Diabetic Neuropathy

Question 1

What is diabetic neuropathy?

Answer 1

progressive nerve injury caused by chronic hyperglycemia

Question 2

Describe pathophysiology of diabetic neuropathy

Answer 2

Chronic hyperglycemia causes glycation of axon proteins + subsequent development of progressive neuropathy; typically affects multiple peripheral nerves

Question 3

What are the most common types of diabetic neuropathy?

Answer 3

Distal symmetric polyneuropathy + autonomic neuropathy

Question 4

List 4 symptoms of distal symmetric polyneuropathy

Answer 4

Distal symmetrical sensory loss: glove + stocking pattern with proximal progression
Numbness
Tingling
Dysesthesia

Question 5

What is dysesthesia? Give an example

Answer 5

Abnormal sensation that manifest with discomfort, irritation, itching, burning
e.g. burning feet syndrome with Sx that worsen at night

Question 6

Describe symptoms in diabetic neuropathy

Answer 6

Asymptomatic in 50%

Question 7

Which limbs are affected first in diabetic neuropathy?

Answer 7

Lower legs d
Due to length of the sensory neurons supplying this area

Question 8

Describe diagnosis of diabetic neuropathy

Answer 8

Dx of exclusion
r/o other causes of polyneuropathy

Question 9

What bloods may be performed in diabetic neuropathy?

Answer 9

FBC: r/o anaemia
ESR: r/o inflammatory disorders
Immunoelectrophoresis: r/o MM
LFTs: r/o hepatic disease
U+Es: r/o renal disease
B12: r/o deficiency
TFTs: r/o thyroid disease
HbA1c

Question 10

Describe management of diabetic neuropathy without pain

Answer 10

Glycemic control

Question 11

Describe management of diabetic neuropathy with pain

Answer 11

1st-line: Amitriptyline, Duloxetine, Gabapentin or Pregabalin
If 1st-line drug ineffective, try 1 of the other 3 drugs

Tramadol: ‘rescue therapy’ for exacerbations of neuropathic pain

Topical capsaicin: localised neuropathic pain

Pain Mx clinics may be useful in patients with resistant problems

Question 12

List 5 manifestations of diabetic autonomic neuropathy

Answer 12

Orthostatic hypotension (cardiovascular)
Diabetic gastroparesis: N+V, bloating
Diabetic diarrhoea
Bladder dysfunction
Erectile dysfunction

Question 13

What can be used for management of ED in diabetic autonomic neuropathy?

Answer 13

Sildenafil

Question 14

What can be used for management of orthostatic hypotension in diabetic autonomic neuropathy?

Answer 14

Adequate fluid intake, low salt diet, medication review
Midodrine

Question 15

What can be used for management of gastroparesis in diabetic autonomic neuropathy?

Answer 15

Erythromycin: increases gastric emptying in a dose-dependent manner

Metoclopramide has anti-emetic properties

Question 16

What can be used for management of diarrhoea in diabetic autonomic neuropathy?

Answer 16

Metronidazole

Question 17

What can be used for management of bladder dysfunction in diabetic autonomic neuropathy?

Answer 17

Bethanechol (parasympathomimetic)