Diabetic Neuropathy

Question 1

When there is hyperglycaemia the sugar in the blood is able to bind with other molecules in the blood, with no enzymatic activity. What is this process called?

1 - enzymatic glycation
2 - non-enzymatic glycation
3 - glycoselation
4 - glucosurinaemia

Answer 1

2 - non-enzymatic glycation

Question 2

When there is hyperglycaemia the sugar in the blood is able to bind with other molecules in the blood, with no enzymatic activity called non-enzymatic glycation. What 2 molecules does sugar typically bind with?

1 - carbohydrates and lipids
2 - lipids and albumin
3 - proteins and lipids
4 - proteins and carbohydrates

Answer 2

3 - proteins and lipids

Question 3

When there is hyperglycaemia the sugar in the blood is able to bind with other molecules in the blood, with no enzymatic activity called non-enzymatic glycation, binding with lipids and proteins. Why is this important?

1 - non-enzymatic glycation molecules are very pro-inflammatory
2 - non-enzymatic glycation increases LDL and atherosclerosis
3 - hyaline atherosclerosis causing stiff blood vessels
4 - a thickening of the basement membrane in blood vessels
5 - all of the above

Answer 3

5 - all of the above

• leads to damage to schwann cells

Question 4

When there is hyperglycaemia the sugar in the blood is able to bind with other molecules in the blood, with no enzymatic activity called non-enzymatic glycation, binding with lipids and proteins creating very pro-inflammatory molecules. This can then lead to:

• non-enzymatic glycation molecules are very pro-inflammatory
• non-enzymatic glycation increases LDL and atherosclerosis
• hyaline atherosclerosis causing stiff blood vessels
• a thickening of the basement membrane in blood vessels

At a blood vessel and membrane basis what 2 effects can the 2 above disease processes then cause?

1 - decreased blood flow
2 - increased blood flow
3 - decreased gas exchange due to basement membrane thickening
4 - leaky basemement membrane

Answer 4

1 - decreased blood flow

3 - decreased gas exchange due to basement membrane thickening

Question 5

Pericytes are specialist cells that are embedded in the basement membrane of blood capillaries. They wrap around endothelial cells of capillaries and have a close relationship between endothelial cells, astrocytes and neurons and are crucial for normal blood vessel function. Which of the following is NOT a function of pericytes?

1 - regulate blood vessel formation (angiogenesis)
2 - regulate blood flow
3 - regulates immune cells flow
4 - regulates blood glucose

Answer 5

4 - regulates blood glucose

Question 6

Diabetic neuropathy is a common condition in both type 1 and 2 diabetes. What % of patients with diabetes is this estimated to affect?

1 - 6-7%
2 - 16-27%
3 - 30-50%
4 - 60-70%

Answer 6

4 - 60-70%

Diabetic neuropathy is the MOST common cause of neuropathy in the world

Question 7

Diabetic neuropathy is damage to nerves caused by diabetes. Is this more common in T1DM and T2DM patients?

Answer 7

• T1DM = 34%
• T2DM = 26%

Question 8

Diabetic neuropathy is a common condition in both type 1 and 2 diabetes. In type 2 diabetes diabetic neuropathy can occur at any time. However, from the point of diagnosis, how long before type 1 diabetics are affected?

1 - immediately
2 - 1 year
3 - 5 years
4 - 10 years

Answer 8

4 - 10 years

BUT 50% of patients are asymptomatic

Question 9

Which of the following is NOT a risk factor for diabetic neuropathy?

1 - smoking
2 - gender
3 - Age >40 years.
4 - poor glycaemic control.
5 - disease duration
6 - hypertension.
7 - coronary heart disease.

Answer 9

2 - gender

All others are typical risk factors for CVD

Question 10

What is diabetic neuropathy is damage to nerve fibres. Are myelinated and non-myelinated both affected?

Answer 10

• yes

Question 11

Excessive levels of glucose in the body mean that in some tissues this can be converted into sorbitol. Sorbitol has been shown to slow the nerve conduction. How does this occur?

1 - reduces number of schwann cells
2 - increases Na+/K+ ATPase activity
3 - forms thrombosis in nerves
4 - reduces Na+/K+ ATPase activity

Answer 11

4 - reduces Na+/K+ ATPase activity

• less Na+ released at nodes of ranvier meaning less depolarisation

Question 12

In diabetic neuropathy, which 2 of the following are commonly reduced, which can lead to increased susceptibility to clot?

1 - vitamin K
2 - thrombomodulin
3 - plasminogen
4 - protein A

Answer 12

2 - thrombomodulin
3 - plasminogen

• both are involved in reducing blood clots

There are also morphological abnormalities and vasa nervorum (blood supply to nerves)

Question 13

Diabetic neuropathy can affect both sensory and motor function. Which is typically affected the most?

