IN THE NAME OF GOD

1. IN THE NAME OF GOD

2. DIABETIC NEUROPATHY 5% per years retinopathy-nephropathy-neuropathy IDDM- NIDDM vulnerable to DN leading cause of peripheralneuropathy

3. frequency of D N 7-80% risk of developing symptomatic D N 5years:4-10% 25years:15% 66% have objective D N IDDM 15%--- NIDDM 13% symptomatic age& D M correlate with abnormal vibration test

4. higher percentage in those with low serum insulin concentration risk factors with increased foot sensation :poor glycemic control-height-age-alcohol EMG&NCV demonstrate subclinical abnormalities in most patients with IDDM after5-10years D N

5. CLASSIFICATION : symmetric focal clinical features distal symmetrical P N most common DN 75% of all DN sensory loss & autonomic symptoms correlate with severity most patients have minor motor sign

6. stocking&glove distribution begin in the toes in more advanced cases anterior chest & abdomen are affected dyeing back process large fiber-------small fiber

7. LARGE FIBER D N painless paresthesias(toe&feet) impairment of vibration&position DTR-ataxia sensory loss DIABETIC POLYRADICULONEUROPATHY onset distal symmetric then proximal segment L S roots-thoracic—cervical E M G –low grade active denervation(thoracic)

8. trigeminal blink reflex is spared DIABETIC POLYRADICULOPATHY normal S N C V —root level is affected(EMG&clinical) NIDDM&IDDM are associated with CIDP ------response to IVIG SMALL FIBER D N deep pain burning-aching-shooting allodynia –temperature & pain are impaired—preservation of deep sense & DTR—autonomic

9. HYPERGLYCEMIC D N can occur before the onset of D M IGT OGTT--------small fiber be undergo GTT DN painful P N (unknown cause)should TREATMENT INDUCED NEUROPATHY lasts for weeks

10. DIABETIC NEROPATHIC CACHEXIA acute painful D N—depression-insomnia-weightloss -impotence M>F ACRODYSTROPHIC NEUROPATHY sensory loss-foot ulcer distal joint destruction CHRONIC FOOT ULCER---trauma ischemia infection

11. NEUROPATHIC ARTHROPATHY(CHARCOTJOINT) -----foot ulcer-autonomic impairment D D syphilis DIABETIC PSEUDOTABES :lancinating pain-loss of joint sensation abnormal pupil EMG&NCV ARE HELPFULIN CONFIRMING NCV – H reflex & amplitude of sural nerve

12. active denervation potential DIABETIC AUTONOMIC NEUROPATHY usually correlate with severity of somatic neuropathy subclinical-sever(heart-GI-GU ) OH-resting tachycardia- H R unresponsive to respiration-------hallmark of autonomic D N OH— failure of sympathic&cardiac compensatory is impaired

13. D D---hypovolemia-medication VAGAL DENERVATION-----tachycardia in rest –silent MI GI motility abnormality-fecal incontinence-delayed gastric emptying(nausea)-diarrhea-bacterial overgrowth-colonic atony(constipation)-bladder atony impotence sudomotor abnormalities

14. distal anhidrosis gustatory sweating pupillary abnormalities ASYMMETRIC PROXIMAL NEUROPATHY(DIABETIC AMYOTROPHY) Bruns Garland syndrome weakness of pelvifemural muscles age>50years NIDDM—unrelated to duration of DM

15. sever pain in lower back&hip&tigh weakness— DTR-opposite leg affect minor paresthesias-weight loss >50% steady progression-pain receds spontaneously-recovery up to 24 months 66% overlap with distal DN EMG: low amplitude-fibs- IMAGING: R/O other causes SURAL NERVE BIOPSY (ischemia)

16. TRUNCAL NEUROPATHY T4-T12 roots involved pain in chest & abdomen- bulging of abdominal wall-older patients NIDDM-allodynia-abrupt onset D D:H Z-mass lesions Recovery :several months E M G :active denervation focal anhidrosis

17. LIMB MONONEUROPATHY mecanisms:1-infarction 2-entrapment infarction: abrupt onset-acute axonal degeneration-slow recovery median-ulnar-proneal(most common) Entrapment :insidious onset-focal conduction block- MULTIPLE MONONRUROPATHIES abrupt onset-proximal nerve-

