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Diagnosis and Management of Diabetic Neuropathies

Diagnosis and Management of Diabetic Neuropathies. Part 1. Aaron I. Vinik, MD, PhD, FCP, MACP

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Diagnosis and Management of Diabetic Neuropathies

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  1. Diagnosis and Management of Diabetic Neuropathies Part 1 Aaron I. Vinik, MD, PhD, FCP, MACP Professor of Medicine/Pathology/NeurobiologyDirector of Research and Neuroendocrine UnitEastern Virginia Medical SchoolStrelitz Diabetes Center for Endocrine and Metabolic DisordersNorfolk, Virginia

  2. An early description of neuropathy in Hittite tablets ‘If King Hattusili III is cured from the fire that burns his feet, I will give a golden cup with a handle of lapis lazuli to Goddess Ningal’ Queen Puduhepa, approx 1250 BC The king could not attend the wedding of his daughter Maathorneferure because of his burning feet Öztürk, 2006

  3. EURODIAB: Risk Factors for Incidence of Polyneuropathy 0.9 1 2 3 4 Odds ratios (95% CI); n = 1101 with type 1 diabetes; follow-up 7.3 ± 0.6 years 1.57 Hypertension 1.38 Smoking 1.48 Hemoglobin A1c 1.36 Change in hemoglobin A1c Model 1: excluding cardiovascular disease and retinopathy 1.40 Diabetes duration 1.27 Body mass index 1.21 Triglycerides 1.15 Total cholesterol Tesfaye S, et al. N Engl J Med. 2005;352:341-350.

  4. Risk Factors for Neuropathic PainMONICA/KORA Augsburg Surveys S2+S3 Multivariate models All subjects (n = 393) Age (years) Weight (kg) Diabetes Peripheral arterial disease (ABI < 0.9) OR (95% CI) 1.08 (1.02, 1.14) 1.03 (1.00, 1.05) 2.61 (1.09, 6.24) 5.72 (2.44, 13.39) P value .0085 .0415 .0305 < .0001 P value .0389 .0539 < .0001 .1378 Subjects With Diabetes (n = 195) Age (years) Weight (kg) Peripheral arterial disease (ABI < 0.9) Albuminuria (mg/L) OR (95% CI) 1.08 (1.00, 1.16) 1.03 (1.00, 1.06) 9.27 (3.44, 25.0) 1.19 (0.95, 1.51) ABI = ankle brachial index; OR = odds ratio; CI = confidence interval Ziegler D, et al. Eur J Pain. 2008, doi:10.1016/j.ejpain.2008.07.007.

  5. Prevalence of Polyneuropathy and Neuropathic PainMONICA/KORA Augsburg Surveys S2S3 Polyneuropathy 30 Neuropathic pain 25 Patients (%) 20 15 10 5 0 Control Impaired fasting glucose Impaired glucose tolerance Diabetes Ziegler D et al. Diabetes Care. 2008;31:464. Ziegler D et al. Eur J Pain. 2009; in press.

  6. Prevalence of Chronic Neuropathic Pain in French General Population Nationwide postal questionnaire survey 30,155 subjects, 81.2% responded 1631 respondents had chronic pain with neuropathic characteristics: 6.9% prevalence 40 30 Patients (%) 20 10 0 0 1 2 3 4 5 6 7 DN4 Score Bouhassira D et al. Pain. 2008;136:380.

  7. Review of computerized longitudinal medical records 362,693 persons; 1,116,215 person-years (PY) Incidence (new cases): 8.2/1000 PY; diabetic neuropathy: 0.72/1000 PY; postherpetic neuralgia: 0.42/1000 PY Most treated with NSAIDs and aspirin; <5% treated with anticonvulsants and tricyclic antidepressants Incidence and Treatment of Neuropathic Pain in Dutch Population 25 20 15 10 5 0 Women Men Incidence rate ratioof women vs men 9 Mononeuropathy 8 2.5 DPN 7 PHN 2 6 5 1.5 Incidence rate/1000 PY 4 Incidence rate/1000 PY Ratio female:male 1 3 2 0.5 1 0 0 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 >90 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 >90 Age (years) Age (years) Dieleman JP et al. Pain. 2008; 137:681.

  8. Neuropathy in Diabetes Prevalence % Things that he stretched but mainly he tells the truth Mark Twain

  9. Neuropathy Is Commonly Underdiagnosed For every mistake made for not knowing, 10 are made for not looking Endocrinologists Non-endocrinologists 100 80 60 Correct diagnosis (%) 40 20 0 Noneuropathy (n=4628) Non-severeneuropathy (n=2209) Severe neuropathy (n=541) Herman W et al. Presented at: 63rd Annual Scientific Sessions of the American Diabetes Association. New Orleans, LA; June 13-17, 2003. Abstract 830-P. Herman et al. Diabetes Care. 2005;28:1480.

  10. Diabetic Neuropathies III VI Truncal Ulnar Median Lateralpopliteal Sensory loss: 0 – +++ (touch vibration) Pain: + – +++ Tendon reflex: N –  Motor deficit: 0 – +++ Sensory loss: 0 – +(thermal allodynia) Pain: + – +++ Tendon reflex: N –  Motor deficit: 0 Sensory loss: 0 – + Pain: + – +++ Tendon reflex:  Proximal motor deficit: + – +++ Sensory loss: 0 – + Pain: + – +++ Tendon reflex: N Motor deficit: + – +++ Sensory loss in nerve distribution: + – +++ Pain: + – ++ Tendon reflex: N Motor deficit: + – +++ N, normal Vinik A et al. Clin Geriatr Med. 2008;24:407.

  11. Mononeuritis Onset sudden Usually single nerve, but may be multiple Common nerves: C3, C6, C7, ulnar, median, peroneal Not progressive and resolves spontaneously Treatment: symptomatic Entrapment Onset gradual Single nerves exposed to trauma Common nerves: median, ulnar, peroneal, medial and lateral plantar Progressive Treatment: rest, splints, diuretics, steroid injections and surgery for failed medical therapy and weakness Mononeuritis vs Entrapment C, cranial nerve Vinik A et al. Diabetes Care. 2004;27:1783.

  12. A Simplified View of the PNS Motor Sensory Autonomic Myelinated Myelinated Thinly myelinated Un- myelinated Thinly myelinated Un- myelinated A alpha A alpha/beta A delta C A delta C Large Small Heart rate, blood pressure, sweating, GIT,GUT, function Muscle control Touch, vibration, position perception Cold perception, pain Warm perception, pain Vinik AI, et al. Nature Clinical Practice Endocrinol Metab. 2006;2:269-281.

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