Skip to main content
Loading Explore guides…
Diabetic Neuropathy · Acedra
Home
Explore
Medicine
Diabetic Neuropathy
Sign in to save
Chat
If YouTube asks you to sign in, open the video on YouTube.
Watch on YouTube
Reload player
Transcript
99 segments
Copy
Hide video
0:00
So lets review diabetic neuropathy understanding it as one of the main complications of diabetes as you know the blue circle is an international symbol for diabetes and that we previously reviewed in the upper link much more information So we must first know somethings about nerves briefly we can divide the nervous system in two main areas, the central nervous system and peripheral nervous system the central nervous system includes the brain and spinal cord, and the peripheral nervous system
0:41
so everything but the previously mentioned so all the other nerves
0:50
and of course the main difference between peripheral and central is the blood-brain barrier which protects the central nervous system that was also reviewed in a previous video so this blood-brain barrier helps the brain and spinal cord be exposed to very specific and controlled concentrations of every substance, toxins glucose, other nutrients, etc while the peripheral nervous system is much more exposed and usually with higher levels usually the same as the rest of the blood stream, so
1:30
when a toxin build up in the periphery our peripheral nervous system is immediately exposed Among our peripheral nerves we can divide the peripheral nervous system in 3 main components sensitive nerves autonomic nerves and motor nerves sensitive nerves carry sensations from the periphery to the central nervous system they are for example in charge of touch light and deep touch temperature and pain, vibrations and also proprioception that we have also covered in the past
2:11
when we reviewed touch and pain
2:15
so these nerves not oncly tell us if something is hurting or touching our skin but also the position of our body later on we will see its relevance Then we have the autonomic nerves that we reviewed in the Autonomic Nervous System video; in charge of unconsciously control all of our organs so they can tell the heart to work more or less or tell the intestines to work more or less according to the bodies needs, this explains why when we start eating our intestines start moving more
2:56
or when we start running our heart pounds faster Finally we have motor nerves that of course are in charge of motion thanks to the activation of muscles, of course these groups of nerves, sensitive, autonomic and motor work together and we have some nerves with mixed functions so they are motor and sensitive or sensitive and autonomic this is relevant because diabetes causes a polyneuropathy affecting the 3 types of nerves and all of its components in these nerves' functions
3:41
Now, how frequent is diabetic neuropathy? Diabetes is toxic for the 3 types of nerves sensitive, autonomic and motor and about 50% of patients develop some level of neuropathy so half of all diabetic patients whether diabetes mellitus type 1 or type 2 will develop neuropathy during their disease the prevalence is similar between type 1 and 2 however in type 1 we diagnose diabetes and many years later neuropathy develops while in type 2 we usually almost in 10% of patients
4:29
when we diagnose diabetes there is already some degree of neuropathy of course showing us that diabetes mellitus type 2 is a silent disease and when we make the diagnosis the patients has years of glucose alterations while diabetes type 1 is quickly diagnosed due to it's severity and the risk it poses to patients' lives but once again both types, 1 and 2 have the same prevalence but with different time of appearance one appears with the diagnosis the other one years after diagnosis
5:09
Now as the disease progresses there is an increase burden over quality of life so it makes diabetic patients have a poor quality of life because it causes frequent falls when patients can't move properly for example their legs causing them to trip they can fall, they have coordination problems and because they loose proprioception that is the ability to know the position of our body, this also leads to lack of balance and further falls The neuropathy, specially when it has sensitive components
5:43
can cause pain poor quality of life and depression The autonomic alterations can also impact quality of life because of its vast implications and it can increase mortality because as we previously mentioned since the autonomic nervous system controls how much does my heart works then patients with diabetic neuropathy can't adapt So all of these thing lead to a poor quality of lfe In the United States where most studies about cost are done it is calculated that 10 billion dollars are spent
6:26
every year in the management of diabetic neuropathy and its complications and we will also see it increasing with age so the older we get the more frequent diabetic neuropathy becomes and of course with duration of diabetes if I have had diabetes for longer its more likely that I have neuropathy
6:51
and a larger percentage of patients will have the neuropathy
6:56
Explaining 2 important risk factors, age and years of diagnosis so the longer the patient has I as a physician have to be much more thorough looking for the neuropathy And I as a patients have to be more careful and strict with every passing year checking my nerves and getting studied for neuropathy
