doctor's notes Claudio Italiano
Painful diabetic neuropathy is a common complication of diabetic patients. The day before yesterday I visited a young patient, with a fair degree of glyco-metabolic compensation, but suffering from aching pain in the lower limbs, which increased during the night, making sleep impossible. Neuropathic pain arises from a lesion of the somatosensory system, ie from the suffering of the nerves that make up the peripheral nervous system. It may present as an asymmetric diabetic neuropathy, as in amyotrophic mononeuropathies or as distal symmetric, sensory and motor polyneuropathies at the same time. The patient tells you that he feels his legs as if they were "made of cork" or of wood, in the sense that he lacks the fineness of perceptual sensitivity and moreover it is as if his legs "caught fire"!
Eye to chronic obstructive obliterans with the same burning pain. Make the differential diagnosis. Painful Diabetic Neuropathy or NDD is the form of symmetric sensory-motor polyneuropathy or PND in which chronic neuropathic pain is present, with various complications in the limbs that also consist of ulcerated lesions or charcot osteoarthropathy (cf. diabetic foot). Estimates of the prevalence of this form of neuropathy, NDD, are around 12-13%, while for PND 30%, then one in three patients will suffer from the painful form. The neuropathic pain of NDD severely compromises the quality of life of these diabetic patients and has significant social costs also because the individual's ability to work is impaired.
Do you feel your legs and feet fall asleep, as if they were plastic or huge?
Yes = points 1 NO = points 0
Do you have burns in your legs or feet? points 1
Are your feet insensitive to touch? You cut your nails and your skin and you do not even understand it? points 1
Do you have cramps in your calves? (see phlebopathy) 0 points
Do you have pinpricks on your feet and legs? points 1
If you rub the sheets on your feet and legs, do you suffer? points 1
If you take a shower, do you know if you wash your feet with hot or cold water? points 1
Did you suffer from corns, ulcerations on your feet, on your fingers, etc.? points 1
Did the doctor tell you about a diabetic neuropathy? points 1
Do you feel weak and weak during the day? (see decompensation) 0 points
Does the night get worse? points 1
If you walk, your legs hurt? points 1
Do your feet feel like wood while you walk? points 1
Is the skin on your feet dry and breaks? Is it dehydrated? points 1
Did you have amputated fingers? points 1
Total score (count the affirmative answers, pay attention to the items in blue color!)
Another test can be administered to the patient: the Diabetic Neuropathy Index, always to evaluate the sensory function and inspect the foot if neuropathic.
Foot inspection:
deformed
Dry skin
Infections
Trophic ulcers
If these signs are present then the score is 1
If absent = 0
Achilles reflex
If present = 1
If with reinforcement = 0.5
If present = 1
Vibratory sensitivity
Present = 0
Absent = 1
Reduced = 0.5
If the score is> 2 then the test is abnormal
Other evaluations that the doctor will do will be to ascertain the glycemia (see glycemic control) and after oral test OGTT; administer these tests, to get some more information about the neuropathy, then evaluate the characteristics of the pain:
Type, if burning, snappy, piercing, pungent, electric shock, pinprick, stabbing, cramping, like frost, like a pinch, beating, like a "toothache"
On the contrary: it is intermittent, paroxysmal or sudden, continuous, exacerbated at night;
It is accompanied by paresthesia, dysaesthesia, hyperesthesia, allodii, hypoalgesia
It has relapses: the patient does not rest, does not work, is depressed?
Are there any other reasons why you can have pain? (tumors, bone metastases, toxic substances, alcoholism,
The first thing to do, according to confirmation, among other things, a study, Epidemiology of Diabetes Interventions and Complications, is a good glycemic control that certainly takes advantage of intensive insulin therapy (treat to target. the role of alpha-lipoic acid or ALA is certainly important in the treatment, since PND recognizes oxidative stress as one of the most important causes.Now the only antioxidant that has shown a therapeutic role against placebo is ALA, cf. ALADIN III, in Sydney, the NATHAN II, the other Sydney II study, where effective oral care is also demonstrated, where treatments must last for at least 3 weeks, then the pain control drugs, gabapentin, antidepressants , anticonvulsivandi and alfa2 ligands.
Tricyclic antidepressants or ATC work by blocking the reuptake of noradrenaline and 5-HT, but at the supraspinal level they are responsible for death in the cardiopaths (sudden deaths), probably due to arrhythmic action. Amitriptyline is used starting from 10-25 mg at bedtime, but the effective dose is about 75 mg / day or even desipramine, with fewer anticholinergic side effects. Among the serotoninenrgici we have the duloxetine, which blocks the reuptake of 5-HT and norepinephrine in a powerful way, but can give dry mouth, hyperhidrosis, inappetence. Anti-convulsants such as carbamazepine, gabapentin, lamotrigine, topiramate, pregabalin, gabapentin. For gabapentin and pregabalin a certain efficacy has been demonstrated; they belong to the family of alpha and deta ligandi. These drugs are administered 3 times / day., The half-life is reduced. Finally, opioids can be used optimally, either alone or associated with gapentin, tramadol and oxycodone.