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Year 3 > Diabetic neuropathy (E&M) > Flashcards

Diabetic neuropathy (E&M) Flashcards

1
Q

Define diabetic neuropathy.

A

Peripheral nerve dysfunction and/or autonomic nerve dysfunction in diabetes patients by blockage of vasa vasorum.

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2
Q

What can diabetic neuropathy lead to?

A

Diabetic foot problems and ulceration (leading cause of diabetes-related hospital admissions and non-traumatic amputation)

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2
Q

How does diabetic neuropathy occur?

A

Chronic hyperglycaemia –> glycation of axon proteins –> neuropathy

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3
Q

Where do neuropathic ulcers usually occur in diabetic neuropathy?

A

Over pressure points like plantar surface of metatarsal head / hallux - painless with normal ABPI

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4
Q

What signs would a neuropathic ulcer from diabetic neuropathy show?

A

Painless with normal ABPI

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5
Q

What management is there for neuropathic ulcers from diabetic neuropathy?

A

Cushioned shoes to reduce callous formation

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6
Q

How can diabetic neuropathy be classified? (3)

A
  • diffuse neuropathy - most common, distal symmetrical sensorimotor polyneuropathy (small-fibre, large-fibre or mixed), glove and stocking distribution
  • mononeuropathy - isolated cranial/peripheral nerve e.g. CNIII, ulnar, median, femoral, peroneal
  • radiculopathy or polyradiculopathy - radiculoplexus neuropathy, thoracic radiculopathy
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7
Q

What is the most common chronic complication of diabetes?

A

Diabetic neuropathy

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8
Q

What does evidence show about the origin of the pain in diabetic neuropathy?

A

Although pain is generated principally by peripheral nerve injury, there is evidence that the CNS may play a significant role in disinhibition and amplification of pain - most effective drugs in treating painful diabetic neuropathy are centrally-acting (pregabalin, duloxetine, tapentadol)

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9
Q

What are the clinical features of peripheral neuropathy (diabetic neuropathy)? (6)

A
  • peripheral pain - burning/sticking/aching, worse at night
    • large-fibre: tight, band-feeling
    • small-fibre: burning
  • loss of peripheral sensation - glove and stocking distribution
  • peripheral dysesthesia - burning sensation in feet
  • reduced/absent ankle reflexes
  • peripheral painless injuries at pressure points
  • may be asymptomatic
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10
Q

How does mononeuropathy present (diabetic neuropathy)?

A

Sudden motor loss e.g. wrist drop, CN III palsy (down and out eye)

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11
Q

How do automatic symptoms of diabetic neuropathy present? (7)

A
  • resting tachycardia
  • urinary frequency/urgency/nocturia/incontinence/hesitancy/weak stream/retention
  • erectile dysfunction
  • constipation
  • difficulty swallowing
  • postural hypotension
  • gastroparesis - N&V, bloating, loss of appetite, early satiety (treated with metoclopramide - prokinetic that improves gastric emptying)
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12
Q

What can we give for gastroparesis in diabetic neuropathy?

A

Metoclopramide - prokinetic that improves gastric emptying

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13
Q

What other problem does autonomic neuropathy in diabetic neuropathy cause?

A

Impaired hypoglycaemia awareness

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14
Q

What are the clinical features of diabetic foot disease? (4)

A
  • ulceration
  • dry skin
  • reduced subcutaneous tissue
  • Charcot’s arthropathy (erythematous, oedema, calor)
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15
Q

How can you classify diabetic foot disease? (4)

A
  • grade 1: no systemic signs, well-demarcated, warm surroundings
  • grade 2: local swelling/induration, erythema<2cm, local pain, warmth and purulent discharge
  • grade 3: abscess, osteomyelitis (deep or chronic wound), septic arthritis, fasciitis
  • grade 4: SIRS (septic), apyrexia, pulse>90, RR>20
16
Q

What is a fetid foot (diabetic neuropathy)?