7:27
Now, what causes the neuropathy without going too deep because we have previously reviewed it but when I eat food passes through my gastric tract where it breaks down into glucose molecules which are absorbed to the blood there are other types of sugars but we will focus on glucose When glucose increases in the blood stream this signals the pancreas which can detect glucose variations and since glucose is building up in my tissues it starts secreting insulin leading to absorption of glucose
8:14
in tissues like muscles, fat and the liver In patients with diabetes mellitus type 1 they don't have cells that can produce insulin in the pancreas so even if it wants, the pancreas is no longer able to produce the hormone because it doesn't have the mechanism any more and in patients with diabetes mellitus type 2 there is an increase in some molecules that block insulin's function so even if insulin is secreted there is no response because of these other substances creating insulin resistance
8:48
Of course when we have insulin resistance, when I eat glucose will build up in other tissues it will not be stored in muscle but will build up elsewhere that glucose will become toxic in the long run specially in neurons and nerves Here we have the neurons and our glial cells these cells are in charge of sending nerve impulses
9:25
when glucose builds up it can hurt neurons and glial cells effectively stopping my nerves from sending the nerve impulse and blocking the signal As a comment this is an image of central nervous system but this phenomena happens in the peripheral nervous system because the blood-brain barrier protects the brain from glucose toxicity if the blood-brain barrier wouldn't work and my neurons where in direct contact with the blood-stream then we would find the same toxicity But again this happens
10:06
mainly in peripheral nervous system Now what is the mechanism behind the damage when I have a high concentration of glucose in my blood this will escape the blood vessel and into neurons we are not sure about the exact mechanism one of the better known is the non-enzymatic protein glication, meaning that all the protein components of my neuron this high concentration of glucose sticks to the proteins and destroys them slowly affecting my nerve function
10:39
from there several other damage mechanisms ensue accumulation of toxic products like sorbitol oxidation by free radicals
10:50
and even a complete degeneration of the neuron causing axon destruction the parto of the neuron that allow for communication so again we will not review each mechanism of the physiopathology and we don't know which one is the most important one and we have no drugs that block any of these damage mechanisms however we know that the excess glucose drives all of the damage mechanisms
11:24
these excess glucose and other risk factors like arterial hypertension, high colesterol other toxins like nicotine tobacco and alcohol and all these risk factors together destroy the peripheral nerve Now from the 3 types of peripheral nerves se have a different rate of damage from the smaller ones to the larger ones, we usually find first a sensitive component so first the nerves in charge of perception are affected then we have damage to the autonomic nerves, the ones that control organs
12:16
telling them how much they must be working and finally damage to the motor nerves Of course while the disease progresses and we have a poorer control this neuropathy gets worse for example progressing from weird sensations like something crawling on my skin or water drops even when my skin is dry
12:47
Until I develop a severe neuropathy with intense pain all of the time
12:54
On top of worsening in the same type of nerve and become more severe, we can also find that a worse control of my diabetes I will start developing mixed neuropathies sensitive plus autonomic like having pain somewhere in my body and lack of sweat causing temperature regulation problems Or pain and arrhythmia beating at an incorrect rhythm
13:27
or lack of adaptation to exercise or even standing up and finally I will have motor neuropathy so patients have pain they can't poop because the intestine has neuropathy and they can't raise their feet because of lack of strength making it difficult to climb a ladder
13:54
This can lead to patients getting injured without even noticing it and since they don't feel for example their feet then the diabetes can cause infection or even the worst version something known as Charcot feet where the lack of sensitivity and motor problems causes the feet to not work properly causing ulcers that the patient doesn't feel because of the neuropathy this leads to fractures fractures can't repair correctly it causes deformities, these deformities
14:37
cause a worse function of the foot and you have a vicious circle with complications building up until we have to amputate the foot
14:50
So how does neuropathy presents itself diabetic neuropathy appears in the peripheral nervous system damaging peripheral nerves mainly in long distal nerves the classic neuropathy is a distal symmetric polyneuropathy so diabetes will cause polyneuropathy because it attacks the 3 types of nerves distal symmetric with a glove stocking distribution as we can see here it starts with the feet, then knees and finally hands as this image shows Being a polyneuropathy it has a sensitive component
