Diabetic peripheral neuropathy: Difference between revisions
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Hyperglycemia DDX}} | {{Hyperglycemia DDX}} | ||
===Peripheral Neuropathy=== | |||
*Mononeuropathy | |||
**Acute (trauma-related) | |||
**Chronic (nerve entrapment) | |||
*Mononeuropathy multiplex | |||
**Acute | |||
***Diabetes mellitus | |||
***Multifocal motor neuropathy | |||
***Vasculitic syndromes | |||
**Chronic | |||
***Acquired immunodeficiency syndrome | |||
***Leprosy | |||
***Sarcoidosis | |||
*Associated with autonomic features | |||
**Alcoholism | |||
**Amyloidosis | |||
**Chemotherapy-related neuropathy | |||
**Diabetes | |||
**Heavy metal toxicity | |||
**Porphyria | |||
**Primary dysautonomia | |||
**Vitamin B12 deficiency | |||
*Associated with pain | |||
**Alcoholism | |||
**Amyloidosis | |||
**Chemotherapy (heavy metal toxicity) | |||
**Diabetes | |||
**Idiopathic polyneuropathy | |||
**Porphyria | |||
**Paraneoplastic syndrome | |||
==Evaluation== | ==Evaluation== | ||
Revision as of 18:27, 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
- Cardiovascular (tachycardia, orthostatic hypotension, malignant arrhythmia)
- Gastrointestinal (gastroparesis, diabetic enteropathy with diarrhea, colonic hypomotility with constipation)
- Urogenital (neurogenic bladder, erectile dysfunction)
- Sudomotor (hypohydrosis, anhidrosis)
Clinical Features
- Spectrum of sensation from numbness to paresthesias to pain
- Autonomic symptoms as above
Differential Diagnosis
Hyperglycemia
- Physiologic stress response (rarely causes glucose >200 mg/dL)
- Diabetes mellitus (main)
- Hemochromatosis
- Iron toxicity
- Sepsis
Peripheral Neuropathy
- Mononeuropathy
- Acute (trauma-related)
- Chronic (nerve entrapment)
- Mononeuropathy multiplex
- Acute
- Diabetes mellitus
- Multifocal motor neuropathy
- Vasculitic syndromes
- Chronic
- Acquired immunodeficiency syndrome
- Leprosy
- Sarcoidosis
- Acute
- Associated with autonomic features
- Alcoholism
- Amyloidosis
- Chemotherapy-related neuropathy
- Diabetes
- Heavy metal toxicity
- Porphyria
- Primary dysautonomia
- Vitamin B12 deficiency
- Associated with pain
- Alcoholism
- Amyloidosis
- Chemotherapy (heavy metal toxicity)
- Diabetes
- Idiopathic polyneuropathy
- Porphyria
- Paraneoplastic syndrome
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]
- 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]
- Gabapentin is a questionably effective medication, but is low cost and has a relatively tolerable side effect profile
- March 2017 systematic review revealed gabapentin is not beneficial[5]
- Effective treatments include duloxetine, venlafaxine, pregabalin, oxcarbazepine, TCAs, atypical opioids (tapentadol)
- 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
- Graduation titration to 1800 - 3600 mg/day is necessary for it to be clinically effective[6][7]
- March 2017 systematic review revealed gabapentin is not beneficial[5]
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
- ↑ Pop-Busui R et al. Diabetic Neuropathy: A Position Statement by the American Diabetes Association. Diabetes Care 2017 Jan; 40(1): 136-154.
- ↑ 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.
- ↑ Moore RA, Straube S, Wiffen PJ, Derry S, McQuay HJ. Pregabalin for acute and chronic pain in adults. Cochrane Database Syst Rev 2009;3).
- ↑ 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.
- ↑ 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.
- ↑ Backonja M, Glanzman RL. Gabapentin dosing for neuropathic pain: evidence from randomized, placebo-controlled clinical trials. Clin Ther 2003;25:81–104.
- ↑ Dworkin RH, O’Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain 2007;132:237–251