Diabetic Neuropathy

Diabetic Neuropathy
About 60-70% of people with diabetes have mild to severe forms of nervous system damage, including:
Impaired sensation or pain in the feet or hands Slowed digestion of food in the stomach 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 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

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

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
Bladder dysfunction

Treatment
Voluntary urination; catheterization Antihistamine Sildenafil, tadalafil Lubricants; estrogen creams

Retrograde ejaculation Erectile dysfunction Dyspareunia

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

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

References
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.