Diabetic neuropathy - Clinicals, Diagnosis, and Management

Neurology

Clinicals - History

Fact Explanation
Paraesthesiae in feet Occurs due to diabetic polyneuropathy. Sensory neuropathy that affects small nerve fibers cause painful anesthesia. Paraesthesiae in feet
Occurs due to diabetic polyneuropathy. Sensory neuropathy that affects small nerve fibers cause painful anesthesia.
Dull, aching and/ or lancinating, pain in lower limbs, worse at night Occurs due to diabetic polyneuropathy. Sensory neuropathy that affects small nerve fibers cause painful anesthesia.
Neuropathic pain has a diurnal variation.
Dull, aching and/ or lancinating, pain in lower limbs, worse at night
Occurs due to diabetic polyneuropathy. Sensory neuropathy that affects small nerve fibers cause painful anesthesia.
Neuropathic pain has a diurnal variation.
Loss of sweating Occurs due to diabetic autonomic neuropathy. Sweat gland is a complex structure with a cholinergic innervation. In diabetics there is a wide spread lesion in small nerve fibers. Loss of sweating
Occurs due to diabetic autonomic neuropathy. Sweat gland is a complex structure with a cholinergic innervation. In diabetics there is a wide spread lesion in small nerve fibers.
Orthostatic hypotention Occurs due to diabetic autonomic neuropathy. Blood pressure regulation in erect posture maintains by both neural and humoral factors. In diabetes this occurs usually due to the damage of the efferent sympathetic vasomotor fibers, especially in the splanchnic vasculature. Orthostatic hypotention
Occurs due to diabetic autonomic neuropathy. Blood pressure regulation in erect posture maintains by both neural and humoral factors. In diabetes this occurs usually due to the damage of the efferent sympathetic vasomotor fibers, especially in the splanchnic vasculature.
Gastroparesis and diarrhoea Occurs due to diabetic autonomic neuropathy. Gastroparesis - Gastric emptying needs proper action of smooth muscle, enteric and extrinsic autonomic nerves, and specialized pacemaker cells, the interstitial cells of Cajal. Diabetes may result in gastric motor dysfunction which include autonomic neuropathy, enteric neuropathy involving excitatory and inhibitory nerves, abnormalities of interstitial cells of Cajal, acute fluctuations in blood glucose, incretin-based medications used to normalize postprandial blood glucose and psychosomatic factors.
Diarrhoea - Due to autonomic dysfunction there is impaired motility in the small bowels.Bacterial overgrowth due to stasis of the bowel may contribute to diarrhea
Gastroparesis and diarrhoea
Occurs due to diabetic autonomic neuropathy. Gastroparesis - Gastric emptying needs proper action of smooth muscle, enteric and extrinsic autonomic nerves, and specialized pacemaker cells, the interstitial cells of Cajal. Diabetes may result in gastric motor dysfunction which include autonomic neuropathy, enteric neuropathy involving excitatory and inhibitory nerves, abnormalities of interstitial cells of Cajal, acute fluctuations in blood glucose, incretin-based medications used to normalize postprandial blood glucose and psychosomatic factors.
Diarrhoea - Due to autonomic dysfunction there is impaired motility in the small bowels.Bacterial overgrowth due to stasis of the bowel may contribute to diarrhea
Erectile dysfunction In diabetes this occurs due to multifactorial etiologies, Neuropathy, metabolic control, vascular disease, nutrition, endocrine disorders, psychogenic factors and anti-diabetic drugs Erectile dysfunction
In diabetes this occurs due to multifactorial etiologies, Neuropathy, metabolic control, vascular disease, nutrition, endocrine disorders, psychogenic factors and anti-diabetic drugs
Gustatory sweating Occurs due to diabetic autonomic neuropathy. Even though aberrant nerve regeneration has been suggested as a possible mechanism, exact mechanism is still unknown. Gustatory sweating
Occurs due to diabetic autonomic neuropathy. Even though aberrant nerve regeneration has been suggested as a possible mechanism, exact mechanism is still unknown.
Neuropathic ulcers Occurs due to multiple factors associate with diabetics, which include neuropathy, vascular disease and immunopathy . Mainly due to the sensory neuropathy in which protective sensation is lost. Neuropathic ulcers
Occurs due to multiple factors associate with diabetics, which include neuropathy, vascular disease and immunopathy . Mainly due to the sensory neuropathy in which protective sensation is lost.
Difficulty in micturition, urinary incontinence, reccurent infection due to atonic bladder Occurs due to diabetic autonomic neuropathy. It affects the sacral nerves and impairs detrusor muscle while pudendal innervation of perineal and periurethral striated muscle is usually unaffected
in diabetic neuropathy.
Difficulty in micturition, urinary incontinence, reccurent infection due to atonic bladder
Occurs due to diabetic autonomic neuropathy. It affects the sacral nerves and impairs detrusor muscle while pudendal innervation of perineal and periurethral striated muscle is usually unaffected
in diabetic neuropathy.

