Diabetic Neuropathy

Question 1

What are the types of diabetic neuropathy

Answer 1

Distal Symmetrical Sensory Neuropathy
Small-fibre Predominant Neuropathy
Diabetic Amyotrophy
Mononeuritis Multiplex
Charcot Arthropathy.
Autonomic neuropathy → gastroparesis, chronic diarrhoea, GORD

Question 2

Describe peripheral neuropathy from diabetes

Answer 2

Sensory loss in glove and stocking distribution
lower legs affected first due to the length of the sensory neurons supplying the area

Distal symmetrical sensory - typically affecting touch, vibration and proprioception.
Small-fibre predominant - pain and temperature sensation

Question 3

Management for peripheral neuropathy

Answer 3

Diabetic neuropathy is now managed in the same way as other forms of neuropathic pain:

first-line: amitriptyline, duloxetine, gabapentin or pregabalin
Second line: try alternative first line
± topical capsaicin for localised neuropathic pain (e.g. post-herpetic neuralgia)
± Pain management clinic referral

Rescue therapy: tramadol

Question 4

Clinical features of autonomic neuropathy as a result of diabetes

Answer 4

Gastroparesis:
- Erratic blood glucose control
- Bloating
- Vomiting
Chronic diarrhoea
- often occurs at night
Gastro-oesophageal reflux disease
- caused by decreased lower esophageal sphincter (LES) pressure

Question 5

Management for diabetic autonomic neuropathy

Answer 5

Metoclopramide
Domperidone
Erythromycin (prokinetic agents)

Question 6

Describe diabetic amyotrophy

Answer 6

Originates from inflammation of the lumbosacral plexus or cervical plexus.
Characterised by severe pain around the thighs and hips, along with proximal weakness.

Question 7

Describe mononeuritis multiplex

Answer 7

Typically painful.
Defined as neuropathies involving two or more distinct peripheral nerves

Question 8

Describe Charcot arthropathy and its management

Answer 8

Destructive changes in the bones and joints
‘6Ds’: Destruction, Deformity, Degeneration, Dense bones, Debris, and Dislocation
Must rule out osteomyelitis -> XR
Management focuses on immobilisation, orthotics, medication to manage pain and bone loss, and surgical interventions in advanced or refractory cases

Question 9

Investigations for diabetic neuropathy

Answer 9

Neuro exam

Glucose
HbA1c
B12/folate
TFTs
LFTs

Nerve conduction studies