DIABETIC NEUROPATHY

PROF. AR ALTAHAN FRCP NEUROLOGY DIVISION

KKUH

Diabetic Neuropathy

Common long term complication 54% type 1 & 45% in type 2

(Dyck et al 93)

Diabetes Mellitus

Diabetes Mellitus is one of the most common chronic health problems in

Saudi Arabia 23.7% overall prevalence36.5% above 60 yrs old

(Alnozha et al 2004)

Diabetic NeuropathyAssociated with increased morbidity

& mortality

Sever neuropathy in ~25% : estimated 450,000 patients in Saudi Arabia

Diabetic Neuropathy Associated with increased morbidity

& mortality

Sever neuropathy increased debilitating complications.

Increased Risk of silent MI & sudden death

Diabetic NeuropathyClinical Features

Multiple clinical pictures, reflecting multiple etiologies

Classification Of DN(Dyck 1993)

Polyneuropathy ..Sensory Focal & Multifocal ..Motor

Distal Sensory DN

The commonest type of DN (80%)

Symmetric & distal distribution Mainly sensory & painless:

Numbness, tingling, tightness walking on cotton-wool…etc.

Painful in 10%: Burning…aching…sharp quality

Distal Sensory DN

Risk factors for developing distal DN :

Age Duration of DM Diabetic control

Male & height (DCCT 90)

Distal Sensory DNComplications

Diabetic Foot Neurogenic Arthropathy Autonomic Neuropathy

Diabetic FootClinical Features

Numbness, hair loss, dry skinPainless ulcersOsteomyelitis, cellulitis, &

abscess Gangrene & Amputation

Diabetic Foot Pathophysiology

Sensory loss & autonomic changes

Small vessel disease-Ischemia Trauma (foreign body) Infection

Neurogenic Arthropathy

Severe loss of pain sensation & painless ulcers

Enhanced by trauma & abnormal posture

XR : painless fractures-disorganization of ANKLES

Autonomic Neuropathy

Correlates with severity of distal sensory DN

Associated with poor prognosis 50 % reduction of 5 yrs survivalIncreased sudden death & silent MI

Autonomic NeuropathyClinical Manifestations

Postural hypotension: BP drop >20 mmHg

Bladder atony (Overflow incontinence)

Gastro-intestinal paresis (Fullness & diabetic diarrhea)

Impotence

Autonomic Neuropathy..Clinical Manifestations

Heat intolerance Unawareness of hypoglycemia

Impaired hypoglycemia counter- regulation

Focal & Multifocal neuropathies

Acute or Subacute onset Predominantly Motor Spontaneous recovery

(Improve control)

Focal & Multifocal neuropathies

Cranial Neuropathies Entrapment Neuropathies (Carpal Tunnel Syndrome) Diabetic amyotrophy

DN PathogenesisMultifactorial

Metabolic Vascular Others

DN Pathogenesis Metabolic Hypothesis

Sorbitol accumulation Non-enzymatic glycation Oxidative stress Others

DN Pathogenesis Vascular Hypothesis

Early endoneural hypoxia Metabolic changes & Microangiopathy & Ischemia

Treatment Of Diabetic Neuropathy

Treatment Of DN

Cornerstone Tight control

IIT 64% risk reduction of

developing DN over 5 yrs (DCCT

93)

Analgesia

Tricyclic anti-depressants Anti-epileptics ( Carbamazepine &

Gabapentin, Pregabalin)

Opioids (Tramadol)

Analgesia

TopicalLidocain patchClonidin patchCapsaicin aching pains

Nerve and Spine stimulators Acupuncture