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Diabetic Neuropathy EMEGOAKOR NONSO. Outline Introduction Epidemiology Classification Risk factors Pathogenesis Clinical presentation Physical examination.

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Presentation on theme: "Diabetic Neuropathy EMEGOAKOR NONSO. Outline Introduction Epidemiology Classification Risk factors Pathogenesis Clinical presentation Physical examination."— Presentation transcript:

1 Diabetic Neuropathy EMEGOAKOR NONSO

2 Outline Introduction Epidemiology Classification Risk factors Pathogenesis Clinical presentation Physical examination Investigations Staging Differential diagnosis Treatment Prognosis Conclusion

3 INTRODUCTION Is the presence of symptoms and signs of nervous dysfunction in people with diabetes after exclusion of other causes It’s the commonest complication of long standing diabetes Up to 50% of diabetics will come down with one form of neuropathy or the other.

4 Epidemiology Up to 70% of people with diabetes will experience neuropathy Some form of neuropathy may already be present at time of making a diagnosis of type 2 DM 95.7% 0f patients with DFU had neuropathy(Ikem et al 2002 More than 60% of nontraumatic lower-limb amputations in the United States occur among people with diabetes following neuropathy

5 Classification of Diabetic Neuropathy Somatic polyneuropathy 1)Symmetrical sensory neuropathy(distal) 2)Asymmetrical motor neuropathy(proximal), including amyotrophy Mononeuropathy and mononeuritis multiplex Autonomic neuropathy

6 Risk Factors Poor glycaemic control Advanced age Long duration of diabetes Hypertension dyslipidaemia HLA DR3/DR4 phenotype  Smoking Heavy alcohol intake  Height i.e tall stature

7 Pathogenesis Hyperglycaemia is directly toxic to cells;altering cell growth,gene and protein expression,hence increasing ECM and TGF beta production Formation of AGES(advanced glycosylation end products); may disrupt neuronal integrity by stimulation of pro-inflammatory cytokines and complements

8 Pathogenesis ctd Polyol pathway; accumulation of sorbitol and fructose in schwann cells lead to decreased nerve myoinositol,reduced Na-k ATPase activity, impaired axonal transport,abnormal AP propagation and breakdown of nerve structure DAG/PKc pathway; pkc alters gene transcription for fibronectin,type 4 collagen,contractile proteins,ECM in the neurones

9 Pathogenesis Oxidative stress; increased free radicals and reactive oxygen species produced in DM cause direct damage to blood vessels(vasa nervorum) leading to nerve ischaemia and hypoxia This may be the major pathogenetic mechanism in mononeuropathies

10 Other mechanisms Immune mechanisms Decreased neurotrophic growth factors Decreased essential fatty acids Depletion of ATP by polyADP ribosylation

11 Symmetrical sensory polyneuropathy Most common form of diabetic neuropathy Affects distal lower extremities and hands (“stocking-glove” sensory loss) Symptoms – Feeling of numbness or deadness – Tingling, prickling,aching, burning sensations – Paresthesia(hyper/hypoasthesia,) – Loss of vibratory sensation – Loss of balance in the dark – Loss of pain sensation

12 Slides current until 2008 Painless nature of diabetic foot disease

13 Slides current until 2008 Sensory nerve damage

14 Asymmetric motor neuropathy Proximal muscle weakness(proximal myopathy) There may be distal involvement too. DM AMYOTROPHY; painful wasting of quadriceps femoris. Neuropathic pain; burning,crawling pain in the feet,shins and anterior thigh Worse at night, with hyperaesthesias No muscle wasting Resolves with good glucose control

15 Slides current until 2008 Motor nerve damage

16 Diabetic Amyotrophy

17 Cheiroarthropathy

18 Trigger finger

19 Mononeuropathy Peripheral mononeuropathy – Single nerve damage due to compression or ischemia – Pain and motor weakness of muscles supplied – Any nerve may be involved – CN 3, 6,7,peroneal nerve e.t.c – Mononeuritis multiplex-Multiple ischemic nerve damage – Occurs in wrist (carpal tunnel syndrome), elbow, or foot (unilateral foot drop)

20 Autonomic neuropathy CVS; resting tachycardia, fixed heart rate, orthostatic hypotension, loss of sinus arrhythmia, reduced exercise tolerance silent MI, hypoglycemia unawareness GIT; gastroparesis, autonomic diarrhea alternating with constipation, abdominal pain, fecal incontinence, abdominal bloating

21 Autonomic neuropathy ctd Urogenital system; incomplete bladder emptying, stasis, UTI,atonic painless distended bladder; erectile dysfunction and retrograde ejaculation, loss of libido, dyspareunia, Sudomotor symptoms; hyperhidrosis, anhidrosis, gustatory sweating, heat intolerance, dry skin

22

23 Physical Examination. Inspect feet for features/sequele of neuropathy; callousties, cracks,fissures, interosseous muscle wasting, flattened foot, high arch, claw toe, charcot arthropathy. Note following features on hand, wasting of small hand muscles, trigger finger, cheiroarthropathy

24 Slides current until 2008 Autonomic nerve damage

25 Slides current until 2008 Localized callus

26 Complications of Sensorimotor/poly neuropathy Ulceration (painless) Neuropathic edema Charcot arthropathy Callosities

27 NEUROLOGICAL ASSESMENT OF THE FOOT Light touch using cotton wool. Pin prick Joint position sense Vibration sense Temperature perception- hot & cold Light pressure using Semmes-Weinstein monofilament Deep tendon reflexes. Heel toe walking test

