Diabetic Neuropathies

Question 1

What is Diabetic neuropathy?

Answer 1

Not a single entity; rather, a number of different syndromes, each with a range of clinical and subclinical manifestations

Question 2

Where does pathology of most DN occur?

Answer 2

In the peripheral (surrounding) nervous system

Question 3

When should patients with DM1 and DM2 be assessed for DPN?

Answer 3

Dx (type 2) and 5 years after dx (type 1) and at least annually thereafter

Question 4

All pt’s with Dm should have what test to ID feet at risk for ulceration and amputation?

Answer 4

10 g monofilament testing

Question 5

True or false: s/s of autonomic neuropathy should be assessed in persons with DM and microvascular complications

Answer 5

True

Question 6

what is characteristic of Diabetic sensorimotor polyneuropathy (DSP)?

Answer 6

pain is bilateral, symmetrical (covering whole foot and particularly the dorsum), worse at night and interfering with sleep

Question 7

What are the most important differential diagnoses for conditions that mimic DN?

Answer 7

ETOH abuse, uremia, hypothyroidism, Vit B12 deficiency PAD, CA, inflammatory/infectious disease, elevated mercury levels, celiac disease and neurotoxic drugs

Question 8

What is the most common form of diffuse neuropathy in DM?

Answer 8

Chronic sensorimotor neuropathy (also referred to as distal diabetic polyneuropathy or distal symmetric polyneuropathy

(primarily involves the sensory nevers)

Question 9

What are the symptoms of chronic sensorimotor neuropathy?

Answer 9

pain, paresthesia, hyperesthesia, deep aching, burning and sharp stabbing sensations similar to put less severe than those described in ASN

Question 10

what characterizes large fiber neuroapthy?

Answer 10

Deep seat pain, wasting and weakness, numbness, pins/needs/tingling/ataxia, impaired vibration perception, loss of position sense, impaired nerve conduction velocity, risk of falling/fractures, interference w/ normal life

Question 11

What characterizes small fiber neuropathy?

Answer 11

Superficial pain, electric shock, burning, allodynia, autonomic dysfunction, thermal imperception, normal strength/reflexes, electrophysiologically silent, produces symptoms, quantitative sensory testing and skin biopsies, leads to morbidity and mortality

Question 12

True or false: When encouraging pt to achieve tight glycemic control, pt should be advised that neuropathy may get worse before getting better

Answer 12

True; during early phase of glycemic control when blood vessels are constricted, blood is shunted away from damaged area exacerbating the pain. Later body adapts by dilating blood vessels and increasing blood flow

Question 13

What is the key to managing acute sensory neuropathy (a variant of chronic sensorimotor neuropathy)

Answer 13

Achieving BG stability. Most pt’s also require med for neuropathic pain. The natural h/o this disease is resolution of symptoms w/in 1 year

Question 14

What is a potential diagnostic tools for chronic sensorimotor neuropathy?

Answer 14

Skin biopsy

Question 15

What is the greatest risk associated with small fiber neuroapthy?

Answer 15

Foot ulceration and subsequent gangrene and amputation

Question 16

What is the difference between nociceptive and non nociceptive pain?

Answer 16

neuropathic non nociceptive pain: arising as direct consequence of lesion or disease of somatosensory symptom

Nociceptive pain that is due to trauma, inflammation, or injury

Question 17

What are the initial pharmacologic treatments for neuropathic pai in DM?

Answer 17

Pregablin, duloxetine, or gabapentin

Three drugs considered to have comparable efficacy and tolerability

Question 18

What simple strategy that has proved effective in preventing amputations?

Answer 18

Diabetes foot care/education

Question 19

True or false: Autonomic neuropathy (AN) significantly impacts survival and QOL

Answer 19

True; almost least recognized and poorly understood complications of DM –> autonomic dysfunction has recently been shown to be a predictor of CV dysfunction

Question 20

What are some symptoms of AN?

Answer 20

Reduced exercise tolerance, syncope, orthostatic tachycardia, orthostatic bradycardia, orthostatic hypotension, edema, paradoxical supine or nocturnal hypertension heat intolerance (defective thermoregulation), GI and GU dysfunction

Question 21

When should pts with DM be screened for CAN?

Answer 21

DM2-at dx

Dm 1 after 5 years

Question 22

Which DM neuropathy is a signifiant cause of morbidity and mortality?

Answer 22

Cardia autonomic neuropathy; associated w/ high risk of cardiac arrhythmia and sudden death, possibly r/t silent myocardial ischemia

Question 23

What should a CDE teach a pt with cardiac denervation syndrome?

Answer 23

avoid heavy exercise, aerobic exercise and straining themselves. Stress test before beginning exercise program. Caution with intense insulin therapy (often have hypoglycemia unawareness)

Question 24

What nerve dysfunction is usually affected by AN r/t gastric emptying?

Answer 24

Vagal nerve is usually responsible for motility

Question 25

How is gastroparesis diagnosed?

Answer 25

solid phase gastric emptying study (BG should be under <240, as hyperglycemia will impair gastric emptying

Question 26

How does lower intestinal tract dysfunction manifest in pt with DM?

Answer 26

Constipation r/t damage of efferent autonomic nerves which leads to hypotonia and poor contraction of the smooth muscles to the gut

**diarrhea may also occur