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Diabetic painful neuropathy
Dr. Ashok Kumar Das
Diabetic painful neuropathy
This is a definite subset of diabetic
neuropathy and requires more attention
owing to its pain...
Diabetic painful neuropathy
Comprises of clinical syndromes like acute
painful neuropathy, chronic sensorimotor
neuropathy...
Diabetic painful neuropathy
* Pain is a feature of small fiber neuropathy.
The small fibers also carry autonomic
impulses....
Diabetic painful neuropathy
Relief of pain is of paramount importance and
obligatory on the part of physician.
But the sta...
Diabetic painful neuropathy
* These modalities range from simple
analgesic to most modern aldolase
reductase inhibitors
* ...
Clinical types of painful diabetic
neuropathy - 1
Although a rigid classification of painful
diabetic neuropathy is very d...
Clinical types of painful diabetic
neuropathy - 2
Symmetrical distal painful polineuropathies
may be grouped as
1. Small f...
Clinical types of painful diabetic
neuropathy - 3
Proximal motor neuropathies can be divided
into two groups
1. Symmetrica...
Focal asymmetric neuropathies-1
1. Predominantly sensory:
a) Intercostal Neuropathy
b) Truncal neuropathy
c) Thoraco-abdom...
Focal asymmetric neuropathies-2
Predominantly motor:
Mononeuritis or mononeuritis
Multiplex which may include -
a) Ocular ...
Diabetic mono-neuropathies
a) Isolated and multiple mononeuropathies
b) Cranial moneuropathies
c) Proximal motor neuropath...
Distal polyneuropathies
a) Acute sensory neuropathy
b) Chronic sensory motor neuropathies
c) Proximal motor neuropathies
d...
Symmetrical distal
polyneuropathies - 1
Small fibre type:
* In small fibre type neuropathy
* Pain and paraesthesis, most c...
Symmetrical distal
polyneuropathies - 1
Paraesthesia may manifest as a sensation of
coldness, numbness, tingling or burnin...
Symmetrical distal
polyneuropathies - 3
* In addition - diminished pain and
temperature perception in the lower
extremity ...
Diabetic neuropathic cachexia:
* Outstanding symptoms - weight loss and
severe pain
* Emotional disturbance
* Anorexia
* I...
Painful-painless leg
* Patient experience pain or paraesthesia
* On neurological examination - pain
sensation absent
* Suc...
Hypoglycemic neuropathy /
insulin neuritis
* Hypoglycaemia is rare - but treatable
* Usually presents symmetrical motor,
s...
Mixed distal sensory motor
neuropathies
* Usually occur in middle aged and elderly
with type 2 diabetes
There are two enti...
Focal asymmetrical diabetic
neuropathy
* Intercostal neuropathy
* Middle aged or older patients
* Present with longstandin...
Truncal neuropathy - 1
* Pain in the trunk
* Abdominal bulge causing muscle weakness
* Clinical features suggestive of mal...
Truncal neuropathy - 2
* Most diabetic with this syndrome are in 5th
or 6th decade of life
* Associated with weight loss, ...
Truncal neuropathy - 3
* Spinal cord compression should be
excluded by appropriate investigations
* Caused by ischaemic in...
Truncal neuropathy - 4
* Involvement of lateral cutaneous nerve may
present with sensory disturbance in thigh
* Usually as...
Cranial neuropathy
* With the exception of pupillary
sparing,disruption of oculomotor nerve
function – most frequent
* Rec...
Drugs used in painful diabetic
neuropathy - 1
* Non steroidal anti inflammatory agents
* Ibuprofen 600mg four times daily
...
Drugs used in painful diabetic
neuropathy - 2
* Carbamazepine upto 200 mg q 6h
* Amitryphyline-fluphenazine combination
* ...
Drugs used in painful diabetic
neuropathy - 3
Tricyclic antidepressant drugs:
Amitriptyline 50-150 mg at night
* Nortripty...
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1362576547 painful neuropathy syndrome, new treatments akdskk

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painful neuropathy syndrome, new treatments akdskk

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1362576547 painful neuropathy syndrome, new treatments akdskk

