Diabetic Neuropathy

Question 1

What is diabetic neuropathy?

Answer 1

Diabetic neuropathy is a type of nerve damage that can occur if you have diabetes. Diabetic neuropathy is a common complication of both type 1 diabetes and type 2 diabetes.

It is characterised by the signs and symptoms of peripheral or autonomic nerve dysfunction. Motor, sensory, and autonomic nerves may all be affected by diabetic neuropathy.

Question 2

When does diabetic neuropathy tend to occur in the duration of diabetes?

Answer 2

It tends to occur relatively early on in the progression of the disease, although many patients will be symptomless.

Question 3

What is the first sign of diabetic neuropathy?

Answer 3

delayed nerve signal transit time

Question 4

Why does delayed nerve signal transit time get effected?

Answer 4

This is a direct result of demyelination, as a result of damage to schwann cells. At this stage, the axon itself is still intact, and thus the potential for repair is still present. At a later stage, the axons become damaged, and here irreversible damage has occurred.

Question 5

Give 3 symptoms associated with diabetic neuropathy:

Answer 5

1) burning
2) numbness
3) paraesthesia

Question 6

Give 3 GI autonomic symptoms of diabetic neuropathy:

Answer 6

1) nausea
2) constipation
3) incontinence

Question 7

What is the epidemiology of diabetic neuropathy?

Answer 7

Can affect around 70% of people with diabetes
Diabetes is the most common cause of peripheral neuropathy globally

Question 8

What are the risk factors of diabetic neuropathy?

Answer 8

Poorly-controlled hyperglycaemia
Prolonged hyperglycaemia
Increasing age
Hypertension
Dyslipidaemia
Coexisting cardiovascular disease or risk factors
Obesity
Smoking

Question 9

What are the 5 types of Diabetic neuropathies?

Answer 9

1. Symmetric sensory neuropathy
2. Mononeuritis multiplex
3. Amyotrophy
4. Autonomic
5. small-fibre predominant neuropathy

Question 10

what is the most common form of diabetic peripheral neuropathy?

Answer 10

distal symmetrical sensory neuropathy

Question 11

what is distal symmetrical sensory neuropathy?

how does it present?

Answer 11

a diabetic peripheral neuropathy due to loss of large sensory fibres

• a glove and stocking distribution
• affects touch, vibration and proprioception

Question 12

what is small-fibre predominant neuropathy?

how does it present?

Answer 12

a diabetic peripheral neuropathy due to loss of small sensory fibres

• a glove and stocking distribution
• affects pain and temperature with episodes of burning

Question 13

what is diabetic amyotrophy?

Answer 13

a diabetic peripheral neuropathy

• causes severe pain around the thigh and hips with asymmetric proximal weakness due to inflammation of the lumbosacral plexus or cervical plexus

Question 14

what is mononeuritis multiplex?

Answer 14

a diabetic peripheral neuropathy involving >2 distinct peripheral nerves

• painful

Question 15

what is autonomic neuropathy?

how does it present?

Answer 15

a diabetic peripheral neuropathy due to damage of the vagus nerve

• postural hypotension
• gastroparesis
• constipation
• urinary retention
• arrhythmias
• erectile dysfunction

Question 16

what are the differential diagnosis for diabetic peripheral neuropathy?

Answer 16

• vitamine B12 deficiency
• alcohol-induced peripheral neuropathy
• chronic inflammatory demyelinating polyneuropathy
• hypothyroidism

Question 17

what are the investigations of diabetic peripheral neuropathy?

Answer 17

• neurological examination (assess sensory and motor deficits)
• nerve conduction studies
• blood tests (identify causes or differentials eg glucose, HbA1c, B12, TFTs and LFTs)

Question 18

what are the complications of diabetic peripheral neuropathy?

Answer 18

• foot ulcers due to loss of sensation
• cardiac, GI and genitourinary disturbances due to autonomic dysfunction

Question 19

what is the management for diabetic peripheral neuropathy?

Answer 19

• controlling blood glucose levels to prevent progression of diabetes
• symptoms control eg pain relief with gabapentin or pregabalin
• treat complications accordingly

Question 20

what is Charcot arthopathy?

Answer 20

a chronic, progressive condition characterised by destruction of bones/joints in patients with neuropathy > loss of sensation

• most commonly caused by diabetic peripheral neuropathy

Question 21

what are the clinical features of Charcot arthropathy?

Answer 21

6D’s

1. Destruction of bone and joint
2. Deformity
3. Degeneration
4. Dense bones
5. Debris of bone fragments
6. Dislocation

Question 22

where does Charcot arthropathy most commonly affect?

Answer 22

tarsometatarsal joints

• can affect any joint that has lost sensation due to neuropathy

Question 23

what is the differential diagnosis for Charcot arthropathy?

Answer 23

OSTEOMYELITITS!!!

Question 24

what are the investigations of Charcot arthropathy?

Answer 24

• clinical diagnosis
• X-ray
• MRI
• bone scans if other tests are inconclusive

Question 25

what is the conservative, medical and surgical management of Charcot arthropathy?

Answer 25

1. conservative

• prolonged off-loading
• orthotics

2. medical

• bisphosphonates (reduce bone destruction)
• neuropathic pain agents = gabapentin or pregabalin
• topical aesthetics

3. surgical

• resection of bony prominences
• correction of severe deformities
• amputation