Halting the March of Painful Diabetic Neuropathy (original) (raw)
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Brain, 2021
Peripheral neuropathy is one of the most common complications of both type 1 and type 2 diabetes. Up to half of patients with diabetes develop neuropathy during the course of their disease, which is accompanied by neuropathic pain in 30–40% of cases. Peripheral nerve injury in diabetes can manifest as progressive distal symmetric polyneuropathy, autonomic neuropathy, radiculo-plexopathies, and mononeuropathies. The most common diabetic neuropathy is distal symmetric polyneuropathy, which we will refer to as DN, with its characteristic glove and stocking like presentation of distal sensory or motor function loss. DN or its painful counterpart, painful DN, are associated with increased mortality and morbidity; thus, early recognition and preventive measures are essential. Nevertheless, it is not easy to diagnose DN or painful DN, particularly in patients with early and mild neuropathy, and there is currently no single established diagnostic gold standard. The most common diagnostic ap...
Painful and non‐painful diabetic polyneuropathy: Clinical characteristics and diagnostic issues
Journal of Diabetes Investigation, 2019
Diabetic neuropathy (DN) is a common complication of diabetes and can be either painful or non-painful. It is challenging to diagnose this complication, as no biomarker or clear consensus on the clinical definition of either painful or non-painful DN exists. Hence, a hierarchical classification has been developed categorizing the probability of the diagnosis into: possible, probable or definite, based on the clinical presentation of symptoms and signs. Pain is a warning signal of tissue damage, and non-painful DN therefore represents a clinical and diagnostic challenge because it often goes unnoticed until irreversible nerve damage has occurred. Simple clinical tests seem to be the best for evaluation of DN in the general care for diabetes. Screening programs at regular intervals might be the most optimal strategy for early detection and interventions to possibly prevent further neuronal damage and to lower the economic burden of this complication. DEFINITIONS AND CLASSIFICATION OF DIABETIC NEUROPATHY The phenotype of DN is heterogeneous. The most common form of DN is a chronic symmetrical length-dependent sensorimotor polyneuropathy, termed diabetic polyneuropathy (DPN), which accounts for 75-90% of all DN cases. Other types of DN include autonomic neuropathy, diabetic radiculoplexopathy (formerly called diabetic amyotrophy), mononeuropathies and treatment-induced neuropathies (Figure 1;Table 1) 4,12,16. In the following, we will focus on DPN, which can be either painful
JPMA. The Journal of the Pakistan Medical Association, 2014
To conclude, diabetes is associated with a variety of chronic and acute neuropathies, the commonest form being distal symmetric polyneuropathy. Performing an annual screening through a good neurological history and clinical examination and using a sensitive screening tool can facilitate an early diagnosis. More sensitive and quantitative measures of detecting early peripheral nerve injury including skin biopsy for intra-epidermal and dermal nerve fiber density and confocal corneal microscopy, hold promise to identify neuropathy patients early in their disease course.
Evaluation in Diagnosis and Management of Diabetic Neuropathy
Journal of Diabetes Mellitus, 2021
The 100-year anniversary of insulin is explored by focusing on diabetic neuropathy. Neuropathy is so common to diabetes, it is well described even in the earliest accounts of diabetes. This article reviews the most common neuropathy syndromes, and the consensus of effective treatment for neuropathic pain. Pharmacological advances in neuropathy are still largely focused on pain control, not neuropathy intervention. The article reviews the established and lesser tested therapies used for pain control. It also reviews the pathophysiology of the disease state, including the many factors and steps that culminate to produce neuropathy and its different iterations. In the future, new ways to treat diabetic neuropathy may be geared toward treating specific pathophysiological step-points on the way to nerve damage. In the future, prevention and a deeper look at the impact of socioeconomic status as a predictor of diabetes will hopefully encompass a bigger part of pre-diabetic care.