15:44
causing a lack of sensation from feet then they loose sensation from the knee down then they start feeling pain on top of the lack of sensations and finally they develop the same in the hands besides they can't sweat lack of piloerection, lose of skin apendix and eventually develop problems with movement that is the classical distribution with diabetic neuropathy Around 30 to 40% have this "clasical" neuropathy some patients have a more focalized neuropathy
16:22
for example something similar to sciatic nerve pain that we also reviewed in a previous video I leave the link on the upper side of the screen so you can check it out
16:32
It is also frequent in sciatic nerve pain and in carpal tunnel syndrome that patients had previous pain or damage on the zone and now the glucose excess causes the nerve to break down faster so in spite of the fact that all nerves are being damaged the one with the previous disease debuts with the neuropathy or becomes more severe We have other types of less frequent neuropathies that may not be symmetrical here we must check for other causes of nerve damage
17:12
And finally we have the autonomic distribution where the heart, stomach, small and large intestines the bladder the reproductive system and the urinary system will have autonomic alterations of any type like for example a slow heart beat a slow intestinal transit
17:40
And as we have mentioned diabetic patients don't have just one of these, they usually have several combined being frequent to have a gloves and stockings distribution plus autonomic, plus carpal tunnel all caused by the damage due to high glucose directly to the nerves so it is very important that patients have an adequate glucose level being the pillar of therapy in these diabetic patients if we manage to keep glucose in a normal level neuropathy progresses much slower
18:20
so if I have a mild pain today it will take for its progression more than ten years, but if I am not careful it might only take a year and a half glucose control might also help alleviate the pain patients feel if a have a pain rated in 4 after glucose control it might be in 1 without taking into account any drug I might take for the pain just by getting glucose in control
18:51
Now which patients develop diabetic neuropathy we mentioned previously patients who have a long history with the disease the more years I have with diabetes the worse the neuropathy gets then we have age, the older the patient the worse the neuropathy gets third glycated haemoglobin because the higher it is, it reflects a poor glucose control so we should keep our glycated haemoglobin between 6 and 7 % we don't want it to be too high because high glucose is toxic to our nerves
19:34
but we don't want it too low either in 4 or 5 because it increases the risk of hypoglycemia and hypoglycemia is just as dangerous or even more than hyperglycemia Hyperglycemia kills cells throughout many years while hypoglycemia kills cells in months or less, so we need to balance glucose not too high, not too low
20:04
Fourth, patients who also have other risk factors from metabolic syndrome that is also toxic to neurons they have a higher risk of neuropathy and progress faster, obesity high colesterol hypertension if they are not controlled in one or several, obesity dyslipidemia of hypertension will have a higher frequency of neuropathy Consumption of other neurotoxic substances such as tobacco or alcohol will also worsen neuropathy and finally a greater height because nerves that are further away
20:46
have the greatest damage because they have to carry the nerve impulse further away
20:54
and since axons are the most affected ones and they are responsible for the long cables so the longer the nerve "cable" the easier it is for high glucose to destroy are nerve, however height is a non-modifiable risk factor
21:09
From the 3 parameters we can have
21:14
or the three types of neuropathy, the first is sensitive most neuropathies have a distal symmetrical polyneuropathy so the foot, usually the first involved we have several components sensitive autonomic in sweating and piloerection but also blood vessel function and movement it will have a glove and stockings distribution and 30 to 50% of patients with neuropathy will develop a painful neuropathy So, from all of the diabetic patients half develop neuropathy meaning nerve damage
21:57
and from that half, half of them or 25% of all diabetic patients will have a painful neuropathy this pain starts as mild and ends up being severe pain and hard to manage I will not mention too much about pain but I leave the link to the video about neuropathic pain so you can review treatments and diagnosis of pain over there Then we have Autonomic neuropathy that may involve any of our organs some of the most frequent is the heart, also known as Cardiac Autonomic Neuropathy causing all of these
22:40
weakness, shortness of breath orthostatic hypotension, so hypotension upon standing dizziness fainting
22:50
