Managing diabetic neuropathy

Learn how to optimize the management of diabetic neuropathy for your patients.

Tracy Tylee, MD
Tracy Tylee, MD
10th Dec 2018 • 4m read

Managing the complications of diabetes can be just as tricky as managing the condition itself! By the end of this video, from our Diabetes Mellitus Masterclass, you'll know all about the optimal management of diabetic neuropathy to provide the best care for your patients.

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Video Transcript

[00:00:00] Diabetes can also affect the nerves, resulting in a number of different neuropathies. In fact, diabetic neuropathy is one of the most common complications of diabetes, affecting nearly 50% of patients. This can have a significant impact on patient's quality of life due to difficult to manage pain, as well as being a leading cause of nontraumatic amputations. Neuropathies can involve peripheral nerves, producing sensory and motor symptoms, as well as autonomic nerves affecting the function of the

[00:00:30] cardiovascular and gastrointestinal symptoms, sweat glands, and sexual function. Neuropathies can have a significant negative impact on a patient's quality of life but the complications of neuropathy can be even more serious. Loss of protective sensation of the feet leads to foot ulcers and amputations. Neuropathies can cause balance trouble increasing risks for fallen fractures and autonomic neuropathies can cause gastroparesis and cardiac arrhythmias. Thus, it's important to recognize patients at risk for neuropathy and intervene when possible

[00:01:00] to prevent its development. The most important risk factor for diabetic neuropathy is longstanding poor glycemic control. Smoking and alcohol intake, along with metabolic abnormalities such as hyperlipidemia and hypertension, may also increase the risk of neuropathy. Let's start by taking a look at peripheral neuropathy. Recognizing neuropathy in your patients is important for early intervention to prevent progression and other complications. The most common form of diabetic neuropathy is symmetric distal sensory neuropathy.

[00:01:30] This presents with symmetric neuropathic symptoms in a glove and stocking distribution. It develops following longstanding hyperglycemia and involves damage to small nerve fibers, resulting in loss of pain and thermal sensation. It can also damage large nerve fibers, resulting in loss of touch in vibration perception and it can cause damage to sensory fibers, which causes paresthesias and pain. Unfortunately, there is no treatment to reverse neuropathy, thus, prevention is

[00:02:00] key. For all patients with diabetes, you should perform a visual inspection of their feet at each visit, to ensure that they have no ulcers or calluses and that their shoes fit appropriately. You should also assess for loss of protective sensation as this has been shown to increase the patient's risk of developing foot ulcers, which can be a serious complication of diabetes. The most commonly performed test to assess for intact sensation is the 10-gram monofilament test. In this test, a nylon monofilament is applied to the plantar [00:02:30] surface of the foot with enough force to cause the filament to buckle, designed to be at 10 grams of force. This should be performed at four areas on the plantar surfaces, the sites most likely to be affected in diabetic neuropathy. Other tests that should be performed include assessment of vibratory sense, using a 128 hertz tuning fork. This should be placed on the tip of the great toe. If the patient is unable to detect the vibration, while the examiner still feels vibration, this test is considered abnormal.

[00:03:00] Assessment for intact peripheral pulses should also be done at every visit. If there is concern for loss of protective function or vascular disease, referral to a podiatrist should be considered for evaluation of proper footwear or other interventions to decrease risk of ulceration. Diabetes can also cause autonomic neuropathies. These may be difficult to diagnose but can significantly impair quality of life. The autonomic neuropathies can affect multiple systems throughout the body. One of the most concerning complications of autonomic

[00:03:30] neuropathy is hypoglycemia unawareness, where patients no longer get autonomic symptoms associated with low blood sugars. They are at risk of loss of consciousness or seizures related to severe hypoglycemic events. Autonomic neuropathies can also involve the cardiovascular system and cause resting tachycardia or postural dizziness. Autonomic neuropathy in the gastrointestinal system causes gastroparesis, diabetic diarrhea or chronic constipation. Erectile dysfunction is a common consequence of autonomic neuropathy,

[00:04:00] and some patients may also note hyperhydrosis, particularly with increased sweating of the upper body and decreased sweating in the lower body. The treatment of the autonomic neuropathies is aimed at managing symptoms, in order to improve patient's quality of life. For hypoglycemia unawareness, a continuous glucose monitor can be life-saving. This will alarm as blood sugars start dropping, allowing patients to treat their low blood sugar, before they become confused. Many of these patients also need higher glucose targets to minimize the risk of developing hypoglycemia.

[00:04:30] For patients with orthostatic hypotension, increasing salt intake and the use of compression stockings can be helpful. If these interventions are not enough to control symptoms, fludrocortisone may be helpful. Patients with gastroparesis may benefit from dietary changes, consuming several small meals throughout the day. Medications that may provide some benefit include metoclopramide, which acts to stimulate gastric motility and domperidone, which is an option for patients who do not respond to or unable to tolerate metoclopramide. This is not available

[00:05:00] in the US but is available in Canada and other countries. Erectile dysfunction, due to autonomic neuropathy, is difficult to treat but patients may benefit from PDE5 inhibitors. Recognizing neuropathy is the first step in helping your patients to manage their symptoms, so be sure to ask about symptoms at each visit and treat as needed.