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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 Joseph V. Campellone, MD Division of Neurology Cooper University Hospital
Diabetic Neuropathies Family of nerve disorders caused by DM
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 neuropathies Distal symmetric polyneuropathy sensory motor length-dependent
Diabetic neuropathies Distal symmetric polyneuropathy Small fiber neuropathy
Distal Symmetric polyneuropathy ~ 1/3 diabetics ½ painful ½ of neuropathy due to diabetes Strong correlate with glycemic control
Distal Symmetric polyneuropathyclinical features in DM Usually accompanies retinopathy nephropathy Pain is most common presenting symptom ataxia weakness
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 NeuropathiesSmall fiber neuropathy ED Orthostasis Arrhythmia / sudden death Gastroparesis Pain
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 PolyneuropathyDiagnosis Clinical presence of DM / IGT Compatible physical findings
Diabetic Symmetric PolyneuropathyDiagnosis Exam reflexes depressed distal > proximal length dependent sensory loss (stocking glove) Romberg distal > proximal motor atrophy, weakness
Diabetic Symmetric PolyneuropathyDiagnosis Exam (cont’d) Autonomic dry feet orthostasis Foot injury / infections
Diabetic Symmetric PolyneuropathyDiagnosis Clinical Electrodiagnosis (NCS / EMG)
Small Fiber NeuropathyDiagnosis – EMG / NCS Myelinated fibers Unmyelinated fibers
Small Fiber NeuropathyDiagnostic testing QST Autonomic testing Nerve biopsy Skin biopsy
Small Fiber NeuropathyDiagnosis - QST Lacomis D. Muscle Nerve 2002
Tests integrity of entire sweat pathway Requires elaborate, dedicated room Results based on % loss and pattern Thermoregulatory Sweat Test(TST)
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 Smith A. Neurology 2001;5:1701-4
Tricyclics Amitriptyline Imipramine Nortriptyline Diabetic neuropathySymptomatic treatment
Tricyclics AEDs Gabapentin Topiramate Pregabalin Other AEDs Diabetic neuropathySymptomatic treatment
Tricyclics AED Topicals Capsaicin Lidocaine cream Diabetic neuropathySymptomatic treatment
Tricyclics AED Topicals SSRIs Paroxetine Citalopram Diabetic neuropathySymptomatic treatment
Tricyclics AED Topicals SSRIs SNRIs Diabetic neuropathySymptomatic treatment Venlafaxine Duloxetine
Podiatric care / ophthalmologic care Treat concurrent vascular disease Glycemic control Diabetic neuropathyOther treatment
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 neuropathies Distal symmetric polyneuropathy Small fiber neuropathy Ischemic mononeuropathy cranial neuropathy Radiculopathy Peripheral
Diabetic cranial neuropathies 3rd 4th 7th
Diabetic neuropathies Regional neuropathic syndromes Diabetic amyotrophy Diabetic thoraco-abdominal neuropathy