Answer 13

• sensory

Question 14

In diabetic neuropathy are the peripheries or distal tissues affected the most?

Answer 14

• peripheries

Poorer blood supply

Question 15

There are different patterns of nerve injury in diabetic neuropathy. Which of the following is the most common presentation?

1 - radiculoplexopathy and radiculopathy
2 - mononeuropathy and mononeuritis multiplex
3 - autonomic neuropathy
4 - treatment-induced neuropathy

Answer 15

1 - radiculoplexopathy and radiculopathy

Also called distal symmetrical polyneuropathy ‘glove and stockings’

• loss of nerve stimulation where gloves and stockings would be worn

Question 16

Radiculoplexopathy and radiculopathy, also called distal symmetrical polyneuropathy ‘glove and stockings’ is the most common form of diabetic neuropathy. Which of the following sensations can be lost?

1 - pinprick
2 - temperature
3 - vibration
4 - proprioception
5 - reflexes
6 - all of the above

Answer 16

6 - all of the above

Increases the risk of foot ulcers and charcot foot. Patient’s advised to avoid weight bearing with a cast and treated with bisphosphonates

Question 17

Reflexes can be lost in diabetic neuropathy, is the ankle of knee reflex lost 1st?

Answer 17

• ankle

Knee reflex occurs later

Question 18

In addition to loss of motor and sensory function, patients can experience polyradiculopathy in diabetic neuropathy, which is damage to multiple nerve roots causing severe pain at the foot. Is this constant or intermittent?

Answer 18

• intermittent

Typically self limiting and resolves over 6-12 months

Caused by glucose inflammation of nerve roots

Question 19

In addition to loss of motor and sensory function, patients can experience polyradiculopathy in diabetic neuropathy, which is damage to multiple nerve roots causing severe pain at the foot. Is this pain worse during the day or the night?

Answer 19

• night

Question 20

There are different patterns of nerve injury in diabetic neuropathy. What is mononeuropathy?

Answer 20

• damage to a single nerve

Carpal tunnel syndrome is an example of this

Question 21

What is autonomic neuropathy?

Answer 21

• nerves controlling involuntary bodily functions are damaged

Question 22

Autonomic neuropathy is where nerves controlling involuntary bodily functions are damaged. How can autonomic neuropathy present?

1 - cardiovascular – resting tachycardia, postural hypotension
2 - gastrointestinal – delayed gastric emptying, diarrhoea, constipation
3 - genitourinary – bladder dysfunction
4 - hypoglycaemia unawareness
5 - hyperhidrosis (excessive sweating)
6 - all of the above

Answer 22

6 - all of the above

Has a high mortality rate (50% within three years) mainly due to chronic kidney disease

Question 23

Although diabetic neuropathy is common in diabetes patients, there are also other differentials that may cause the same symptoms in diabetes. Which of the following is the least likely differential for diabetic neuropathy?

1 - B12 deficiency (important for myelin production)
2 - hypothyroidism (increased fluid retention that compresses nerves)
3 - inflammatory conditions
4 - lupus

Answer 23

4 - lupus

B12 deficiency = important for myelin production

Hypothyroidism = increased fluid retention that compresses nerves

Question 24

From the age of 12, all patients with diabetes will have an annual review. Which of the following should be reviewed during the annual review?

1 - HbA1c test
2 - BP blood and cholesterol
3 - renal function
4 - weight and BMI
5 - eye check
6 - foot check
7 - all of the above

Answer 24

7 - all of the above

Education is essential alongside early detection of poor health

Question 25

Pain associated with diabetic neuropathy can be treated using analgesics. Which of the following is NOT a 1st line medication?

1 - tramadol
2 - amitriptyline
3 - duloxetine
4 - gabapentin
5 - pregabalin

Answer 25

1 - tramadol

Duloxetine = SNRIs anti-depressant
Amitriptyline = Tricyclic antidepressants
Gabapentin = epilepsy medication

Question 26

The following are a 1st line medications used to treat pain associated with diabetic neuropathy. Which of the following is contraindicated in patients with

1 - amitriptyline
2 - duloxetine
3 - gabapentin
4 - pregabalin

Answer 26

1 - amitriptyline

Decreases bladder detrusor muscle contraction

Question 27

The following are a 1st line medications used to treat pain associated with diabetic neuropathy:

• amitriptyline
• duloxetine
• gabapentin
• pregabalin

Which 2 of the following are a second line drug if the above drugs are ineffective?

1 - tramadol
2 - topical capsaicin
3 - haloperidol
4 - prochlorperazine

Answer 27

1 - tramadol
2 - topical capsaicin

If medications fail, can refer to the pain clinic