18. nerve infarction due to occlusion of vasnervorum D D :systemic vasculitis CRANIAL MONO NEUROPATHIES third nerve palsy is most common pupillary sparing 4th-sixth&seventh are affected acute ischemic damage Recovery : after 3-5 months

19. INCREASED INCIDENCE OF ENTRAPMENT NEUROPATHY D M is found in 8-12%patients with CTS—25%DM patients have electrodiagnostic CTS—8%symptomatic risk of CTS---women 2/2 men 2/5 times reason ? ischemia or hypoxia entrapment----- possibility of DM

20. LABORATORY FINDINGS ; confirmation of DM :random BS>200mg FBS>126mg/dl 2HPP>200mg/dl IGT---- BS=140-200 FBS=110-126 mg/dl EMG&NCV abnormalities S>M D>P leg>hand PATHOLOGY: small vessel occlusion—immune mediate—loss of myelinated fibers—axonal degeneration

21. painless distal D N----large fiber painful distal D N-----small fiber PATHOGENESIS OF D N: nerve blood flow- endoneurial vascular resistance– myoinositol-activate polyol pathway------aldosereductase)-accumulation of sorbitol & fructose - autooxidation -endoneurial hypoxia : impairment of axonal transport & reduce nerve NA-K ATP ase activity----- axonal atrophy

22. TREATMENT optimal glucose control insulin pump----at 5 years reduce 64% pancreas transplantation prevents of DN myoinositol ? alberstatin ? lipoic acid----improved sensory symptoms(and also C peptide) VEGF----- nerve blood flow

23. IV methyl prednisolone—IVIG SYMPTOMATIC O H: 6-10 inches head elevated—drinking two cups of cofee—eating more frequent small meals—daily fluid intake & salt ingestion(10-20gr/d)-elastic body stocking-fludrocortisone(/1-/6mg/d)-midodrin Fluoxetin-dDAVP-octreotide NSAIDs(ibuprofen)-phenylpropanolamine-metoclopramide-tetracycline or erythromycin-clonidin

24. G U COMPLICATIONS-----urologist frequent voiding-manual abdominal compression-intermittent cathaterization—betanechol-sildenafil-proper skin care

25. Management of neuropathic pain 30-50% reduction of pain ASA-acetaminophen-NSAIDs TCA block of serotonin &NE reuptake amitriptyline(10-25mg)-desiprmine nortriptyline SSRI are less effective

26. Venlafaxine has fewer side effect than TCA 150-225 mg/day Doxepin Duloxetine 60-120 mg/day moderate effect Bupropion 300 mg/day 30%reduced pain Anticonvulsants: Carbamazepine 1000-1600mg/day Oxcarbazepine1200mg/d

27. Gbapentin300mg/d--------900-3600mg/d Pregabalin150-600mg/d Topiramatehas minor effect Lamotrigine200-400mg/d moderate relief Mexiletine(oral analog of lidocaine) ? Tramadol 200-400mg/d Dextromethorphan high dose---partial relief ataxia-sedation

28. Narcotic analgesics should be limited-oxycodon Alpha lipoic acid 600 mg/d TENS 15-30 min/d 4 weeks Acetyl L carnitin100mg tds Topical agents: capsaicin cream o.o25 or o.o75 patches containing 5% lidocain

30. STROKE & DM Increased risk of CVD 2-4 folds mortality & morbidity Macrovascular involvement is leading cause of death due to DM DM atherosclerosis-cardiac embolism

31. Retinopathy & autonomic neuropathy increased risk of ischemic stroke High insulin level in DM is associated with risk of athersclerosis and cerebrovascular small vessel disease DM abnormalities of platelet-rheological- coagulation-fibrinolytic may play a role in the pathogenesis of stroke

32. HCT-fibrinogen-factor 5&7-platlet aggregation& adhesion-release of beta thromboglobulin--- RBC deformability and fibrinolytic activity

33. SLEEP DISORDER IN DM Particulary autonomic DN causes OSA&CSA CSA fragmentation of sleep EDS

34. Hypoglycemic Encephalopathy This condition is now relatively infrequent but is an impor­ tant cause of confusion, convulsions, stupor, and coma;

35. Hyperglycemia Seizures and focal signs such as a hemiparesis, a hemisensory defect, choreoathetosis, or a homonymous visual field defect are more common than in any other metabolic encephalopathy and may erroneously suggest the possibility of a stroke.