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  1. 1. Diabetic Neuropathy
  2. 2. Diabetic Neuropathy by Prof Ashraf Abdou Neuropsychiatry dept. Alexandria Univ.
  3. 3. Definition of diabetic neuropathy Epidemiology Pathogenesis. Clinical presentations. Management. Session Objectives:
  4. 4. Definition “The presence of signs and/or symptoms of peripheral nerve dysfunction in diabetic patient after exclusion of other causes.” 6Boulton AJ, Gries FA, Jervell JA: Guidelines for the diagnosis and outpatient management of diabetic peripheral neuropathy. Diabet Med 15:508–514, 1998
  5. 5. Peripheral NERVES Cranial Peripheral Autonomic Motor Sensory
  6. 6. Peripheral NERVES
  7. 7. Epidemiology 50% of patients who have diabetes for >25 yrs (Pirart. Diabetes Care 1978) Late in type 1, may be 1st presentation of type 2 DM 50% are painful neuropathy
  8. 8. Pathogenesis Metabolic Vascular
  9. 9. Risk factors Duration of diabetes Control of diabetes  Hyperlipaedemia  Overweight  Smoking  Alcohol  Old age
  10. 10. ‫ررر‬ ‫ررر‬ ‫رررر‬‫ررر‬ ‫ررر‬ ‫رررر‬19301930
  11. 11. Clinical presentations Diffuse neuropathy Symmetric sensorimotor polyneuropathy Autonomic neuropathy Focal neuropathy  Cranial neuropathy  Plexopathy  Polyradiculopathy  Mononeuropathy
  12. 12. Peripheral sensori-motor neuropathy  Distal, bilateral,symmetrical, stocking-glove distribution.  Symptoms range from numbness (“deadness”) to severe pain. Burning, alteration of temperature sensation, parathesias, shooting, or stabbing pains are common.  May worsen at night.  Minor motor involvement causing weakness.
  13. 13. Peripheral sensori-motor neuropathy (cont.) Decrease or absent reflexes Loss or diminished vibratory sensation (128Hz tuning fork), pin prick, light touch, or pressure perception Muscle atrophy Foot complications, ulcerations, blisters, deformities (Charcot’s joint)
  14. 14. 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
  15. 15. 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
  16. 16. Genitourinary Autonomic Neuropathy Sign/Symptom Treatment Bladder dysfunction Voluntary urination; catheterization Retrograde ejaculation Antihistamine Erectile dysfunction Sildenafil, tadalafil Dyspareunia Lubricants; estrogen creams
  17. 17. Gastrointestinal Autonomic Neuropathy Symptoms/Signs Gastroparesis resulting in anorexia, nausea, vomiting, and early satiety Diabetic enteropathy resulting in diarrhea and constipation
  18. 18. Cardiovascular Autonomic Neuropathy Symptoms/Signs Exercise intolerance Postural hypotension
  20. 20. ‫للللل‬ ‫لللل‬1930
  21. 21. Treatment Based on pathogenesis Symptomatic
  22. 22. Based on Pathogenesis Compound Status of RCTs alpha- lipoic acid Effective in RCTs Vasodilators Effective in 1 trial ACE inhibitor Effective in 1 trial Protein kinase inhib Ongoing NGF Ineffective
  23. 23. Symptomatic
  24. 24. Symptomatic Analgesics  Antidepressant s Antiepileptic s  Antiarrhythmic s.
  25. 25. Symptomatic treatment Antidepressants Compound Dose NNT TCAs; oAmitriptyline oimipramine 100 -150mg 2.1 Venlafaxine 150 – 275mg 5.5 Duloxetine 60 – 120mg 4
  26. 26. Symptomatic treatment Antiepileptics Compound Dose NNT Carbamazepine 600mg 2.3 Gabapentin 2400 – 3600mg 3.9 Pregabalin 300 – 600 mg 4.2
  27. 27. Symptomatic treatment Other agents Compound Dose NNT Capsaicin cream 6.7 Tramadol 200 – 400mg 3.5 Mexilitine 400 – 600mg 2.2
  28. 28. FDA approved: •Pregabalin •Duloxetine
  29. 29. Diabetic neuropathy OR Neuropathy in diabetic patient ? Chronic inflammatory demyelinating polyneuropathy B12 deficiency Uremia Hypothyroidism Monoclonal gamopathies 1/3 of diabetics have neuropathy unrelated to diabetes
  30. 30. Diabetic neuropathy OR Neuropathy in diabetic patient ? o Rapidly progressive o Prominent motor o Cranial nerves o Predominant large fiber
  31. 31. Summary Diabetic neuropathy is common [up to 40-50% over a 10-25 year span] Tight control can prevent neuropathy Once a patient develops neuropathy, there are few treatments proven to be effective Foot care is essential in preventing neuropathic complications Neuropathy in diabetic patient may be caused by other etiologies