A

Chronic soft tissue and bone infection causes a foul exudate and usually requires extensive surgical debridement and/or amputation

17
Q

What might you find on examination in peripheral neuropathy (diabetic neuropathy)? (5)

A
  • peripheral loss of sensation
  • peripheral dysesthesia, weakness
  • gait ataxia
  • reduced/absent ankle reflexes
  • painless injuries
18
Q

What are some risk factors for diabetic neuropathy? (9)

A
  • poorly controlled hyperglycaemia
  • prolonged duration of diabetes (>10y)
  • older age (>70y)
  • tall stature
  • hypertension
  • dyslipidaemia with elevated triglycerides
  • CVD risk factors
  • obesity
  • smoking
19
Q

How is diabetic neuropathy usually diagnosed?

A

Clinical diagnosis

20
Q

What bloods do we do for diabetic neuropathy? (3)

A
  • fasting blood glucose
  • HbA1c (correlates with degree of glycaemic control)
  • serum lipid profile
21
Q

What blood tests do we do as exclusions for diabetic neuropathy? (7)

A
  • TSH
  • vitamin B12
  • electrolytes
  • U&Es
  • LFTs
  • FBC
  • ESR
22
Q

How do we test sensation in diabetic neuropathy? (3)

A
  • 10g monofilament
  • tuning fork (decreased vibration sense)
  • pinprick assessment (decreased sensation)
23
Q

What do nerve conduction studies show in diabetic neuropathy? (5)

A
  • slowing of conduction
  • decreased amplitude of sensory nerve action potentials
  • decreased amplitude of compound muscle action potentials
  • relative preservation of proximal conduction velocities
  • evidence of fibrillation potentials
24
Q

What are some differential diagnoses for diabetic neuropathy (treatable causes of neuropathies)? (8)

A
  • toxins (alcohol)
  • neurotoxic medications (chemotherapy)
  • vitamin B12 deficiency (especially if on metformin or PPI)
  • hypothyroidism
  • renal disease, monoclonal gammopathy
  • infections (HIV)
  • chronic inflammatory demyelinating neuropathy
  • inherited neuropathies and vasculitis
25
Q

What do we need to optimise to manage diabetic neuropathy?

A

Glycaemic control

26
Q

What is the 1st-line management for peripheral diabetic neuropathy without pain?

A
  • glycaemic control and supportive measures
  • diabetic foot care
27
Q

What is 1st-line (to 5th-line) for painful diabetic neuropathy?

A
  • 1st line: pregabalin / gabapentin / duloxetine
  • 2nd line: amitriptyline / venlafaxine (antidepressant / Na+ channel blocker)
  • 3rd line: topical capsaicin
  • 4th line: TENS, PENS or acupuncture
  • 5th line: spinal cord stimulation
28
Q

Which patients do we avoid amitriptyline in (diabetic neuropathy)?

A

Patients with BPH as it can cause urinary retention

29
Q

How do we manage automatic neuropathy in diabetic neuropathy? (5)

A
  • orthostatic hypotension - midodrine –> ephedrine –> fludrocortisone
  • gastroparesis - domperidone, metoclopramide, diet
  • diarrhoea - metronidazole, octreotide
  • bladder dysfunction - bethanechol
  • erectile dysfunction - sildenafil (PDE-5 inhibitor)
30
Q

How do we manage diabetic foot disease? (4)

A
  • mild (S. aureus or Streptococci) - flucloxacillin, co-amoxiclav
  • moderate to severe (gram +ve, -ve and obligate anaerobes) - ceftriaxone, flucloxacillin and metronidazole
  • P. aeruginosa - usually not necessary to treat
  • suspected MRSA - involve microbiology
31
Q

What are some complications of diabetic neuropathy? (7)

A
  • foot wounds/ulcers
  • wound infection/gangrene
  • amputation
  • silent MI (impaired heart rate variability)
  • depression
  • death
  • Charcot foot
32
Q

What is Charcot foot (complication of diabetic neuropathy)? (4)

A
  • loss of protective sensation in foot
  • increased blood flow to foot - due to autonomic neuropathy –> bone loss and weak bones susceptible to injury
  • unrecognised trauma
  • Charcot arthropathy - erythematous, oedema, calor
33
Q

Describe the prognosis of diabetic neuropathy.

A

Depends on how well diabetes is managed - improvement in BGC control may slow progression but recovery may be very slow

Year 3 (145 decks)

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