Diabetic peripheral neuropathy: Difference between revisions
 
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===Categories===
===Categories===
*Distal symmetric polyneuropathy (DSPN), most common at 75% of all neuropathies
*Distal symmetric polyneuropathy (DSPN), most common at 75% of all neuropathies
*Mononeuropathies (cranial nerves, radiculopathy)
*Mononeuropathies ([[cranial nerve palsies|cranial nerves]], radiculopathy)
*Diabetic autonomic neuropathies
*Diabetic autonomic neuropathies
**Cardiovascular (tachycardia, orthostatic hypotension, malignant arrhythmia)
**Cardiovascular ([[tachycardia]], orthostatic [[hypotension]], malignant [[arrhythmia]])
**Gastrointestional ([[gastroparesis]], diabetic enteropathy with diarrhea, colonic hypomotility with constipation)
**Gastrointestinal ([[gastroparesis]], diabetic enteropathy with [[diarrhea]], colonic hypomotility with [[constipation]])
**Urogenital (neurogenic bladder, erectile dysfunction)
**Urogenital (neurogenic bladder, erectile dysfunction)
**Sudomotor (hypohydrosis, anhidrosis)
**Sudomotor (hypohydrosis, anhidrosis)


==Clinical Features==
==Clinical Features==
*Spectrum of sensation from numbness to paresthesias to pain
*Spectrum of sensation from [[numbness]] to [[paresthesias]] to pain
*Autonomic symptoms as above
*Autonomic symptoms as above


==Differential==
==Differential Diagnosis==
{{Hyperglycemia DDX}}
{{Hyperglycemia DDX}}


==Workup==
 
{{Peripheral neuropathy DDX}}
 
==Evaluation==
*Clinical diagnosis
*Blood glucose level
*Blood glucose level
*See [[diabetes]]
*See [[diabetes]]
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**March 2017 systematic review revealed gabapentin is not beneficial<ref>Waldfogel et al. Pharmacotherapy for diabetic peripheral neuropathy pain and quality of life. ublished online before print March 24, 2017, doi: http:/​/​dx.​doi.​org/​10.​1212/​WNL.​0000000000003882
**March 2017 systematic review revealed gabapentin is not beneficial<ref>Waldfogel et al. Pharmacotherapy for diabetic peripheral neuropathy pain and quality of life. ublished online before print March 24, 2017, doi: http:/​/​dx.​doi.​org/​10.​1212/​WNL.​0000000000003882
Neurology.</ref>
Neurology.</ref>
***Effective treatments include [[duloxetine]], [[venlafaxine]], [[pregabalin]], [[oxcarbazepine]], TCAs, atypical opioids (tapentadol)
***Effective treatments include [[duloxetine]], [[venlafaxine]], [[pregabalin]], [[oxcarbazepine]], [[TCAs]], atypical [[opioids]] (tapentadol)
***Ineffective treatments include [[dextromethorphan]], [[gabapentin]], typical opioids (oxycodone),  topical capsaicin
***Ineffective treatments include [[dextromethorphan]], [[gabapentin]], typical [[opioids]] ([[oxycodone]]),  topical '[[capsaicin]]
**Gabapentin 300 mg QHS, increased to 300 mg BID, increased to 300 mg TID over 2-3 weeks
**Gabapentin 300 mg QHS, increased to 300 mg BID, increased to 300 mg TID over 2-3 weeks
**Graduation titration to 1800 - 3600 mg/day is necessary for it to be clinically effective<ref>Backonja M, Glanzman RL. Gabapentin dosing for neuropathic pain: evidence from randomized, placebo-controlled clinical trials. Clin Ther 2003;25:81–104.</ref><ref>Dworkin RH, O’Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain 2007;132:237–251</ref>
**Graduation titration to 1800 - 3600 mg/day is necessary for it to be clinically effective<ref>Backonja M, Glanzman RL. Gabapentin dosing for neuropathic pain: evidence from randomized, placebo-controlled clinical trials. Clin Ther 2003;25:81–104.</ref><ref>Dworkin RH, O’Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain 2007;132:237–251</ref>
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*[[Weakness]]
*[[Weakness]]


==Sources==
==References==
<references/>
<references/>


[[Category:Endocrinology]]
[[Category:Endocrinology]]

Latest revision as of 21:57, 23 April 2025

Background

  • Diagnosis of exclusion
  • Most prevalent chronic complication of diabetes, risk of injuries due to insensate feet
  • Ultimately need follow up with primary care, not to be managed in the ED

Categories

  • Distal symmetric polyneuropathy (DSPN), most common at 75% of all neuropathies
  • Mononeuropathies (cranial nerves, radiculopathy)
  • Diabetic autonomic neuropathies

Clinical Features

Differential Diagnosis

Hyperglycemia


Peripheral neuropathy



^A condition in which a single nerve is damaged or compressed.
^^A condition where damage to at least two separate peripheral nerves results in a painful, asymmetric, and asynchronous presentation of sensory and motor deficits.

Evaluation

  • Clinical diagnosis
  • Blood glucose level
  • See diabetes

Management

  • Optimize glucose control
  • First-line medications per ADA position paper 2017[1]
    • Pregabalin 50 - 100 mg PO TID, starting at 50 mg TID, increasing to 100 mg TID after 1 week, max dose 600 mg/day[2]
      • More rapid onset of action and less titration necessary as compared to gabapentin[3]
      • However, extremely cost prohibitive for self-pay
    • Duloxetine at 60 - 120 mg/day, starting 30 mg PO BID, increasing to goal after 1 week, max 120 mg/day
      • SNRI, anti-depressant, not as cost-prohibitive as pregabalin
      • Does not appear to be associated with significant cardiovascular risk[4]
  • Gabapentin is a questionably effective medication, but is low cost and has a relatively tolerable side effect profile

Disposition

  • Follow up with primary care for long-term management and up-titration of medications if started in the ED
  • Admission for severe complications, such as severe diabetic foot infection

See Also

References

  1. ↑ Pop-Busui R et al. Diabetic Neuropathy: A Position Statement by the American Diabetes Association. Diabetes Care 2017 Jan; 40(1): 136-154.
  2. ↑ Freeman R, Durso-Decruz E, Emir B. Efficacy, safety, and tolerability of pregabalin treatment for painful diabetic peripheral neuropathy: findings from seven randomized, controlled trials across a range of doses. Diabetes Care 2008;31:1448–1454.
  3. ↑ Moore RA, Straube S, Wiffen PJ, Derry S, McQuay HJ. Pregabalin for acute and chronic pain in adults. Cochrane Database Syst Rev 2009;3).
  4. ↑ Wernicke J et al. An evaluation of the cardiovascular safety profile of duloxetine: findings from 42 placebo-controlled studies. Drug Saf. 2007;30(5):437-55.
  5. ↑ Waldfogel et al. Pharmacotherapy for diabetic peripheral neuropathy pain and quality of life. ublished online before print March 24, 2017, doi: http:/​/​dx.​doi.​org/​10.​1212/​WNL.​0000000000003882 Neurology.
  6. ↑ Backonja M, Glanzman RL. Gabapentin dosing for neuropathic pain: evidence from randomized, placebo-controlled clinical trials. Clin Ther 2003;25:81–104.
  7. ↑ Dworkin RH, O’Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain 2007;132:237–251
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