Diabetic peripheral neuropathy: Difference between revisions
 
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===Peripheral Neuropathy===
{{Peripheral neuropathy DDX}}
*[[Peripheral nerve syndromes]] (mononeuropathy)^
**Acute trauma
**Chronic nerve entrapment
*Mononeuritis multiplex^^
**Acute
***[[Diabetic peripheral neuropathy|Diabetes mellitus]]
***[[Polyarteritis nodosum]]
***Connective tissue diseases (e.g., [[SLE]], [[rheumatoid arthritis]])
**Chronic
***Multiple compressive neuropathies
***[[AIDS]]
***[[Sarcoidosis]]
***[[Acromegaly]]
***[[Leprosy]]
***[[Lyme disease]]
***Idiopathic
*Associated with autonomic features
**Alcoholism
**Amyloidosis
**Chemotherapy-related neuropathy
**Diabetes
**Heavy metal toxicity
**Porphyria
**Primary dysautonomia
**Vitamin B12 deficiency
*Associated with pain
**[[Alcohol user disorder]]
**Amyloidosis
**Chemotherapy (heavy metal toxicity)
**[[Diabetic peripheral neuropathy|Diabetes mellitus]]
**Idiopathic polyneuropathy
**[[Porphyria]]
**Paraneoplastic syndrome
**Vitamin B1 or B12 deficiency
**Arsenic or thallium poisoning
 
 
 
:^A condition in which a single nerve is damaged or compressed.
:^^A condition where damage to at least two separate peripheral nerves results in a painful, asymmetric, and asynchronous presentation of sensory and motor deficits.


==Evaluation==
==Evaluation==

Latest revision as of 21:57, 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

Clinical Features

Differential Diagnosis

Hyperglycemia

Diabetic Emergencies

Diabetes Mellitus (New or Known)

Medication/Drug-Induced

Physiologic Stress Response

  • Sepsis / critical illness (stress hyperglycemia — very common in the ED)
  • Trauma / major surgery / burns
  • Acute coronary syndrome / myocardial infarction
  • Stroke (especially hemorrhagic)
  • Pancreatitis (both a cause and consequence)
  • Shock (any etiology)
  • Pain (catecholamine surge)
  • Seizure (postictal)
  • Physiologic stress alone rarely causes glucose >200 mg/dL in non-diabetics; glucose >200 in a "stress response" should prompt evaluation for undiagnosed diabetes or prediabetes

Endocrine

Pancreatic

  • Pancreatitis (acute or chronic — destruction of islet cells)
  • Pancreatic malignancy (adenocarcinoma, neuroendocrine tumors)
  • Post-pancreatectomy
  • Cystic fibrosis-related diabetes
  • Hemochromatosis (iron deposition in pancreas — "bronze diabetes")

Toxic/Overdose

Other

  • Renal failure (chronic kidney disease, acute kidney injury — impaired insulin clearance AND insulin resistance)
  • Cirrhosis / hepatic failure (impaired glycogenolysis regulation)
  • Pregnancy (gestational diabetes, steroid administration for fetal lung maturity)
  • Parenteral nutrition (TPN, dextrose-containing fluids)
  • Post-transplant diabetes (immunosuppressants)

Complications of Diabetes (Not Causes of Hyperglycemia)

These are associated conditions that may be present alongside hyperglycemia but do not themselves cause elevated glucose:


Peripheral neuropathy



^A condition in which a single nerve is damaged or compressed.
^^A condition where damage to at least two separate peripheral nerves results in a painful, asymmetric, and asynchronous presentation of sensory and motor deficits.

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]
  • Gabapentin is a questionably effective medication, but is low cost and has a relatively tolerable side effect profile

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

  1. ↑ Pop-Busui R et al. Diabetic Neuropathy: A Position Statement by the American Diabetes Association. Diabetes Care 2017 Jan; 40(1): 136-154.
  2. ↑ 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.
  3. ↑ Moore RA, Straube S, Wiffen PJ, Derry S, McQuay HJ. Pregabalin for acute and chronic pain in adults. Cochrane Database Syst Rev 2009;3).
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ Backonja M, Glanzman RL. Gabapentin dosing for neuropathic pain: evidence from randomized, placebo-controlled clinical trials. Clin Ther 2003;25:81–104.
  7. ↑ Dworkin RH, O’Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain 2007;132:237–251
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