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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

Joseph V. Campellone, MD

Division of Neurology

Cooper University Hospital


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Diabetic Neuropathies

Family of nerve disorders caused by DM


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DiabetesPrevalence


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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


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Diabetic neuropathies

Distal symmetric polyneuropathy

sensory

motor

length-dependent


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Diabetic neuropathies

Distal symmetric polyneuropathy

Small fiber neuropathy


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Distal Symmetric polyneuropathy

~ 1/3 diabetics

½ painful

½ of neuropathy due to diabetes

Strong correlate with glycemic control


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Distal Symmetric polyneuropathyclinical features in DM

Usually accompanies

retinopathy

nephropathy

Pain is most common presenting symptom

ataxia

weakness






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Pure SFN

Most common diabetic SFN

+ / - Abnl Sural NCS

Abnl nerve biopsy

May evolve into mixed

large & small fiber neuropathy

Diabetic Small Fiber Neuropathy


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Diabetic NeuropathiesSmall fiber neuropathy

ED

Orthostasis

Arrhythmia / sudden death

Gastroparesis

Pain


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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


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Diabetic Symmetric PolyneuropathyDiagnosis

Clinical

presence of DM / IGT

Compatible physical findings


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Diabetic Symmetric PolyneuropathyDiagnosis

Exam

reflexes depressed distal > proximal

length dependent sensory loss

(stocking glove)

Romberg

distal > proximal motor

atrophy, weakness


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Diabetic Symmetric PolyneuropathyDiagnosis

Exam (cont’d)

Autonomic

dry feet

orthostasis

Foot injury / infections



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Diabetic Symmetric PolyneuropathyDiagnosis

Clinical

Electrodiagnosis (NCS / EMG)


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Small Fiber NeuropathyDiagnosis – EMG / NCS

Myelinated fibers

Unmyelinated fibers


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Small Fiber NeuropathyDiagnostic testing

QST

Autonomic testing

Nerve biopsy

Skin biopsy


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Small Fiber NeuropathyDiagnosis - QST

Lacomis D. Muscle Nerve 2002


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Tests integrity of entire sweat pathway

Requires elaborate, dedicated room

Results based on % loss and pattern

Thermoregulatory Sweat Test(TST)





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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.


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ENF density in IGT

Smith A. Neurology 2001;5:1701-4


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Tricyclics

Amitriptyline

Imipramine

Nortriptyline

Diabetic neuropathySymptomatic treatment


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Tricyclics

AEDs

Gabapentin

Topiramate

Pregabalin

Other AEDs

Diabetic neuropathySymptomatic treatment


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Tricyclics

AED

Topicals

Capsaicin

Lidocaine cream

Diabetic neuropathySymptomatic treatment


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Tricyclics

AED

Topicals

SSRIs

Paroxetine

Citalopram

Diabetic neuropathySymptomatic treatment


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Tricyclics

AED

Topicals

SSRIs

SNRIs

Diabetic neuropathySymptomatic treatment

Venlafaxine

Duloxetine


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Podiatric care / ophthalmologic care

Treat concurrent vascular disease

Glycemic control

Diabetic neuropathyOther treatment


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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


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Diabetic neuropathies

Distal symmetric polyneuropathy

Small fiber neuropathy

Ischemic mononeuropathy

cranial neuropathy

Radiculopathy

Peripheral




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Diabetic neuropathies

Regional neuropathic syndromes

Diabetic amyotrophy

Diabetic thoraco-abdominal neuropathy


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