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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

Diabetic Neuropathies

Joseph V. Campellone, MD

Division of Neurology

Cooper University Hospital

diabetic neuropathies2
Diabetic Neuropathies

Family of nerve disorders caused by DM

nerve fibers
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

diabetic neuropathies6
Diabetic neuropathies

Distal symmetric polyneuropathy

sensory

motor

length-dependent

diabetic neuropathies7
Diabetic neuropathies

Distal symmetric polyneuropathy

Small fiber neuropathy

distal symmetric polyneuropathy

Distal Symmetric polyneuropathy

~ 1/3 diabetics

½ painful

½ of neuropathy due to diabetes

Strong correlate with glycemic control

distal symmetric polyneuropathy clinical features in dm

Distal Symmetric polyneuropathyclinical features in DM

Usually accompanies

retinopathy

nephropathy

Pain is most common presenting symptom

ataxia

weakness

diabetic small fiber neuropathy
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 neuropathies small fiber neuropathy

Diabetic NeuropathiesSmall fiber neuropathy

ED

Orthostasis

Arrhythmia / sudden death

Gastroparesis

Pain

diabetic neuropathies small fiber neuropathy16

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 polyneuropathy diagnosis
Diabetic Symmetric PolyneuropathyDiagnosis

Clinical

presence of DM / IGT

Compatible physical findings

diabetic symmetric polyneuropathy diagnosis18
Diabetic Symmetric PolyneuropathyDiagnosis

Exam

reflexes depressed distal > proximal

length dependent sensory loss

(stocking glove)

Romberg

distal > proximal motor

atrophy, weakness

diabetic symmetric polyneuropathy diagnosis19
Diabetic Symmetric PolyneuropathyDiagnosis

Exam (cont’d)

Autonomic

dry feet

orthostasis

Foot injury / infections

diabetic symmetric polyneuropathy diagnosis21
Diabetic Symmetric PolyneuropathyDiagnosis

Clinical

Electrodiagnosis (NCS / EMG)

small fiber neuropathy diagnosis emg ncs
Small Fiber NeuropathyDiagnosis – EMG / NCS

Myelinated fibers

Unmyelinated fibers

small fiber neuropathy diagnostic testing
Small Fiber NeuropathyDiagnostic testing

QST

Autonomic testing

Nerve biopsy

Skin biopsy

small fiber neuropathy diagnosis qst
Small Fiber NeuropathyDiagnosis - QST

Lacomis D. Muscle Nerve 2002

thermoregulatory sweat test tst
Tests integrity of entire sweat pathway

Requires elaborate, dedicated room

Results based on % loss and pattern

Thermoregulatory Sweat Test(TST)
slide31
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
ENF density in IGT

Smith A. Neurology 2001;5:1701-4

diabetic neuropathy symptomatic treatment
Tricyclics

Amitriptyline

Imipramine

Nortriptyline

Diabetic neuropathySymptomatic treatment
diabetic neuropathy symptomatic treatment34
Tricyclics

AEDs

Gabapentin

Topiramate

Pregabalin

Other AEDs

Diabetic neuropathySymptomatic treatment
diabetic neuropathy symptomatic treatment35
Tricyclics

AED

Topicals

Capsaicin

Lidocaine cream

Diabetic neuropathySymptomatic treatment
diabetic neuropathy symptomatic treatment36
Tricyclics

AED

Topicals

SSRIs

Paroxetine

Citalopram

Diabetic neuropathySymptomatic treatment
diabetic neuropathy symptomatic treatment37
Tricyclics

AED

Topicals

SSRIs

SNRIs

Diabetic neuropathySymptomatic treatment

Venlafaxine

Duloxetine

diabetic neuropathy other treatment
Podiatric care / ophthalmologic care

Treat concurrent vascular disease

Glycemic control

Diabetic neuropathyOther treatment
insulin neuritis
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 neuropathies40
Diabetic neuropathies

Distal symmetric polyneuropathy

Small fiber neuropathy

Ischemic mononeuropathy

cranial neuropathy

Radiculopathy

Peripheral

diabetic neuropathies43
Diabetic neuropathies

Regional neuropathic syndromes

Diabetic amyotrophy

Diabetic thoraco-abdominal neuropathy

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