Clinicals - Examination

Fact Explanation
'glove and stoking' type sensory loss Occurs due to diabetic sensory polyneuropathy. small myelinated and unmyelinated axons become impaired. Longest nerve fibers are affected first. 'glove and stoking' type sensory loss
Occurs due to diabetic sensory polyneuropathy. small myelinated and unmyelinated axons become impaired. Longest nerve fibers are affected first.
Dry skin Occurs due to diabetic autonomic neuropathy. Sweat gland is a complex structure with a cholinergic innervation. In diabetics there is a lesion in small nerve fibers that supply to the skin and the sweating get impaired. Dry skin
Occurs due to diabetic autonomic neuropathy. Sweat gland is a complex structure with a cholinergic innervation. In diabetics there is a lesion in small nerve fibers that supply to the skin and the sweating get impaired.
Orthostatic hypotention Occurs due to diabetic autonomic neuropathy. In any condition orthostatic hypotention can be occur due to defective contraction
of resistance vessels in the standing position or abnormal reduction in blood volume or diminished cardiac output in the standing position due either to reduced venous return or to inability to accelerate the heart, or both. In long term diabetes above mention all three factors may be involved. In diabetes this occurs usually due to the damage of the efferent sympathetic vasomotor fibers, especially in the splanchnic vasculature.
Orthostatic hypotention
Occurs due to diabetic autonomic neuropathy. In any condition orthostatic hypotention can be occur due to defective contraction
of resistance vessels in the standing position or abnormal reduction in blood volume or diminished cardiac output in the standing position due either to reduced venous return or to inability to accelerate the heart, or both. In long term diabetes above mention all three factors may be involved. In diabetes this occurs usually due to the damage of the efferent sympathetic vasomotor fibers, especially in the splanchnic vasculature.
Fixed heart rate and Resting tachycardia Occurs due to diabetic autonomic neuropathy. There is combined vagal and sympathetic impairment, the rate remains elevated. Fixed heart rate and Resting tachycardia
Occurs due to diabetic autonomic neuropathy. There is combined vagal and sympathetic impairment, the rate remains elevated.
Loss of vibratory sensation and joint position sensation Large myelinated fibers and other proprioceptive afferent fibers impairment leads to disturbance of light touch sensation, sensibility to pressure and vibration, and joint position sense. Loss of vibratory sensation and joint position sensation
Large myelinated fibers and other proprioceptive afferent fibers impairment leads to disturbance of light touch sensation, sensibility to pressure and vibration, and joint position sense.
Cranial nerve palsies Third, sixth and seventh nerve palsy occurs due to diabetic associated central nervous system involvement. Cranial nerve palsies
Third, sixth and seventh nerve palsy occurs due to diabetic associated central nervous system involvement.
Neuropathic osteoarthropathy (Charcot joints) Occurs due to diabetic associated multifactorial etiological factors. Neuropathic joint degeneration, recurrent trauma due to loss of protective joint sensation and osteopenia, possibly because of increased blood flow from sympathetic denervation,
are the main predisposing factors.
Neuropathic osteoarthropathy (Charcot joints)
Occurs due to diabetic associated multifactorial etiological factors. Neuropathic joint degeneration, recurrent trauma due to loss of protective joint sensation and osteopenia, possibly because of increased blood flow from sympathetic denervation,
are the main predisposing factors.
Loss of muscle power and muscle wasting Occurs due to proximal diabetic neuropathy of the lower limbs, wasting of the quadriceps and loss of the patellar reflex occur at an early stage in the disease. In nerve biopsies immune-mediated epineurial microvasculitis has been reported. Loss of muscle power and muscle wasting
Occurs due to proximal diabetic neuropathy of the lower limbs, wasting of the quadriceps and loss of the patellar reflex occur at an early stage in the disease. In nerve biopsies immune-mediated epineurial microvasculitis has been reported.

Investigations - Diagnosis

Fact Explanation
Nerve conduction test Velocity of the nerve conduction is slow due to the demyelination and loss of large myelinated fibers, and a decrease in nerve action potentials owing to loss of axons. Nerve conduction test
Velocity of the nerve conduction is slow due to the demyelination and loss of large myelinated fibers, and a decrease in nerve action potentials owing to loss of axons.
Cardiovascular reflex tests It is used to diagnose cardiovascular autonomic dysfunction. It consist of five non invasive cardiovascular reflex tests, Valsalva maneuver,heart rate response to deep breathing, heart rate response to standing up, blood pressure response to standing up, and blood pressure response to sustained hand grip. Cardiovascular reflex tests
It is used to diagnose cardiovascular autonomic dysfunction. It consist of five non invasive cardiovascular reflex tests, Valsalva maneuver,heart rate response to deep breathing, heart rate response to standing up, blood pressure response to standing up, and blood pressure response to sustained hand grip.
Upper GI endoscopy or barium studies To rule out structural or mucosal
abnormalities of the GI tract in diabetic gastropheresis.
Upper GI endoscopy or barium studies
To rule out structural or mucosal
abnormalities of the GI tract in diabetic gastropheresis.