28 Screening for Neuropathy 128 Hz tuning fork for testing of vibration perception 10g Semmers monofilament The main reason is to identify patients at risk for development of diabetic foot(LOPS)

29 Slides current until 2008 Diabetic peripheral neuropathy screening tests Test sensation – Biothesiometer – Tuning fork – 10 gm monofilament Ankle reflexes

30 Diagnosis Tests for peripheral neuropathy Light touch and pin prick Vibration Deep tendon reflexes Muscle bulk and power

31 Tests for autonomic neuropathy Resting heart rate >100bpm HR variation during deep breathing (6 breaths per minute) – Max-min > 15bpm (<10 is abnormal) – R-R interval >1.17 HR response to vasalva-R-R>1,2 <16mmHg diastolic pressure rise during sustained hand grip Postural BP-2 mins after standing – Fall< 10mmHg normal – >30 mmHg abnormal

32 Investigations FBS and HbA1c EMG Nerve biopsy ECG FBC SEUC Vitamin B12 and folate levels ESR,CRP TFT ANA RF Serum protein electrophoresis MRI and CT

33 Staging N0-No neuropathy N1-Signs but no symptoms N2a-Mild symptomatic,pxt able to heel walk N2b-Severe symptomatic,pxt unable to heel walk N3-disabling diabetic polyneuropathy

34 Differential diagnosis Herpes Simplex mononeuropathy Ethanol neuropathy Vasculitic neuropathy Amyloid polyneuroathy Chronic inflammatory demyelinating olyradiculopathy B12/folate Malignancy Myocardial infarction Renal failure Drugs Cord problems Leprosy HIV/AIDS

35 Treatment Tight and stable glucose control slows the progression of neuropathy Drugs used in peripheral neuropathy include the antidepressants(amitryptiline, desipramine, imipramine, nortriptyline) SSRIs e.g duloxetine anticonvulsants like pregabalin, gabapentin, carbamazepine, lamotrigine However response haven’t been satisfactory and patients need lots of psychological support.

36 Neuropathic treatment ctd Other measures include, opiates,mexiletine,Topical capsaicin, lipoic acid, transdermal lidocaine patches TENS(transcutaneous electrical nerve stimulation) Use of custom shoes for neuropathic foot deformities Occupational therapy

37 Autonomic neuropathy-GIT Gastroparesis Improve glycaemic control Frequent small easier to digest meals Prokinetic drugs – Metoclopramide, domperidone, cisapride, erythromycin (250 mg tds) Jejunostomy Diarrhoea Codeine/loperamide/diphenoxylate Treat bacterial overgrowth (oxytet/erythromycin) if suspected/present Constipation; laxatives e.g senna

38 Autonomic neuropathy-CVS Orthostatic hypotension;  Increase dietary fluid and salt intake  Avoid dehydration  Compression stockings  Fludrocortisone, midodrine, clonidine

39 Autonomic neuropathy-UGS Bladder and voiding problems  Intermittent or permanent self catheterization  Prophylactic antibiotics ED: phosphodiesterase type 5 inhibitors, apomorphone, intracarvenosal or intraurethral prostaglandins, vacuum devices, or penile prosthesis, psychotherapy

40 Further measures Management and avoidance of other risk factors;  Treat hypertension and dyslipidemia  Avoid alcohol and smoking  Folate and B12 supplementation Follow up;  Examine feet  Use monofilament and tuning fork  Glycaemic assessment (HBA1c)

41 Counselling for patients with neuropathic foot Do check your feet each day for blisters, cuts, scratches, reddened areas. Use a mirror or ask someone else to help look at the soles. Do wash your feet each day. Dry them carefully especially between the toes. Do avoid extremely hot or cold water. Test them with your hand or elbow before use. Do apply a very thin coat of lubricating oil or cream on the skin after bathing if your skin is dry but not between the toes

42 Counseling ctd Do ask about therapeutic shoes if you have a foot deformity, such as bunions or claw toes or previous ulcer Do see your care provider for regular foot examination. Always protect your feet. Wear shoes both in and outside the house to avoid injury

43 Counseling ctd Don’t walk barefoot. Don’t walk on hot surfaces, such as sandy beaches or the cement, roads etc. Don’t put hot water bottles, electric blanket or heating pad on your feet. Don't cut corns, calluses or use chemical agents, corn plasters, strong antiseptics on your feet. Don’t soak your feet unless professionally advised. Don’t wear shoes without stockings. Don’t wear sandals with thongs between the toes. Avoid pointy-toe shoes, high heels, stilettos, strapless and backless shoes Don’t smoke Don’t put jewellery on your feet

44 Prognosis Repetitive trauma to a neuropathic area may cause ulceration and infection and amputations Neuropathic foot ulceration and amputation is the commonest cause of admission of DM patients Mortality is mainly from cardiac autonomic neuropathy. Such patients are at risk of sudden death

45 conclusion DM neuropathy is the commonest chronic complication in diabetics Poor glycaemic control and prolonged duration of DM are the greatest risk factors Major cause of non traumatic lower limb amputations as well as sudden deaths Strict blood glucose control is advised to prevent or delay it’s progression

46 THANK YOU FOR LISTENING


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