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