taquicardia or bradycardia when the patient is sitting and exercise intolerance because when his/her heart should start working more, it can't because the autonomic nervous system is not working anymore We have also gastrointestinal features known as gastroparesis although it might have other non-gastric manifestations patients present with nausea, distention before or after meals, changes in apetite reflux, dysphagia and vomit they might also have diarrhea or constipation
23:30
can't go to the bathroom, or can't stop going
23:38
We will also have bladder issues known as diabetic cystopathy causing urine retention and incapacity to urinate even if the bladder is full urinary incontinence so urine is spilled when the patient doesn't want it to spill urinary retention frequently leads to infections due to incomplete emptying of the bladder while incontinence causes social problems and it causes urgency, so the patient goes from not feeling anything to immediately an extreme need to urinate
24:18
it may cause sexual dysfunction of many types like impotence, dryness decrease in libido dyspareunia among others, and autonomic problems in the skin like we previously mentioned with sweat motor dysfunction the patient can't sweat as it should of course sweat is essential to regulate our temperature and may lead, especially when it's hot to heat stroke and excessive heat and faint and also dryness of the skin and in some mucous membranes finally motor neuropathy
24:58
happens in nerves in charge of movement so we first find muscle weakness obviously muscle weakness may not be detected at first the patient may even think their muscles are normal or it happens so slow that the patient doesn't notice it so I have to ask my patient to perform some movements and surpass the strength of my muscles or gravity to detect this muscle weakness again I will first evaluate the feet then legs and hands we may also find a lack of coordination
25:30
especially in hand movements, which are coordination intensive frequent tripping wether reported by the patient or upon questioning and difficulty raising their arms over their shoulders another indicator of important muscle weakness Now how can I diagnose neuropahty it starts with a thorough physical exploration of my patient there are also some questionnaires that may guide us firstly we have this tool from Michigan University ussed to assess neuropathy and answering these questions I can know
26:09
the risk my patient has of developing neuropathy this doesn't give me the diagnosis but it shows me which patients have a higher risk if I have over 2 bad responses so I answer something that is not normal then I need a much more thorough evaluation here are the questions do you feel your legs or feet numb? everything is assessed for the past week
26:37
have you ever had a burning pain in legs or feet? are your feet to sensitive to touch? do you feel muscle cramps on your legs or feet? do you feel a sting in legs or feet? do you feel pain whan the bed sheets touch your skin? when you're taking a shower do you feel the water temperature different from the real one? have you had an open wound on your feet that took you long to realize? has your physician ever told you you have diabetic neuropathy? do you often feel weak?
27:08
are your symptoms worse at night? do your legs sore when you walk? can you feel your feet when you walk? being abnormal the lack of sensation is the skin on your feet so dry it crackles? and have you ever had an amputation? so again if we have 2 or more we need a very detailed evaluation and of course there are some pretty evident ones for example amputations or a previous diagnosis of diabetic neuropathy probably means you have it and require an aggressive management
27:45
Now when we explore this patients to find diabetic neuropathy we have to evaluate the sensitive branch exploring first the feet, then legs and finally hands followed by other areas and we assess the perception of temperature, vibration light touch, crude touch and pain This follows a couple of steps that we will review in a moment but it is essential to determine if those nerves work properly or if they work too much or too little and frequently we find both a hyperfunction
28:24
and a hypofunction at the same time as we will show besides this sensitive exploration I also have to evaluate strength and movement so we assess strength, so if the patient can with his feet, then his legs and then hands and arms move beating my strength beating gravity muscle tone, so I touch them and feel if there is atrophy, i.e. a very small muscle or it is of a regular volume so the patient still has muscle mass and how much are those muscles basally activated
29:09
And of course within the evaluation of strength muscle tone and sensibility we evaluate reflexes, an essential step to evaluate the reflexes in feet, legs, hands and arms and then other regions because a bad reflex response shows something is wrong with either the sensitive
29:35
or motor components Finally it is important to explore for distal pulse we previously spoke in other videos that one common finding is an important damage to arteries and veins so it further complicates my neuropathy and can make progress much faster
29:54
We must search for complex diseases such as Charcot's foot with a severe bone deformation besides the neuropathy and also search for autonomic neuropathy because once again it is one of the deadliest
30:11
