TREATMENT OF DIABETIC POLYNEUROPATHY

1. Diabetic
Neuropathy

2. Diabetic Neuropathy
by
Prof Ashraf Abdou
Neuropsychiatry dept.
Alexandria Univ.

3. Definition of diabetic neuropathy
Epidemiology
Pathogenesis.
Clinical presentations.
Management.
Session Objectives:

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. Peripheral
NERVES
Cranial
Peripheral
Autonomic
Motor
Sensory

6. Peripheral NERVES

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. Pathogenesis
Metabolic Vascular

9. Risk factors
Duration of diabetes
Control of diabetes
 Hyperlipaedemia
 Overweight
 Smoking
 Alcohol
 Old age

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12. Clinical presentations
Diffuse neuropathy
Symmetric sensorimotor
polyneuropathy
Autonomic neuropathy
Focal neuropathy
 Cranial neuropathy
 Plexopathy
 Polyradiculopathy
 Mononeuropathy

14. 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.

15. 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)

16. 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

17. 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

18. Genitourinary Autonomic
Neuropathy
Sign/Symptom Treatment
Bladder dysfunction Voluntary urination;
catheterization
Retrograde ejaculation Antihistamine
Erectile dysfunction Sildenafil, tadalafil
Dyspareunia Lubricants; estrogen
creams

19. Gastrointestinal Autonomic
Neuropathy
Symptoms/Signs
Gastroparesis resulting in anorexia,
nausea, vomiting, and early satiety
Diabetic enteropathy resulting in
diarrhea and constipation

20. Cardiovascular Autonomic
Neuropathy
Symptoms/Signs
Exercise intolerance
Postural hypotension

21. TREATMENTTREATMENT

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23. Treatment
Based on pathogenesis
Symptomatic

24. 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

25. Symptomatic

26. Symptomatic
Analgesics
 Antidepressant
s
Antiepileptic
s
 Antiarrhythmic
s.

27. Symptomatic treatment
Antidepressants
Compound Dose NNT
TCAs;
oAmitriptyline
oimipramine
100 -150mg 2.1
Venlafaxine 150 – 275mg 5.5
Duloxetine 60 – 120mg 4

28. Symptomatic treatment
Antiepileptics
Compound Dose NNT
Carbamazepine 600mg 2.3
Gabapentin 2400 – 3600mg 3.9
Pregabalin 300 – 600 mg 4.2

29. Symptomatic treatment
Other agents
Compound Dose NNT
Capsaicin cream 6.7
Tramadol 200 – 400mg 3.5
Mexilitine 400 – 600mg 2.2

30. FDA approved:
•Pregabalin
•Duloxetine

31. 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

32. Diabetic neuropathy OR Neuropathy
in diabetic patient ?
o Rapidly progressive
o Prominent motor
o Cranial nerves
o Predominant large fiber

33. 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