Painful diabetic neuropathy: Diagnosis and management
Diabetes & Metabolism, 2011
The prevalence of painful diabetic peripheral neuropathy (PDN) is about 20% in patients with type 2 diabetes and 5% in those with type 1. Patients should be systematically questioned concerning suggestive symptoms, as they are not usually volunteers. As PDN is due to small-fibre injury, the 10 g monofilament pressure test as well as the standard electrophysiological procedures may be normal. Diagnosis is based on clinical findings: type of pain (burning discomfort, electric shock-like sensation, aching coldness in the lower limbs); time of occurrence (mostly at rest and at night); and abnormal sensations (such as tingling or numbness). The DN4 questionnaire is an easy-to-use validated diagnostic tool. Three classes of drugs are of equal value in treating PDN: tricyclic antidepressants; anticonvulsants; and selective serotonin-reuptake inhibitors. These compounds may be prescribed as first-line therapy following pain assessment using a visual analogue scale. If the initial drug at its maximum tolerated dose does not lead to a decrease in pain of at least 30%, another drug class should be prescribed; if the pain is decreased by 30% but remains greater than 3/10, a drug from a different class may be given in association.
Advances in the epidemiology, pathogenesis and management of diabetic peripheral neuropathy
Diabetes/Metabolism Research and Reviews, 2012
Diabetic peripheral neuropathy (DPN) affects up to 50% of patients with diabetes and is a major cause of morbidity and increased mortality. Its clinical manifestations include painful neuropathic symptoms and insensitivity, which increases the risk for burns, injuries and foot ulceration. Several recent studies have implicated poor glycaemic control, duration of diabetes, hyperlipidaemia (particularly hypertryglyceridaemia), elevated albumin excretion rates and obesity as risk factors for the development of DPN. Although there is now strong evidence for the importance of nerve microvascular disease in the pathogenesis of DPN, the risk factors for painful DPN are not known. However, emerging evidence regarding the central correlates of painful DPN is now afforded by brain imaging. The diagnosis of DPN begins with a careful history of sensory and motor symptoms. The quality and severity of neuropathic pain if present should be assessed using a suitable scale. Clinical examination should include inspection of the feet and evaluation of reflexes and sensory responses to vibration, light touch, pinprick and the 10-g monofilament. Glycaemic control and addressing cardiovascular risk is now considered important in the overall management of the neuropathic patient. Pharmacological treatment of painful DPN includes tricyclic compounds, serotonin-norepinephrine reuptake inhibitors (e.g. duloxetine), anticonvulsants (e.g. pregabalin), opiates, membrane stabilizers, the antioxidant alpha lipoic acid and others. Over the past 7 years, new agents with perhaps less side effect profiles have immerged. Management of patients with painful neuropathy must be tailored to individual requirements and will depend on the presence of other co-morbidities. There is limited literature with regard to combination treatment.
Diabetic Neuropathy: A Position Statement by the American Diabetes Association
Diabetes Care
Table 1-Classification for diabetic neuropathies Diabetic neuropathies A. Diffuse neuropathy DSPN c Primarily small-fiber neuropathy c Primarily large-fiber neuropathy c Mixed small-and large-fiber neuropathy (most common) Autonomic Cardiovascular c Reduced HRV c Resting tachycardia c Orthostatic hypotension c Sudden death (malignant arrhythmia) Gastrointestinal c Diabetic gastroparesis (gastropathy) c Diabetic enteropathy (diarrhea) c Colonic hypomotility (constipation) Urogenital c Diabetic cystopathy (neurogenic bladder) c Erectile dysfunction c Female sexual dysfunction Sudomotor dysfunction c Distal hypohydrosis/anhidrosis, c Gustatory sweating Hypoglycemia unawareness Abnormal pupillary function B. Mononeuropathy (mononeuritis multiplex) (atypical forms) Isolated cranial or peripheral nerve (e.g., CN III, ulnar, median, femoral, peroneal) Mononeuritis multiplex (if confluent may resemble polyneuropathy) C. Radiculopathy or polyradiculopathy (atypical forms) Radiculoplexus neuropathy (a.k.a. lumbosacral polyradiculopathy, proximal motor amyotrophy) Thoracic radiculopathy Nondiabetic neuropathies common in diabetes Pressure palsies Chronic inflammatory demyelinating polyneuropathy Radiculoplexus neuropathy Acute painful small-fiber neuropathies (treatment-induced) care.diabetesjournals.org Pop-Busui and Associates 137 Exercise intolerance Constipation c May alternate with explosive diarrhea care.diabetesjournals.org Pop-Busui and Associates 145