Investigations - Management

Fact Explanation
Electrocardiography (ECG\EKG) To asses cardiac function, and detect ischemic changes Electrocardiography (ECG\EKG)
To asses cardiac function, and detect ischemic changes
Plasma glucose levels To asses glycemic contol Plasma glucose levels
To asses glycemic contol
Renal function tests, urine culture, postvoid ultrasound and cystrometry To asses bladder function Renal function tests, urine culture, postvoid ultrasound and cystrometry
To asses bladder function
Assessment of sensory function All patients should screen for sensory impairment annually. It starts with the diagnosis of type 2 Diabetes melitus or 5 years after the diagnosis of type 1 diabetes. Pinprick method, temperature, vibration perception(using a 128Hz tuning fork) and pressure sensation (using 10g monofilament) is done to assess this. Assessment of sensory function
All patients should screen for sensory impairment annually. It starts with the diagnosis of type 2 Diabetes melitus or 5 years after the diagnosis of type 1 diabetes. Pinprick method, temperature, vibration perception(using a 128Hz tuning fork) and pressure sensation (using 10g monofilament) is done to assess this.

Management - Supportive

Fact Explanation
Maintain optimum glycemic control To prevent developing diabetic neuropathy Maintain optimum glycemic control
To prevent developing diabetic neuropathy
Foot care To prevent foot ulcers and bone infections Foot care
To prevent foot ulcers and bone infections
Improve nutrition, reduce fat, alcohol and tobacco consumption to prevent end organ damage Improve nutrition, reduce fat, alcohol and tobacco consumption
to prevent end organ damage

Management - Specific

Fact Explanation
Intensive insulin therapy To achieve strict diabetic control Intensive insulin therapy
To achieve strict diabetic control
Pain management Carbamazepine, phenytoin, clonazepam, or paracetamol in combination with codeine phosphate can be useful. Tricyclic antidepressants, such as imipramine or amitriptyline, are often effective; the usual dose varies from 30–150 mg per day. Tricyclic antidepressants might aggravate postural hypotension. The recently introduced drugs duloxetine and pregabalin are also useful. Pain management
Carbamazepine, phenytoin, clonazepam, or paracetamol in combination with codeine phosphate can be useful. Tricyclic antidepressants, such as imipramine or amitriptyline, are often effective; the usual dose varies from 30–150 mg per day. Tricyclic antidepressants might aggravate postural hypotension. The recently introduced drugs duloxetine and pregabalin are also useful.
Management of symtomatic postural hypotention. Midodrine - alpha adrenoceptor antagonist (not license in everywhere) is more effective than using 9-alpha-fluorohydrocortisone, which is the most effective treatment for postural hypotension but carries a risk of hypertension. Management of symtomatic postural hypotention.
Midodrine - alpha adrenoceptor antagonist (not license in everywhere) is more effective than using 9-alpha-fluorohydrocortisone, which is the most effective treatment for postural hypotension but carries a risk of hypertension.
Management of Gastroinestinal neuropathy 1- Gastroparesis - Frequent small meals, prokinetic agents (metoclpramide, domperidone)
2- Abdominal pain or discomfort, early
satiety, nausea, vomiting, belching,
bloating - Antibiotics, antiemetics (phenergan, compazine, tigan, scopolamine), bulking agents, tricyclic antidepressants, pancreatic extracts, pyloric Botox, gastric pacing, enteral feeding
3- Diarrhea, often nocturnal alternating
with constipation and incontinence - Trials of soluble fiber, gluten and lactose restriction, anticholinergic agents, cholestyramine, antibiotics, clonidine,
somatostatin, pancreatic enzyme
supplements
Management of Gastroinestinal neuropathy
1- Gastroparesis - Frequent small meals, prokinetic agents (metoclpramide, domperidone)
2- Abdominal pain or discomfort, early
satiety, nausea, vomiting, belching,
bloating - Antibiotics, antiemetics (phenergan, compazine, tigan, scopolamine), bulking agents, tricyclic antidepressants, pancreatic extracts, pyloric Botox, gastric pacing, enteral feeding
3- Diarrhea, often nocturnal alternating
with constipation and incontinence - Trials of soluble fiber, gluten and lactose restriction, anticholinergic agents, cholestyramine, antibiotics, clonidine,
somatostatin, pancreatic enzyme
supplements
Management of Erectile dysfunction Sex therapy, psychological counseling,
sildenafil, vardenafil, tadalafil, prostaglandin
E1 injection, device or prosthesis
Management of Erectile dysfunction
Sex therapy, psychological counseling,
sildenafil, vardenafil, tadalafil, prostaglandin
E1 injection, device or prosthesis
Management of Bladder dysfunction Bethanechol, intermittent catheterization Management of Bladder dysfunction
Bethanechol, intermittent catheterization
Management of sweating dysfunction Emollients and skin lubricants, scopolamine, glycopyrrolate, botulinum toxin, vasodilators Management of sweating dysfunction
Emollients and skin lubricants, scopolamine, glycopyrrolate, botulinum toxin, vasodilators

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