Diabetic neuropathy

short notes for ophthalmologists

  • needs good control of diabetes/blood pressure (see targets)
  • first line Cymbalta...duloxetine 60mg once a day (120mg day maximum dose; side effects: nausea, dry mouth, headache, sleepiness, dizziness see)
  • second line Pregabalin (side effects: sleepiness, dizziness) see. Dose 150 to 600 mg per day given in either two or three divided doses dose.
  • alternatives amitriptyline , Gababpentin
  • beware: carpal tunnel and serious cervical spine problems can cause pain, just like diabetic neuropathy. Low B12 can also cause a sensory neuropathy.
  • link for patients
  • Obstructive sleep apnoea can make the neuropathy worse, as can alcohol (as it is neurotoxic)
  • neuropathy can increase temporarily if diabetic control suddenly improves, but this type of neuropathy later does start to improve: good diabetic and blood pressure control is very helpful
  • see 2011 The Toronto Expert Panel on Diabetic Neuropathy
  • different types of neuropathy
    • proprioception
    • acute painful neuropathy
    • focal neuropathy (self-limiting)
    • motorneuropathy
    • pressure palsy
    • automomic neuropathy
  • types of automnomic neuropathy
    • cardiac..tachycardia
    • gastroparesis
    • bladder
    • erectile
    • sudomotor..sweaty skin
    • tests
      • standing and blood pressure
      • valsalva manaouvre and pulse
      • and other standard tests
  • pain from neuropathy
    •  worse at night
    • throbbing, stabbing, numbness, buring, shooting, electric shocks, pins and needles
    • reducing the peripheral oedeam schanging the drugs may help
    • pain is from lack of input into the spinal cord..then the spinal cord amplifies signals that it does receive.
  • neuropathy is from small fibre nerve damage; patients may not be diabetic, but may be pre-diabetic. Need GTT or 1 hour GTT.
  • at time of diagnsosi 10% of type 2 patietns have retinopathy, about the same as retinopathy. and 5% of patients develop it a year.

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