交通银行太平洋百思买信用卡收费表.ppt

Diabetic Neuropathy Beverly J. Mathis, D.O. November 2007 Definition nComplex syndrome of neurological abnormalities caused by the metabolic and vascular complications of diabetes. Class I Subclinical Neuropathy nAbnormal electrodiagnostic tests Decreased nerve conduction velocity Decreased amplitude of evoked muscle or nerve action potential nAbnormal quantitative sensory testing Vibratory/ warming/cooling nAbnormal autonomic function tests Sinus arrhythmia (beat-to-beat heart rate variation) Increased pupillary latency Class II Clinical Neuropathy Diffuse neuropathy nDistal symmetric sensorimotor polyneuropathy nPrimarily small fiber neuropathy nPrimarily large fiber neuropathy nMixed Class II Clinical Neuropathy Autonomic neuropathy nAbnormal pupillary function nSudomotor dysfunction nGenitourinary autonomic neuropathy Bladder dysfunction nSexual dysfunction Class II Clinical Neuropathy Autonomic neuropathy Gastrointestinal autonomic neuropathy nGastric atony nGall bladder atony nDiabetic diarrhea nHypoglycemic unawareness (adrenal medullary neuropathy) Classification nDistal symmetric polyneuropathy nIndividual cranial or peripheral nerve palsies, especially cranial nerve III nAutonomic neuropathy nThoracic and lumbar nerve root disease nMononeuropathy multiplex (assymmetric involvement of peripheral nerves Incidence n10-18 percent have evidence at diagnosis of diabetes nIncreases up to 41 % at 10 years nProgession and severity directly correlates with diabetes control Glycemic control prevents diabetic neuropathy DCCT, NEJM 1993 Signs and Symptoms of Diabetic Peripheral Neuropathy nLoss of vibratory sensation and altered proprioception reflecting large-fiber loss nImpairment of pain, light touch and temperature is secondary to loss of small fibers Complications of Peripheral Neuropathy nFoot ulcers due to progressive sensory loss nMuscular Atrophy nCharcot foot with fractures, subluxation and sclerosis of bone Criteria for Diagnosis nLoss of touch sensation using a monofilament on the distal toes nLoss of vibratory sensation using a 128 Hz tuning fork at the first MCP joint nAbsent achilles reflex nMost important is to inspect the feet for callus formation Differential nVascular disease ischemia, vasculitis nMetabolic thyroid disease, B12 or B6 deficiency nDisc disease Pathogenesis nMetabolic accumulation of advanced glycosalation end products, accumulation of sorbitol and increased oxidative stress nIschemic small vessel disease nImpaired peripheral nerve repair Prevention nGLUCOSE CONTROL nOther risk factors though not proven include cigarette smoking, blood pressure control,no alcohol consumption and lipid treatment. Treatment of painful diabetic neuropathy nTier I Pregabalin Duloxetine Tier II Tricyclics, gabapentin, oxycodone Treatment of painful diabetic neuropathy nCapsaicin cream nAnticonvulsants lamotrigine, carbamazepine, topiramate nAnesthetic drugs mexilitine, lidocaine patches nAlpha-lipoic acid nTramadol Less studied treatments nL carnitine nNitro spray nNSAIDS (stay away from this one!) nTENS unit nVenlafaxine nACE inhibitors nAldose reductase inhibitors (too toxic) Autonomic neuropathy nOrthostasis use vasodilators and avoid overdiuresis. nNeurogenic bladder self cath, suprapubic catheter nGastroparesis motility agents metoclopramide, erythromycin, dulcolax, gastric pacemaker Autonomic neuropathy nDiabetic diarrhea due to stasis, often over treated with antimotility agents which can make it worse Soluble fiber Fibercon, metamucil firms up the stool Cholestyramine, Colistid bile resin binders 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