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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 myelinatedSkeletal muscle efferents Tendon reflex efferents

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Diabetic Neuropathies

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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


DiabetesPrevalence


Nerve Fibers

Large diam myelinatedSkeletal muscle efferents

Tendon reflex efferents

Vibration / proprioception

Small diam myelinatedPreganglionic sympathetics efferents

g-motor neuron fibers

Cold sensory afferents

UnmyelinatedWarm sensory afferents

Autonomic


Diabetic neuropathies

Distal symmetric polyneuropathy

sensory

motor

length-dependent


Diabetic neuropathies

Distal symmetric polyneuropathy

Small fiber neuropathy


Distal Symmetric polyneuropathy

~ 1/3 diabetics

½ painful

½ of neuropathy due to diabetes

Strong correlate with glycemic control


Distal Symmetric polyneuropathyclinical features in DM

Usually accompanies

retinopathy

nephropathy

Pain is most common presenting symptom

ataxia

weakness


Sensory Neuropathy - Symptoms


Motor Neuropathy Symptoms


Neuropathy - Signs


Autonomic Neuropathy Symptoms


Pure SFN

Most common diabetic SFN

+ / - Abnl Sural NCS

Abnl nerve biopsy

May evolve into mixed

large & small fiber neuropathy

Diabetic Small Fiber Neuropathy


Diabetic NeuropathiesSmall fiber neuropathy

ED

Orthostasis

Arrhythmia / sudden death

Gastroparesis

Pain


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


Diabetic Symmetric PolyneuropathyDiagnosis

Clinical

presence of DM / IGT

Compatible physical findings


Diabetic Symmetric PolyneuropathyDiagnosis

Exam

reflexes depressed distal > proximal

length dependent sensory loss

(stocking glove)

Romberg

distal > proximal motor

atrophy, weakness


Diabetic Symmetric PolyneuropathyDiagnosis

Exam (cont’d)

Autonomic

dry feet

orthostasis

Foot injury / infections


Diabetic Symmetric PolyneuropathyDiagnosis


Diabetic Symmetric PolyneuropathyDiagnosis

Clinical

Electrodiagnosis (NCS / EMG)


Small Fiber NeuropathyDiagnosis – EMG / NCS

Myelinated fibers

Unmyelinated fibers


Small Fiber NeuropathyDiagnostic testing

QST

Autonomic testing

Nerve biopsy

Skin biopsy


Small Fiber NeuropathyDiagnosis - QST

Lacomis D. Muscle Nerve 2002


Tests integrity of entire sweat pathway

Requires elaborate, dedicated room

Results based on % loss and pattern

Thermoregulatory Sweat Test(TST)


QSART


Heart Rate Variability


Epidermal Nerve Fiber Density


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.


ENF density in IGT

Smith A. Neurology 2001;5:1701-4


Tricyclics

Amitriptyline

Imipramine

Nortriptyline

Diabetic neuropathySymptomatic treatment


Tricyclics

AEDs

Gabapentin

Topiramate

Pregabalin

Other AEDs

Diabetic neuropathySymptomatic treatment


Tricyclics

AED

Topicals

Capsaicin

Lidocaine cream

Diabetic neuropathySymptomatic treatment


Tricyclics

AED

Topicals

SSRIs

Paroxetine

Citalopram

Diabetic neuropathySymptomatic treatment


Tricyclics

AED

Topicals

SSRIs

SNRIs

Diabetic neuropathySymptomatic treatment

Venlafaxine

Duloxetine


Podiatric care / ophthalmologic care

Treat concurrent vascular disease

Glycemic control

Diabetic neuropathyOther treatment


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


Diabetic neuropathies

Distal symmetric polyneuropathy

Small fiber neuropathy

Ischemic mononeuropathy

cranial neuropathy

Radiculopathy

Peripheral


Diabetic cranial neuropathies

3rd

4th

7th


Diabetic Neuropathies


Diabetic neuropathies

Regional neuropathic syndromes

Diabetic amyotrophy

Diabetic thoraco-abdominal neuropathy


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