DIABETIC POLYNEUROPATHY Pr SONAN- DOUAYOUA Th Pr ASSI B FATO- YAMOUSSOUKRO 10/5/2013
INTRODUCTION
• Bilateral distal symmetrical and synchronous PN
• Frequency: PN (80%) / MN (PFP, CCS), PRN
• Symptomatic or subclinical (detection)
• Need for prevention as treatment is difficult
• Quality of life = handicapping
• Pain: 15 to 20% (T2DM)
• Diabetic foot:
• Amputation = 0.3 - 45%
• Early-mortality : > 50% (Kenya - Ethiopia)
EPIDEMIOLOGY
• Aggravating factors:
• Nutritional state (Ethiopia),
• Poor foot hygiene,
• Delayed diagnosis
• Sociocultural factors,
• Vascular: HBP, dyslipidemia,
• Modifiable factors: prevention and education
• Good glycemic control
• Good foot hygiene Tesfaye S, GillG:chronic diabetic complications in Africa African jour of diabetes 2011; 19: 37-40 Abbas Z, Archibald L. The diabetic foot in sub-Saharan Africa: a new management paradigm. Diab Foot J 2007; 10: 128–36 Nyamu P : risk factors and prevalence of diabetic foot ulcers at Kenyatta national hospital , Nairobi East Af Med J 2003 ; 80 36-42
CLINICAL DIAGNOSIS
1. History : distal painful paresthesias
– spontaneous or induced, nighttime / DN4 ≥ 4
2. Physical:
– Loss of sensitivity / pain and temperature: in a sockinglike distribution
– Impaired vibratory perception
– Deep Tendon Reflex : abolished or reduced
DN4 ≥ 4 + abnormalities in physical examination
1- burning
2- painful cold
3- electric shock
Yes
Yes
Yes
No
No
No
4- Tingling
5- Pins and needles
6- Numbness
7- Ichting
Yes Yes Yes Yes
No
No
No
No
8- hypoesthsia to touch
9- hypoesthesia to pin prick
Yes Yes
No
No
10- brushing: allodynia Yes No
SCORE / 10
QUESTIONNAIRE DN4
SCORE / 7
ELECTROPHYSIOLOGY
• Unsystematic examination: atypical forms :
asymmetric or motor
• Normal (small fiber neuropathy)
• Abnormal: sensory and axonal PN (80%)
TREATMENT- MONITORING
Etiological: glycemic control
Symptomatic: co-analgesics
Reduce neuronal hyperexcitability : antiépileptic drugs
paroxysmal pain (
Stimulate inhibition mechanisms : antidepressant
continous pain (burning)
Monitoring/ clinical examination: senstivity, reflex,
foot examination
Parry JP .Management of diabetic neuropathy. Am J Med , 1999, 107(2B), 27S- 33S.
ANALGESICS AND CO-ANALGESICS
ICD / CLASS BRAND NAME DOSAGE
Amitriptylin / ADTC Laroxyl drops or tabs 25 75 – 100MG/d
Clomipramin / ADTC Anafranil tabs 25 10mg 10-150 mg/d
Imipramin / ADTC Tofranil tabs 25mg 10-150 mg/d
Duloxetin / IRSNA
Venlafaxin/IRSNA
Cymbalta tabs 30 mg
Effexor tabs 25 - 50mg
60 mg/d
150mg- 225mg/d
Carbamazepin / AE Tégretol tabs LP 200 -400 mg 600-1600 mg/d
Clonazebam / AE Rivotril drops/tabs 0,5-3 mg/j1-2mg/d
Gabapentin / AE Neurontin tabs 100 -200 à 300 -600 mg 1200-3600 mg/d
Prégabalin / AE
Lamotrigin/ AE
Lyrica caps 25 5O 150 mg
Lamictal tabs 25 50 100 mg
300- 600mg/d
200- 500mg/d
Tramadol / OPIOID Trabar tabs 200-400 mg/d