And this autonomic neuropathy has to be evaluated by special tests like the tilt table however in the bedside we can assess things like blood pressure and heart rate wile the patient is sit and then upon standing of course a large variation means an orthostatic hypotension wo a lack of adaptation from the heart to standing up But again it is very important if there is a chance to a specialized lab to check this dysautonomia Now how do we evaluate the sensitive aspect of the diabetic neuropathy
30:51
we will first use a diapason ot 128 htz frequently used in vibration evaluation and a von-frey filament of 10 grams this type of filaments are already proven and when you stimulate the feet you are testing mechanical sensitivity and the diapason tests vibration sensitivity we will have to do our evaluation in 10 hotspots these 10 triger points will be essential to make the diagnosis of diabetic neuropathy the first hotspot is in the tip of the toe the middle finger and the tiny toe
31:35
these are the 3 first trigger spots these are the next 3 hotspots 2 more in the middle of the foot an a final spot on the base of the ankle so I will check with the diapason every one of these spots and later on I will check them with the filament this applies to both feet, I must check the symmetry so both feet feel the same because as we previously mentioned diabetic neuropathy is distal so these hotspots in the feet will be affected first and it is also a symmetric neuropathy
32:11
so I can will find it in both feet once I tested these 10 hotspots I have to then evaluate the back of the foot in this red spot I'm showing These evaluation will show the sensitive aspect I can later evaluate further up but if I don't find alterations here I probably won't find them in other spots like legs or hands it can happen sometimes but searching for neuropathy on the foot is a good screening tool to detect most patients with diabetic neuropathy Once I evaluated sensitivity I can
32:51
evaluate the motor aspect of neuropathy for this test I will ask my patient to extend his toes so I should find that the patient can separate his big toe from the others the patients should also be able to do a plantar flexion so I will ask the patient to point his big toe towards his face the more flexed the better because it means the patient has a better movement range, finally the autonomic evaluation, it's tough we search for pulse in the arteries of the feet we can search for sweat reflex
33:32
and piloerection, but again autonomic neuropathy must be evaluated with specialized tools
33:40
Now getting to the point of neuropathic pain how can I know my patient has pain caused my its diabetic neuropathy we already talked about it on the "neuropathic pain" video I already left the link to that video but basically to make the diagnosis is 1 a neuroanatomical plausible lession here is the hand and stockings distribution or even just the feet at the beginning and the patient must have a previous history that shows risk factor for diabetic neuropathy so a long time with the disease
34:20
older age a poor control of the diabetes and previous signs of neuropathy so it may begin with lack of symptoms or signs but upon exploration I always found problems to feel vibrations 6 months later the patient felt the foot strange, 6 months later he started with a little pain, 6 months later the pain got worse, but progression must be slow if an intense pain appears from one day to the other that's probably not diabetic neuropathy so after I ensured the 2 first steps I now
34:59
explore my patient and I have to find
35:05
positive and negative signs i.e. that the nerve is working more and less at the same time and finally some patients, although not everyone needs it I can ask for especial studies for example in diabetic neuropathy I can ask for evoked potentials and an elctromyography a study where I send signals through the nerves and show that the impulse is not traveling as it should again this last step is not always performed and it's not completely necessary for a diagnosis of painful diabetic neuropathy
35:46
and to begin treatment
35:50
Just as a reminder of positive and negative signs, here we have them upon exploration the patient has at the same time less sensitivity like less heat of cold sensitivity or lack of vibration perception or if I sting him the patient can't feel it or perceive it when I use the filament there is no response but at the same time we have an over sensitivity, so I can find that with a little heat the patient reports pain or there is pain when I touch the feet
36:26
even thou I'm touching it with the filament or even my finger so the patient is presenting at the same time positive signs so the nerve is hyperactive and it's also working less this shows that this is a neuropathic pain
36:43
Now following the diagnosis there are scales that allow us to be more specific and the most used one is the MIchigan diabetic neuropathy score and these are the things we evaluate on this score in the sensitive evaluation we assess vibration perception in the thumb of the feet and we score it as normal, diminished or absent remember this is done with the diapason of 128 htz then we use the 10gm filament and again we score it in normal, diminished or absent
37:13
