increase < 10 beats /min |
Differential Diagnosis
Diabetic neuropathy has a plethora of presentations that must be differentiated
from other disorders that may have similar features such as alcoholic
neuropathy, B12 deficinecy etc.
As many as 10-20 % of people with diabetes may have an alternative cause
for the neuropathy. If motor deficit or proprioceptive involvement predominates,
it is important to consider nondiabetic causes of neuropathy
For a partial list of common conditions in the differential diagnosis
of diabetic peripheral neuropathy, see Appendix 9b
Somatic Neuropathy
Glycemic Control
Tight and stable glycemic control is probably the only treatment approach
that may provide symptomatic relief and slow the progression of the diabetic
neuropathy. Fluctuations of in the blood glucose levels can aggravate
and induce neuropathic pain rather than the level of hyperglycemia. Some
suggest that the stability rather than the actual level of glycemic control
may be more important in relieving neuropathic pain.
Specific Therapy
Control of the Hyperglycemia
Whilst this may not always ensure that diabetic neuropathy will not occur
or progress, there is adequate evidence to show that optimal management
of the blood glucose levels is of significant importance. More over there
is some evidence that as much as the plasma glucose levels, wide fluctuations
in these levels is also very detrimental to the nerves.
Aldose reductase inhibitors, a-Lipoic acid, ?-Linolenic acid have been
used with varying results, especially the last two. Aldose reductase inhibitors
did not live up to their supposed potential to treat diabetic neuropathy.
Injections of B1, B6, and B12 are routinely used by many doctors when
faced with a patient with diabetic neuropathy. Unless there is manifest
evidence of the deficiency of these vitamins in the patient, the injections
would be of use only as a placebo.
Painful Neuropathy
One of the most difficult conditions to manage in patients with diabetic
peripheral neuropathy is the painful neuropathies. At the same time, many
newer drugs are now available which do tend to improve our ability to
give relief in such cases, provided that they are used with care.
Commonly used drugs to treat painful neuropathy
| Commonly used drugs to treat painful neuropathy |
| Category |
Drugs |
Side Effects |
| |
| Tricyclic Antidepressants |
Nortriptyline, start at10-25 mg at bedtime andtitrate every 3-4
days to maximum of 75-150 mg/day |
Side effects common to all tricyclic antidepressants
include include dry mouth, drowsiness, diziness, constipation, urinary
retneion, blurred vision, confusion, disorientation, increased appetite,
tachycardia |
| |
Amitryptiline, start at10-25 mg at bedtime andtitrate every 3-4
days to to maximum of 75-150 mg/day |
| Anticonvulsants |
Carbamazepine,400 mg po tid |
Requires titration; side effectsinclude ataxia, dizziness, somnolence,
dyspepsia, nausea, vomiting, blurred vision, confusion, weakness,
fatigue, nystagmus, aplastic anemia |
| |
Gabapentin, Usual starting dose is 300mg at bedtime and can be titrated
upwards every week to a maximum of 1800-3000mg/day in three divided
doses depending on the tolerability and efficacy. Elderly patients
should start at much lower doses. |
Requires titration; side effectsinclude ataxia, diplopia, blurred
vision, tremors, dyspepsia, nausea, vomiting, constipation, fatigue,
leukopenia |
| |
Pregabalin, Dosing can begin at 150mg/day in divided doses and may
be increased to 300/day within a week depending on the tolerability
and efficacy. Dose should be reduced in patients with renal dysfunction; |
Requires titration; side effects similar to gabapentin but relatively
better tolerated; |
| |
Lamotrigine, start at 50mg/day increase by 100mg biweekly till 200-600mg.day
is reached depending on the tolerability and efficacy |
Requires titration; side effectsinclude ataxia, dizziness, somnolence,
diplopia, blurred vision, nystagmus, headache, dyspepsia, nausea,
vomiting, constipation, fatigue, rash, impaired memory |
| Nonopioid analgesics |
Tramadol, start at 50mg daily and titrate upwards by 50mg weekly
till a dose of 200-400mg is reached depending on the tolerability
and efficacy |
Nausea, constipation, somnolence, headache, dry mouth, seizures,
confusion, tremors, anorexia, urinary retention |
| Opioids |
Oxycodone, start with 20mg every 12 hours and increase gradually
by 10mg/ week till 40-160/ day in divided doses is reached depending
on the tolerability and efficacy |
Dizziness, somnolence, diplopia, headache, dyspepsia, nausea, vomiting,
constipation, dry mouth, sweating, low blood pressure |
| Local therapy |
5% lidocaine patch applied to painful areas; apply for 12 hours,
off for 12 hours, upto 3-4 patches maximum at a time |
Localised erythema, burning, swelling |
| |
Isosorbide dinitrate spray. |
|
Pharmacologic treatment of autonomic neuropathy
| |
Drug |
Dosage |
Common Side effects |
| Orthostatic hypotension |
9 alpha flouro hydrocortisone, mineralocorticoid |
0.5-2 mg/day |
Congestive heart failure, hypertension |
| |
Clonidine, alpha2 adrenergic agonist |
0,1-0,5 mg, at bedtime |
Hypotension, sedation, dry mouth |
| Gastroparesis diabeticorum |
Metoclopramide, D2 -receptor antagonist |
5-20 mg 30-60 minutes before meals and at bedtime |
Galactorrhea, extrapyramidal symptoms drowsiness, restlessness,
diarrhea, weakness |
| |
Domperidon, D2-receptor antagonist |
25 mg, 3 times/day |
Galactorrhea |
| |
Erythromycin, motilin receptor agonist |
250 mg, 30 minutes before meals |
Abdominal cramp, nausea, diarrhoea, rash |
| |
Levosulpide, D2-receptor antagonist |
25 mg, 3 times/day |
Galactorrhea |
| Diabetic diarrhea |
Metronidazole, broad spectrum antibiotics |
250 mg, 3 times/day, minimum 3 weeks |
Orthostatic hypotension |
| |
Clonidine, alpha 2 adrenergic agonist |
0.1 mg, 2-3 times/day |
Hypotension, sedation, dry mouth |
| |
Cholestyramine, bile acid sequestrant |
4 g, 1-6 times/day |
|
| |
Loperamide, opiate-receptor agonist |
2 mg, four times/day |
Toxic megacolon |
| Cystopathy |
Bethanechol, acetylcholine receptor agonist |
10 mg, 4 times/day |
|
| |
Doxazosin, alpha1 adrenergic antagonist |
1-2 mg, 2-3 times/day |
Hypotension, headache, palpitation |
| Erectile dysfunction |
Sildenafil 25-100mgTadlafil 5-20mgVardenafil 2.5-20mg
GMP type-5 phosphodiesterase inhibitor |
Lowest possible dose
Patients over the age of 65 years, or those with significant liver
disease or renal dysfunction and those who are taking CYP3A4 inhibitors
(eg, indinavir, erythromycin, ketoconazole) should begin treatment
at lower doses. |
Nitrates in any form are contraindicated. Caution should also be
used with other antihypertensive agents in order to avoid hypotension.
Patients taking alpha blockers should avoid vardenafil and tadalafil.
Lower dosages of sildenafil (25 mg) are preferable if these two types
of drugs have to be combined. Headache, flushing, nasal congestion,
dyspepsia, muscoloskeletal pain, blurred vision; |
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