  1. 1. Diabetic painful neuropathy Dr. Ashok Kumar Das
  2. 2. Diabetic painful neuropathy This is a definite subset of diabetic neuropathy and requires more attention owing to its painful condition, disability and wide spectrum of clinical syndrome
  3. 3. Diabetic painful neuropathy Comprises of clinical syndromes like acute painful neuropathy, chronic sensorimotor neuropathy, proximal painful symmetrical motor neuropathy, proximal painful asymmetrical motor neuropathy (diabetic amyotrophy) painful diabetic external ophthalmoplegia, treatment induced insulin neuritis, hypoglycaemic neuritis and painful painless leg .
  4. 4. Diabetic painful neuropathy * Pain is a feature of small fiber neuropathy. The small fibers also carry autonomic impulses. * It seems logical to expect increased incidence of autonomic denervation in painful diabetic neuropathies
  5. 5. Diabetic painful neuropathy Relief of pain is of paramount importance and obligatory on the part of physician. But the state of the art of pain relief in this syndrome is far from satisfactory. Many modalities of treatment have been advocated but the arena of therapy is full of claims and counter claims.
  6. 6. Diabetic painful neuropathy * These modalities range from simple analgesic to most modern aldolase reductase inhibitors * In the national context, pain relief must be obtained by simple measures
  7. 7. Clinical types of painful diabetic neuropathy - 1 Although a rigid classification of painful diabetic neuropathy is very difficult they may be grouped under following three major categories 1. Symmetrical distal painful poly- neuropathies 2. Proximal motor neuropathies 3. Focal asymmetrical painful neuropathies
  8. 8. Clinical types of painful diabetic neuropathy - 2 Symmetrical distal painful polineuropathies may be grouped as 1. Small fibre type 2. Mixed large and small fibre type 3. Hypoglycaemic neuropathy/insulin neuritis 4. Mixed distal sensory-motor neuropathy
  9. 9. Clinical types of painful diabetic neuropathy - 3 Proximal motor neuropathies can be divided into two groups 1. Symmetrical proximal motor neuropathy 2. Asymmetrical proximal motor neuropathy - diabetic amyotrophy
  10. 10. Focal asymmetric neuropathies-1 1. Predominantly sensory: a) Intercostal Neuropathy b) Truncal neuropathy c) Thoraco-abdominal radiculopathy d) Neuropathy due to involvement of lateral cutaneous nerve of thigh
  11. 11. Focal asymmetric neuropathies-2 Predominantly motor: Mononeuritis or mononeuritis Multiplex which may include - a) Ocular neuropathy b) Femoral neuropathy c) Sciatic neuropathy d) Median neuropathy
  12. 12. Diabetic mono-neuropathies a) Isolated and multiple mononeuropathies b) Cranial moneuropathies c) Proximal motor neuropathies d) Truncal polyneuropathy
  13. 13. Distal polyneuropathies a) Acute sensory neuropathy b) Chronic sensory motor neuropathies c) Proximal motor neuropathies d) Truncal polyneuropathy
  14. 14. Symmetrical distal polyneuropathies - 1 Small fibre type: * In small fibre type neuropathy * Pain and paraesthesis, most commonly of the lower extremities are the characteristic symptoms * Pain - dull, burning, aching, lancinating, crushing and cramp-like
  15. 15. Symmetrical distal polyneuropathies - 1 Paraesthesia may manifest as a sensation of coldness, numbness, tingling or burning On exam - dysesthesia and calf tenderness
  16. 16. Symmetrical distal polyneuropathies - 3 * In addition - diminished pain and temperature perception in the lower extremity with less involvement of reflex and position and vibratory sensation * Autonomic dysfunction most prevalent
  17. 17. Diabetic neuropathic cachexia: * Outstanding symptoms - weight loss and severe pain * Emotional disturbance * Anorexia * Impotence * Mild diabetes * Simultaneous onset of diabetes and neuropathy
  18. 18. Painful-painless leg * Patient experience pain or paraesthesia * On neurological examination - pain sensation absent * Such patients are at greatest risk of painless injury to the feet
  19. 19. Hypoglycemic neuropathy / insulin neuritis * Hypoglycaemia is rare - but treatable * Usually presents symmetrical motor, sensory or mixed neuropathies of uncertain aetiology * Distal symmetrical symptoms * More common in nondiabetic patients subjected to insulin shock therapy
  20. 20. Mixed distal sensory motor neuropathies * Usually occur in middle aged and elderly with type 2 diabetes There are two entities 1. Subacute proximal neuropathy of insidious onset 2. Ischaemic mononeuropathy multiplex of acute onset
  21. 21. Focal asymmetrical diabetic neuropathy * Intercostal neuropathy * Middle aged or older patients * Present with longstanding diabetes with abrupt onset of unilateral pain * Associated with peripheral sensory neuropathy,weight loss and worsening of pain at night * Condition recovers in 3 months
  22. 22. Truncal neuropathy - 1 * Pain in the trunk * Abdominal bulge causing muscle weakness * Clinical features suggestive of malignant disease * Electromyography reveals correct diagnosis * Spontaneous and complete recovery
  23. 23. Truncal neuropathy - 2 * Most diabetic with this syndrome are in 5th or 6th decade of life * Associated with weight loss, beginning with the onset of pain * Denervation of paraspinal muscles present * Lesion is proximal, either in the nerve roots or the spinal nerves
  24. 24. Truncal neuropathy - 3 * Spinal cord compression should be excluded by appropriate investigations * Caused by ischaemic infarction of nerve * No pathological evaluation of involved intercostal nerve has been reported
  25. 25. Truncal neuropathy - 4 * Involvement of lateral cutaneous nerve may present with sensory disturbance in thigh * Usually asymmetrical without motor deficit * Recover spontaneously
  26. 26. Cranial neuropathy * With the exception of pupillary sparing,disruption of oculomotor nerve function – most frequent * Recovery usually occurs within 6-12 weeks * Lower cranial nerves can get involved. * Internuclear opthalmoplegia
  27. 27. Drugs used in painful diabetic neuropathy - 1 * Non steroidal anti inflammatory agents * Ibuprofen 600mg four times daily * Sulindac 200 mg twice daily
  28. 28. Drugs used in painful diabetic neuropathy - 2 * Carbamazepine upto 200 mg q 6h * Amitryphyline-fluphenazine combination * Gabapentin 900 mg q 8h * Whereas lignocaine and phenytoin failed to do so * Mexiteline 150 mg – 450 mg / day
  29. 29. Drugs used in painful diabetic neuropathy - 3 Tricyclic antidepressant drugs: Amitriptyline 50-150 mg at night * Nortriptyline 50-150 mg at night * Imipramine 100 mg daily * Paroxetine 40 mg daily Other drugs: Capsaicin 0.075% q 6h Fluphenazine 1 mg/day

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