then we do pin prick evaluation which means with a pin to sting the patient and comparing it with something that doesn't prick to evaluate painful sensation again in the feet we assess it as normal, diminished or absent We then evaluate muscle strenght we previously mentioned it but it consist of toe separation extension of the thumb and foot dorsiflexion so the thumb must point to their face and finally we evaluate the reflexes the braquial biceps and triceps in the arm
37:46
and the femoral biceps and achilles in the legs and they can be present, present with effort or absent
37:55
after this evaluation we get a score so we add the points the patient has and it takes us to a scale 0 to 6 is a patient without neuropathy maybe we found something but nothing to relevant or it could be due to the exploration and the next time we explore them it might be different with a score of 7 to 12 its a mild neuropathy 13 to 29 a moderate neuropathy and 30 to 46 a severe neuropathy Note that this score is for diabetic neuropathy not for painful neuropathy those are two different entities
38:31
we already said that between all of my patients with diabetic neuropathy half of them will develop a painful neuropathy, not all of them and we can find patients with severe neuropathy without pain Now what is the treatment for neuropathy as we previously mentioned it is essential to control the risk factors
38:50
and the most important one is glycemic control so the patient must have a level of glycated hemoglobin between 6 and 7% it can be a bit lower ideally not higher, but also we shouldn't be so strict and try to achieve the extreme like a higher glycated hemoglobin or much lower, the second strategy is to diminish other neurotoxic factors like smoking, alcohol consumption, hypercholesterolemia and control the weight of the patient through diet and exercise
39:23
now it is important to remember that exercise is very good but a patient with autonomic neuropathy might present exercise intolerance so all of the exercise must be adequately prescribed to know which exercises are ideal for these patients besides as part of the management we must prevent other complications, not just slow down the neuropathy because some of the complications are even more severe being a common one diabetic foot that once again we already reviewed it in a previous video
39:54
you can check it out on the link on the top right corner so part of our exploration must be checking the feet every day and be extremely mindful of possible lessions or the presence of infections ensure the patient is using comfortable shoes which is complicated because if I don't feel my foot, the shoe might be too small and I don't notice so we must be very careful with shoes and socks in these patients because socks when they are too tight or when there are folds
40:22
especially with a deformed foot like in "Charcot's foot" we must clip our nails very carefully and they must be clipped straight we must also be very careful with falls we saw that these patients are susceptible to falling due to muscle weakness and the lack of perception of body position after the damage of nerves in charge or proprioception here education is essential because patients will need rehabilitation so the patients learn to move without proprioception
40:55
with a diminished motor capacity and lack of sensation so its important to remember to send our patients to rehabilitation for training its also important to prescribe exercise like yoga, tai chi and some others that have shown improvement in recovery of muscle mass and balance
41:16
We must also always manage the pain patients might present with their neuropathy I will focus on this finally we must manage disautonomy another complicated finding so we must have a directed approach however we will not review them on this video we will later have a video on diabetic dysautonomy And when we have Charcot's foot special shoes to compensate the deformity and surgery if needed The foot is extremely important because when our diabetic foot gets infected
41:56
it may lead to amputations and these of course worsens the future of my patient because it hampers movement and it can lead to other complications and finally, management for painful diabetic neuropathy
42:16
we have 3 groups of drugs gabapentinoids mainly gabapentin and pregabalin, Selective Inhibitors of Noradrenaline and Serotonin recapture with duloxetine and venlafaxin and finally tricyclic antidepressants where we find amitriptyline and imipramine these 3 groups are recommended as 1st line treatment in painful diabetic neuropathy However some patients may not achieve relief with just one so you start with one you increase the dose of the original drug
42:53
if the patient can cope you go up to maximum dose then you combine 2 different groups for example a noradrenaline serotonin reuptake inhibitor and a gabapentinoid, depending of the safety profile and the efficacy that we find and finally we added an other group of drugs among others we might add opioids like tramadol or tapentadol, commonly used in neuropathic pain due to their doble effect as an opioid and a serotonin reuptake inhibitor property However this requires being careful
43:35
