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Diabetic Neuropathies

Diabetic Neuropathies. Joseph V. Campellone, MD Division of Neurology Cooper University Hospital. Diabetic Neuropathies. Family of nerve disorders caused by DM. Diabetes Prevalence. Nerve Fibers. Large diam myelinated Skeletal muscle efferents Tendon reflex efferents

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Diabetic Neuropathies

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  1. Diabetic Neuropathies Joseph V. Campellone, MD Division of Neurology Cooper University Hospital

  2. Diabetic Neuropathies Family of nerve disorders caused by DM

  3. DiabetesPrevalence

  4. Nerve Fibers Large diam myelinated Skeletal muscle efferents Tendon reflex efferents Vibration / proprioception Small diam myelinated Preganglionic sympathetics efferents g-motor neuron fibers Cold sensory afferents Unmyelinated Warm sensory afferents Autonomic

  5. Diabetic neuropathies Distal symmetric polyneuropathy sensory motor length-dependent

  6. Diabetic neuropathies Distal symmetric polyneuropathy Small fiber neuropathy

  7. Distal Symmetric polyneuropathy ~ 1/3 diabetics ½ painful ½ of neuropathy due to diabetes Strong correlate with glycemic control

  8. Distal Symmetric polyneuropathyclinical features in DM Usually accompanies retinopathy nephropathy Pain is most common presenting symptom ataxia weakness

  9. Sensory Neuropathy - Symptoms

  10. Motor Neuropathy Symptoms

  11. Neuropathy - Signs

  12. Autonomic Neuropathy Symptoms

  13. Pure SFN Most common diabetic SFN + / - Abnl Sural NCS Abnl nerve biopsy May evolve into mixed large & small fiber neuropathy Diabetic Small Fiber Neuropathy

  14. Diabetic NeuropathiesSmall fiber neuropathy ED Orthostasis Arrhythmia / sudden death Gastroparesis Pain

  15. Diabetic NeuropathiesSmall fiber neuropathy ED 30-40% prevalence in DM DM is #1 risk factor for ED 4-12% men w/ ED have undiagnosed DM

  16. Diabetic Symmetric PolyneuropathyDiagnosis Clinical presence of DM / IGT Compatible physical findings

  17. Diabetic Symmetric PolyneuropathyDiagnosis Exam reflexes depressed distal > proximal length dependent sensory loss (stocking glove) Romberg distal > proximal motor atrophy, weakness

  18. Diabetic Symmetric PolyneuropathyDiagnosis Exam (cont’d) Autonomic dry feet orthostasis Foot injury / infections

  19. Diabetic Symmetric PolyneuropathyDiagnosis

  20. Diabetic Symmetric PolyneuropathyDiagnosis Clinical Electrodiagnosis (NCS / EMG)

  21. Small Fiber NeuropathyDiagnosis – EMG / NCS Myelinated fibers Unmyelinated fibers

  22. Small Fiber NeuropathyDiagnostic testing QST Autonomic testing Nerve biopsy Skin biopsy

  23. Small Fiber NeuropathyDiagnosis - QST Lacomis D. Muscle Nerve 2002

  24. Tests integrity of entire sweat pathway Requires elaborate, dedicated room Results based on % loss and pattern Thermoregulatory Sweat Test(TST)

  25. QSART

  26. Heart Rate Variability

  27. Epidermal Nerve Fiber Density

  28. Epidermal nerve fiber density 50m vertical section, immunostained with the panaxonal marker anti-protein gene product 9.5 McArthur, J. C. et al. Arch Neurol 1998;55:1513-1520.

  29. ENF density in IGT Smith A. Neurology 2001;5:1701-4

  30. Tricyclics Amitriptyline Imipramine Nortriptyline Diabetic neuropathySymptomatic treatment

  31. Tricyclics AEDs Gabapentin Topiramate Pregabalin Other AEDs Diabetic neuropathySymptomatic treatment

  32. Tricyclics AED Topicals Capsaicin Lidocaine cream Diabetic neuropathySymptomatic treatment

  33. Tricyclics AED Topicals SSRIs Paroxetine Citalopram Diabetic neuropathySymptomatic treatment

  34. Tricyclics AED Topicals SSRIs SNRIs Diabetic neuropathySymptomatic treatment Venlafaxine Duloxetine

  35. Podiatric care / ophthalmologic care Treat concurrent vascular disease Glycemic control Diabetic neuropathyOther treatment

  36. Insulin Neuritis Neuropathic symptoms, sensory / pain Start in first few weeks after glycemic control Exam, NCS usually normal Good prognosis, may take months Rx: Venlafaxine Diabetes Nutr Metab. 2004 Aug;17(4):247-9

  37. Diabetic neuropathies Distal symmetric polyneuropathy Small fiber neuropathy Ischemic mononeuropathy cranial neuropathy Radiculopathy Peripheral

  38. Diabetic cranial neuropathies 3rd 4th 7th

  39. Diabetic Neuropathies

  40. Diabetic neuropathies Regional neuropathic syndromes Diabetic amyotrophy Diabetic thoraco-abdominal neuropathy

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