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Diagnosis and Management of Diabetic Neuropathies

Diagnosis and Management of Diabetic Neuropathies. Part 2. 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 2 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. Distal Symmetric Diabetic NeuropathiesSubtypes Diabetologia 2000;43(8):957-973. Vinik A et al. Diabetic neuropathies. Adapted from Tables 1, 2. With kind permission of Springer Science+Business Media.

  3. Distal symmetric diabetic neuropathies: subtypes Neuropathy Large-fiber1 Deep-seated pain (A- type) Wasting and weakness Numbness, pins and needles, tingling,ataxia Impaired vibration perception Loss of position sense Loss of reflexes Impaired nerve conduction velocity Interferes with normal life Risk of falling and fractures Small-fiber2 Superficial pain (C-fiber type) Electric shock, burning, allodynia Autonomic dysfunction Thermal imperception Normal strength and reflexes Electrophysiogically silent Quantitative sensory testing and skin biopsies Produces symptoms Leads to morbidity and mortality 1Strotmeyer & Vinik, 2006; 2Vinik et al, 2001

  4. Large Fiber Neuropathies • Clinical presentation • Impaired vibration perception • Pain is A-delta type, deep-seated, gnawing • Numbness, ataxia • Wasting of small muscles of hands and feet "intrinsic minus" • Weakness • Increased blood flow, the hot foot • Risk • Falling and fractures • Charcot neuropathy Strotmeyer E, et al. J Bone Min Res. 2006;21:1803-1810.

  5. Impaired Glucose Tolerance and Neuropathy • Prospective screening of patients with “idiopathic sensory neuropathy” • 30% to 50% have IGT • IGT neuropathy • Overweight, family history of diabetes, primarily sensory (81%), pain (92%) (Hopkins, Utah studies) • IGT neuropathy similar to early diabetic neuropathy: 669 patients • 60% sensory, impotence in 40%, autonomic involvement in 33% Singleton JR et al. Diabetes. 2003;52:2867.

  6. Clinical Presentation:Small Fiber Neuropathy • Pain is C-fiber type, burning, superficial, allodynia • Early hyperesthesia and hyperalgesia, impaired neurovascular function • Late hypoesthesia and hypoalgesia • Impaired warm thermal and pain thresholds, decreased IENF • Decreased sweating • Normal strength, reflexes, and EMG!!! Vinik AI, et al. Exp. Clin. Endocrinol Diabetes. 2001;1099(Suppl 2):S451-S473.

  7. IENF Loss in Diabetic Neuropathy Control Metabolic Syndrome Diabetes Vinik AI, et al. Nature Clinical Practice Endocrinol Metab. 2006;2:269-281.

  8. Minimum Criteria for Diagnosis of DSP • Clinical methods are not sufficient • eg,  ankle reflexes not sensitive enough • Do not account for anthropometric parameters(age, height...) • Validated tests of nerve function are required • ≥2 abnormalities • Neuropathic symptoms (NSS ≥2) • Neuropathic signs (NIS ≥2) • Nerve conduction (NC) • Quantitative sensory tests (QST) • Quantitative autonomic test (QAT), with one of the two being 3 or 5 American Diabetes Association. Muscle Nerve. 1988;11:661.Dyck et al. Neurology. 1993;43:817. DSP, distal symmetric polyneuropathy

  9. Diabetic NeuropathiesStatement by American Diabetes Association • Diagnosis • Asymptomatic • ≥2 abnormalities • NE, NC, QAFT, QST, QMT • Symptomatic • ≥ 2 abnormalities • NE, NC, QAFT, QST, QMT NE, neurologic examination;NC, nerve conduction;QAFT, quantitative autonomic function test; QST, quantitative sensory test;QMT, quantitative motor test Boulton et al. Diabetes Care. 2005;28:956.

  10. ExaminationBedside Sensory Tests

  11. And What We Mistake for Diabetic Neuropathy • Claudication • Morton’s neuroma • Osteoarthritis • Radiculopathy • Charcot’s neuroarthropathy • Plantar fasciitis • Fibromyalgia • Tarsal tunnel syndrome

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