DIABETIC

POLYNEUROPATHY

Pr SONAN- DOUAYOUA Th

Pr ASSI B

FATO- YAMOUSSOUKRO 10/5/2013

INTRODUCTION

• Bilateral distal symmetrical and synchronous PN

• Frequency: PN (80%) / MN (PFP, CCS), PRN

• Symptomatic or subclinical (detection)

• Need for prevention as treatment is difficult

• Quality of life = handicapping

• Pain: 15 to 20% (T2DM)

• Diabetic foot:

• Amputation = 0.3 - 45%

• Early-mortality : > 50% (Kenya - Ethiopia)

PLAN

1 - EPIDEMIOLOGY

2- DIAGNOSIS

3- TREATMENT

EPIDEMIOLOGY

• Aggravating factors:

• Nutritional state (Ethiopia),

• Poor foot hygiene,

• Delayed diagnosis

• Sociocultural factors,

• Vascular: HBP, dyslipidemia,

• Modifiable factors: prevention and education

• Good glycemic control

• Good foot hygiene Tesfaye S, GillG:chronic diabetic complications in Africa African jour of diabetes 2011; 19: 37-40 Abbas Z, Archibald L. The diabetic foot in sub-Saharan Africa: a new management paradigm. Diab Foot J 2007; 10: 128–36 Nyamu P : risk factors and prevalence of diabetic foot ulcers at Kenyatta national hospital , Nairobi East Af Med J 2003 ; 80 36-42

CLINICAL DIAGNOSIS

1. History : distal painful paresthesias

– spontaneous or induced, nighttime / DN4 ≥ 4

2. Physical:

– Loss of sensitivity / pain and temperature: in a sockinglike distribution

– Impaired vibratory perception

– Deep Tendon Reflex : abolished or reduced

DN4 ≥ 4 + abnormalities in physical examination

DIAGNOSIS

Bilateral distal symetric synchronous

EASY

1- burning

2- painful cold

3- electric shock

Yes

Yes

Yes

No

No

No

4- Tingling

5- Pins and needles

6- Numbness

7- Ichting

Yes Yes Yes Yes

No

No

No

No

8- hypoesthsia to touch

9- hypoesthesia to pin prick

Yes Yes

No

No

10- brushing: allodynia Yes No

SCORE / 10

QUESTIONNAIRE DN4

SCORE / 7

ASSESSMENT OF PAIN

QUALITY OF LIFE: Psychological impact, sleep, work, family

ELECTROPHYSIOLOGY

• Unsystematic examination: atypical forms :

asymmetric or motor

• Normal (small fiber neuropathy)

• Abnormal: sensory and axonal PN (80%)

TREATMENT- MONITORING

Etiological: glycemic control

Symptomatic: co-analgesics

Reduce neuronal hyperexcitability : antiépileptic drugs

paroxysmal pain (

Stimulate inhibition mechanisms : antidepressant

continous pain (burning)

Monitoring/ clinical examination: senstivity, reflex,

foot examination

Parry JP .Management of diabetic neuropathy. Am J Med , 1999, 107(2B), 27S- 33S.

ANALGESICS AND CO-ANALGESICS

ICD / CLASS BRAND NAME DOSAGE

Amitriptylin / ADTC Laroxyl drops or tabs 25 75 – 100MG/d

Clomipramin / ADTC Anafranil tabs 25 10mg 10-150 mg/d

Imipramin / ADTC Tofranil tabs 25mg 10-150 mg/d

Duloxetin / IRSNA

Venlafaxin/IRSNA

Cymbalta tabs 30 mg

Effexor tabs 25 - 50mg

60 mg/d

150mg- 225mg/d

Carbamazepin / AE Tégretol tabs LP 200 -400 mg 600-1600 mg/d

Clonazebam / AE Rivotril drops/tabs 0,5-3 mg/j1-2mg/d

Gabapentin / AE Neurontin tabs 100 -200 à 300 -600 mg 1200-3600 mg/d

Prégabalin / AE

Lamotrigin/ AE

Lyrica caps 25 5O 150 mg

Lamictal tabs 25 50 100 mg

300- 600mg/d

200- 500mg/d

Tramadol / OPIOID Trabar tabs 200-400 mg/d

THANKS