first with the combination of these two groups because tricyclic antidepressants and noradrenaline serotonin reuptake inhibitors can't go together because they both increase noradrenaline and serotonin so if we mix them they can cause in these patients serotoninergic syndrome a very dangerous complication thats also why we must be very careful combining these with these other two they can be combined but being very careful after these drugs we can find a hundred more
44:16
they don't have such strong evidence things like local lidocaine or capsaicine and thats why I will only mention these ones and from these groups I will only show the safest ones and most used ones per group even thou there are others so first gabapentin 900mg/day in 3 takes maximum dose a day 3600mg we must always be wary with the adverse events in these patients for example gabapentin usually causes dizziness, confusion and falls so if my patient is already in risk of
45:00
falling or has already fallen in the past then gabapentin might be risky we should start with a low dose and then slowly ramp un I start with 300mg once a day, when I see Its safe I take it up to 600 then 900 I keep it there, if the patient still has pain I might combine it with another one that doesn't cause dizziness or increase the dose even more but really slowly so here we can understand why it's so complicated to manage these patients, they might already have
45:34
adverse events because the drug worsens alterations the patient already had and the patient might still have intense pain so they are complicated patients then we have duloxetin, quite safe quite effective, and has the advantage that it also have an antidepressant effect very useful in patients with chronic pain where depression is common we can tackle both with this drug here we start with 60mg a day one take maximum dose 120mg a day in one take
46:09
these patients might have nausea, vomit, dry mouth a loss of apetite, and again if my patient already has gastroparesis or maybe nausea associated to the diabetic neuropathy or vomit, it might not be the best drug but in another patient with risk of falling its much better than gabapentin because its not associated with dizziness and falling as much and of course the antidepressant effect Finally the representative of tricyclic antidepressants is amitriptyline
46:41
50 mg a day in one take up until 150 mg a day in 3 takes these group has a ton of adverse events like dizziness, confusion, somnolence, dry mouth and arrhythmias, so always before prescribing it we need to get a study of cardiac dysautonomia that my patient may have however they are also very effective to manage neuropathic pain also in patients with low risk of falling or dry mouth
47:18
they also have antidepressant effects and is also a sleep inducer so if my patient has sleep disturbances also frequent with chronic pain this would be a suitable treatment again with a priority on their safety profile so these are the three prototypes for their groups but there are many drugs for 1st line treatment and a ton more with less evidence we should start with 1 drug from the 1st line group if it fails after reaching the therapeutical dose so these doses here
47:54
and if I don't want to increase the dose further I can combine them gabapentinoid + one of these either tricyclic antidepressant or noradrenaline serotonin reuptake inhibitor we can't combine these two, just this one with this one
48:12
and if I still can't control pain I add a 2nd and 3rd line treatment maybe low doses of opioids, maybe a rescue opioid maybe a topical treatment with these drugs etcetera
48:29
And in a patient with diabetic neuropathy it is essential to check the eyes because these patients can develop diabetic retinopathy and we will talk about diabetic retinopathy in a specific video and of course renal function because chronic kidney disease is one of the most frequent complications of diabetic patients and patients with diabetic neuropathy frequently develop these other complications We have also reviewed in the past chronic kidney disease
49:02
you can check it out in the link on the upper right corner so you can know more about this disease and the impact in diabetic patients
49:12
Well this was everything in todays video, thank you very much especially to the member in patreon and youtube membership, they give us an economic support every month so we can do these videos so we can increase the "Sinapsis" community and and so we can have more and more activities in this video I would like to especially thank Jose Zelarayan Maria Eugenia Sobrino and Jose Enrique Martinez and Camila Cerda they have been an invaluable support through the months and they really
49:41
allow us to keep to content coming and be able to hire medical writers like Fernando Espinosa Lira and the rest of the team that are essential for our operations so thank you a lot finally here I show the references where I got the information you can check it out to know more of the subject and learn more well this is it for today I hope you liked and enjoyed the content Don't forget to leave any doubts in the comments also subscribe if you want to keep receiving our content
50:20
click the bell so Youtube lets you know when we upload a new video and as always help us change the world, share the information
Here to help you learn
Sign in to keep a private conversation with your course tutor.
Ask me anything about the material…
Sign in to chat