NEUROLOGIC

COMPLICATIONS IN
DIABETES MELLITUS
Done by- FATEMA BURHAN RAVAT
DTMU 4TH YEAR
January 2020
Introduction

● 50% of type 2 DM patients affected

● Most common- peripheral and autonomic
● Cause- unknown;
○ may be due to ischemic infarction of
involved nerve (cranial nerve palsy &
diabetic amyotrophy)
○ Metabolic complications (symmetric
sensory & motor peripheral) ANA MORALES
● No effective treatment
Risk Factors

Modifiable Non-modifiable

● Poor glycemic control ● Obesity

● Alcohol ● Older age
● Hypertension ● Male sex
● Cigarette smoking ● Height
● Hyperlipidemia ● Family hx
● APOE genotype
● Long duration of diabetes
Types of neuropathies
Mechanism
Common Symptoms
Physical Examination
Diagnostic tests
SUDOSCAN
Distal Symmetric Polyneuropathy

● Most common type

● Glove-stocking pattern due to axonal neuropathic
process
● Longer nerves vulnerable- foot affected
● Motor and sensory affected, reflexes may be absent
● Sensory occurs first- bilateral, symmetric, dull
vibration and temperature

Dx- examined with a 5.07 Semmes-Weinstein filament

Symptoms & Signs

1. Pain- may be absent (sensory deficit), mild discomfort or incapacitating

2. Numbness, tingling, sharpness or burning- spreads proximally
3. Clawing of toes
4. Displacement of submetatarsal fat pad
5. Callus and ulceration in high pressure areas eg. Metatarsal heads
6. Charcot foot and charcot arthropathy-> rocker bottom deformity
7. Osteoclastic destruction-> deranged joints particularly midfoot
Management

● Improve glycemic control

● Mechanical unloading
● Antibiotics for infections
● Healing time - 8-10 weeks
● PDGF (becaplermin) - side effect-> cancer
● Therapeutic footwear after ulcer heals
● Education, inspection, seek care from podiatrist

ANA MORALES
Isolated Peripheral Neuropathy

● Mononeuropathy or mononeuropathy multiplex

● Sudden onset -> recovery of all function
● Due to vascular ischemia or traumatic damage
● Most common- Cranial and Femoral nerves
● Recovery within 6-12 weeks
Symptoms & signs

1. Cranial nerve involvement- III, IV, VI -> diplopia, pupil spared

2. Diabetic Amyotrophy -> severe pain in thigh
3. After onset of pain, weakness & wasting in quadriceps
Management

● Improved glycemic control

● Analgesia
● Improves by 6-18 months

Wojtek Bąbski
Diabetic Polyradiculopathy

● characterized by severe disabling pain in the

distribution of one or more nerve roots
● May be accompanied by motor weakness
● Intercostal or truncal radiculopathy -> pain over the
thorax or abdomen
● Lumbar plexus or femoral nerve -> severe pain in the
thigh or hip, muscle weakness in the hip flexors or
extensors (diabetic amyotrophy)
● self-limited and resolve over 6–12 months
Painful Diabetic Neuropathy

● Due to hypersensitivity to light touch

● Characterized by severe burning pain, typically at night
● DOC- Amitryptiline 25-75 mg at bedtime
○ Side effect- mild drowsiness
○ Discontinued if no improvement within 5 days
● Others- Nortriptyline, Desipramine (25-150 mg/d), Gabapentin (900-1800
mg/d), Pregabalin, Duloxetin
● Capsaicin- as a cream used 2-4 times daily
○ Gloves used to avoid hand contamination -> discomfort in eyes and sensitive areas
● 5% lidocaine patch over painful area
Diabetic Neuropathic Cachexia

● Symmetric peripheral neuropathy

● Profound weight loss (upto 60%) and depression
● Painful dysesthesias affecting proximal lower limbs, hands or lower trunk
● Treatment- Insulin & analgesics
● Resolves within 1 year
Autonomic Neuropathy

● Late complication of long

standing diabetes
● Affect cholinergic, adrenergic
or peptidergic nerves
(substance P, etc)
● Can affect any organ - heart,
blood pressure, GIT and GU
Cardiovascular system
● Tachycardia
● Orthostatic hypotension
○ Jobst fitted stockings, tilting the head of the bed, and arising slowly from the supine
position
○ Fludrocortisone acetate 0.1-0.2 mg BID or Midodrine
● Abnormal exercise-induced performance
● Silent MI
● Ventricular arrhythmias
● Decreased heart variability or fixed rhythm

Dx- measure BP and HR changes following Valsalva maneuver, standing,

handgrip, deep breathing
Gastrointestinal system

● Nausea, vomiting, postprandial fullness (gastric atony), reflux dysphagia

(esophagus), constipation and diarrhea, fecal incontinence
● Gastroparesis
○ Type 1 DM with variability in glucose levels after food
○ Dx- radiographic studies
○ Tx- Metoclopramide 10 mg Orally TID/QID, 30 mins before meals & at bedtime
■ Side effects- drowsiness, fatigue, restlessness, tardive dyskinesia, EPS
○ Erythromycin - bind to motilin receptors 250 mg TID
○ Botulinum toxin into pylorus- decrease sphincter resistance
○ Gastric electrical stimulation
Cont.

● Diarrhea- responds to broad spectrum antibiotics

● Refractory diabetic diarrhea due to impaired sphincter control & fecal
incontinence
○ Tx- loperamide 4-8 mg/d
○ Diphenoxylate with atropine, 2 tablets QID
○ If severe- tincture of paregoric or codeine - 60 mg tablets
○ Clonidine- side effect- orthostatic hypotension
● Constipation relieved by laxatives - senna
● Other treatment choice- metamucil (debulking agent)
Genitourinary System
● Bladder dysfunction & Urinary incontinence
○ Bethanechol 10-50 mg TID
○ Catheter decompression
● Erectile dysfunction - can be neuropathic or psychogenic
○ To distinguish- administer papaverine in corpus cavernosum - if blood supply is competent -
erection
○ Tx- Sildenafil, 50-mg tablet taken approximately 1 hour before sexual activity (max 100 mg)
○ Vardenafil & Tadalafil 10 mg
○ Side effects -transient mild headache, flushing, dyspepsia, altered color vision, priapism
○ CI- nitrates
○ Others- intracorporeal injection of papaverine alone, papaverine with phentolamine, and
alprostadil (prostaglandin E1)
○ External vacuum therapy
● Retrograde ejaculation
Other

● Anhidrosis in lower extremities -> drying of skin -> crackling and ulceration
○ Emolients, skin lubricants
● Reduction of counterregulatory hormone release - hypoglycemic
unawareness
○ Eat frequent meals
○ Self monitor blood glucose
● Pupillary dysfunction
Prevention
● Intensive glycemic control
● Improve modifiable cardiovascular risk factors
○ Obesity
○ Hyperlipidemia
○ Hypertension
● Improve lifestyle
 Thank You
for your attention
References

● Greenspan’s Basic and Clinical Endocrinology

● Harrison’s Principles of Medicine
● Cardiovascular Autonomic Dysfunction: diagnosis and prognosis
● Diabetic Peripheral Neuropathy: an overview