Balgrist Symposium zum Diabetischen Fuss. Der Charcot-Fuss Oktober diabetic neuropathies. symptoms. signs. sensory disorders.

Transcription

1 symptoms sensory disorders spontaneous paraesthesia tingling burning by touch, pressure dysaesthesia sign pain continuous boring cutting drawing paroxysmal lancinating neuralgiform causalgic fluctuating, burning modulated by exogenous factors numbness through cellophane trough cardboard signs hypaesthesia dysaesthesia allodynia hyperpathia duration boundary Tinel s sign hypalgesia thermhypesthesia pallanaesthesia by touch pain by touch exceeding time of touching exceeding typical region of innervation Valleix s point

2 ceterum autem censeo Cato the elder Urs Schwarz junior

3 vibratory sense propagation of 128 Hz through the nervous system excellent parameter to judge evolution of neuropathy normal value if diminished 8 / 8 inattentive cerebral disorder skin problem neuropathy

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5 anatomy

6 clinical presentation small-fiber np burning pain + allodynia later hypoalgesia defective warm thermal sensation large-fiber np gnawing, dull toothache in the bones impaired vibration sensation sensory ataxia wasting of small muscles diminished reflexes increased blood flow (hot feet) autonomic np cardiovascular resting tachycardia orthostatic hypotension silent myocardial infarction gastrointestinal gastroparesis diarrhea/constipation genitourinary bladder dysfunction erectile dysfunction defective autonomic function decreased sweating dry skein impaired vasomotion remarkable intactness of tendon reflexes motor strength foot ulceration and gangrene electrophysiologically silent skin biopsy depressed tendon reflexes peripheral gustatory sweating pupillary abnormalities disturbed neurovascular flow edema metabolic hypoglycemia unawareness unresponsiveness

7 clinical presentation large-fiber np small-fiber np prox motor np acute mono np pressure palsies sensory loss motor deficit tendon reflexes pain N (+) allodynia 0 N N in nerve N + ++

8 Neurology 2011;76;1099

9 assessment of neurologic deficit and classification of neuropathic syndromes NDS NSS QAFT QST neuropathic disability score neuropathic symptom score quantitative autonomic function test quantitative sensory testing

10 1195 Patienten mit Polyneuropathie Häufigkeitsverteilung der Aetiologie Engelhardt, 1994

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12 theoretical pathophysiologic framework Diabetologia (2000) 43:957

13 the patient typically presents with an individual pattern of various neuropathic syndromes in addition, other causes may further complicate the clinical picture

14 clinical presentation

15 management of small-fiber neuropathies large-fiber neuropathies

16 treatment TREAT DIABETES medication

17 management of painful diabetic neuropathy

18 treatment cause best possible treatment of diabetes remove additional toxins (alcohol) supply vitamins alternatives comfortable shoes local application of cold or warmth Transcutaneous Electrical Nerve Stimulation medication primarily as monotherapy try at least for 4 weeks before judging efficacy

19 time frame studies 2234 > 463

20 LYRICA Kosten Lyrica 300mg: 168 = > 5.50/d -> 2000/a Tegretol 400mg: 200 = > 1.20/d -> 420/a

21 adverse effects of treatment tricyclic antidepressants anticholinergic arrhythmia body weight SSRI antidepressants dizziness nausea sexual dysfunctions antiepileptics opiate opioids topic dizziness nausea withdrawal symptoms confusional state exanthema liver disorders kidney stones dependence initially painful