Diabetic Neuropathy

Question 1

Definition of diabetic neuropathy

Answer 1

Characterised by the presence of symptoms/signs of peripheral nerve dysfunction and/or autonomic nerve dysfunction
• Usually a diagnosis of exclusion, but most patients are asymptomatic

Question 2

Aetiology of diabetic neuropathy

Answer 2

• Hyperglycaemia induced complication
• Other risk factors:
◦ Age
◦ Duration of diabetes (due to increased exposure to hyperglycaemia)
◦ Poor glycaemic control
◦ Height (longer nerves in lower limbs of tall people)
◦ Smoking
◦ Hypertension
◦ Presence of diabetic retinopathy (increased risk if already have microvascular complications)

Question 3

Pathophysiology of diabetic neuropathy

Answer 3

• Small vessels supplying nerves are called vasa nervorum
• Neuropathy occurs when the vasa nervorum get blocked; hence the nerves get affected

Question 4

History and examination of diabetic neuropathy

Answer 4

• Asymptomatic: 50% of patients are asymptomatic

Peripheral
• Pain (peripheral): often the reason for presentation. Can experience sticking, burning, aching, prickling or excessively sensitive type pain. Often worse at night and can disturb sleep
• Loss of sensation (peripheral): Usually affected in a ‘glove and stocking’ distribution
• Reduced or absent ankle reflexes
• Painless injuries: commonly develop at the feet. May see foot ulceration in more severe cases

Autonomic
• Resting tachycardia
• Postural hypotension
• Delayed gastric emptying, nausea and vomiting
• Constipation
• Urinary frequency, urgency, nocturia, incontinence, hesitancy etc

Question 5

Investigations of diabetic neuropathy

Answer 5

• Clinical diagnosis

Question 6

Treatment for diabetic neuropathy

Answer 6

Peripheral neuropathy:
1) Glycaemic control + Supportive care:
◦ Manage glycaemic control and risk factors to slow progression
◦ Supportive care includes, regular inspection of feet, good footwear, avoid walking barefoot (podiatry if required)
If PAINFUL: can give pregabalin or gabapentin

Peripheral neuropathy with ulceration:
1) Glycaemic control
+Offloading: bed rest to allow for wound to heal
+ Antibiotics if infected
+ Orthotic footwear
+ Amputation if all else fails

Question 7

Prevention and prognosis of diabetic neuropathy

Answer 7

Control hyperglycaemia
Annual diabetic foot check where sensation and foot pulses can be checked for as well . Ensure proper care of the feet

• Depends on how well the diabetes is managed. Improvement of glycaemic control can slow the progression of the neuropathy
• Autonomic neuropathy is associated with increased mortality

Question 8

Complications of diabetic neuropathy

Answer 8

• Foot wounds/ulcers
• Wound infection/gangrene
• Amputation silent MI/cardiac death