A renowned specialist panel consisting of a cardiologist, ophthalmologist, neurologist and nephrologist discusses how to manage complications of diabetes - neurology session.
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Our next speaker is Dr Tarek was Nell, who is a neurologist here in San Diego, at the Neurology Center in San Diego, where she has a special interest in neuro muscular conditions. And we'll be talking about some of the neurologic complications related to diabetes. Thank you. Thank you for having me. I'm going to talk about the neurological complications that we see in the setting of diabetes. All right, there's several Paulie neuropathy that come along with diabetes. On these couldn't be modern neuropathy. These involving the cranial nerves. For example, there's the diabetic, third nerve palsy. Uh, there are the seventh nerve palsy, your facial palsy bells policies which come along, uh, yeah, uh, at a higher incidents in patients with diabetes say Mazar carpal tunnel syndrome patients. Um, commonly, we're going to see what we call a distal, symmetrical Paulie neuropathy, where the nerves of the extremities are most affected and these tend to be symmetrical. It tends to be what we call external relating thio fiber loss. There's various forms of axonal neuropathy. Excuse me, autonomic neuropathy with various manifestations. Additionally, I'm going to touch on some acute diabetic neuropathy because thes can be quite distressing to the patients once they developed. Um, important to know is that the neuropathy is that we see in patients with type one diabetes. Um is different, uh, than are patients with type two diabetes in type one. The extent of the neuropathy is directly related. Thio the glycemic control eso in these patients, uh, glycemic control is going to be the most important thing that we can do to reduce their risk of developing neuropathy. Um, of note. When we do see these patients, uh, they're neuropathy may have been going on for many years before it's come to their attention because they're less likely to have the initial symptoms of a painful neuropathy instead. Rather, a sensory loss in Type two diabetes Glycemic control remains very important. However, treating factors of the metabolic syndrome are crucial. Um, at the time of diagnosis, more than 15% of patients will already have a distill symmetric Pauling, or apathy in about half of patients will a 10 years. So with all these patients, we will need to address management of hypertension, their lipids addressing their weight and obesity and tobacco sensation. If they are smoker, the neuropathy that we see in Type two diabetes is very similar to what we'll see in pre diabetes or even in patients with a metabolic syndrome. Uh, this consists of the distal symmetric Paula neuropathy, or can even just be what we call a small fiber neuropathy. With the small fiber neuropathy. Patients tend to have a lot more the painful neuropathy symptoms without actually any of the actual sensory loss or even motor involvement. It is not uncommon that I will see patients for neuralgia or nerve pain and then learned that this is a one of the first manifestations of their pre diabetes, um, touching again on the poly neuropathy. That's most common that we see. It's what we call a large fiber neuropathy. Often they're mixed, and patients will have small fiber involvement, and typically they will have the small fiber neuropathy that will go on to have some large fiber involvement. Most of the time, you'll be able to diagnose this in your patients based on their history and their sensory and motor examination alone. E. M. G and nerve conduction studies can be done to classify the large fiber neuropathy but are not necessary. This is something that you'll want to do if there's some abnormal features with their examination, such as them being a symmetric or significant motor involvement? Or patients that may have a mixed picture having spinal disease rarely when you have both the proximal weakness and the distal weakness along with century loss may need to consider a rare de militating neuropathy, such a C i. D. P. And in that case, these patients would benefit from undergoing electro diagnostic studies. Management off just a symmetric palling around with E basically goes back to the causes of it, and most of the cases are going to be glycemic control management of lipids and blood pressure smoking sensation. And in all these patients, discussing the importance of increasing their exercise if they don't already have a regular regimen, set up and regular foot care to ensure that we're not missing any injuries to the foot. No Europe. A thick pain becomes important factor in managing the symptoms. Not everyone develops neuropathic pain, but if they do, they're numerous, uh, medications that we use kind of based on other core mobility's patient has on bond other medications that they may be taking the most common ones that we use are the Gabba Penton oId on serotonin norepinephrine reuptake inhibitors and the tricyclic antidepressants. Okay, there are various forms of autonomic neuropathy that are also seeing in patients with diabetes, cardiovascular, autonomic neuropathy. These are one of the more significant ones that can occur, especially because the Ortho static hypotension that occurs does significantly increase mortality in these patients. Um, early signs of autonomic neuropathy can just be resting tachycardia, so it's something that we should always be keeping our eye out for. Management of. This again, uh, comes down to treating, controlling diabetes, the contributing factors, making sure their medications aren't also contributing to their symptoms and managing the symptoms. Whether this is wearing compression stockings, increasing their hydration or salt intake and then, if needed, more specific medications. They're gastrointestinal neurotic with E that can occur. This can include gaster, praecis, constipation or diarrhea, which is typically nocturnal. In this case, management of these, uh, depends on the manifestation. They don't always necessarily come together. Motility specialist can be of use for this, okay, and of course, reviewing their medications to make sure they're not contributing your genital dysfunction occurs. This could be trouble with emptying the bladder and urinary retention. Sexual dysfunction can occur in both men and females. Management is addressed. Symptomatically in the last part of the diabetic autonomic neuropathy is the pseudo motor dysfunction or the sweating dysfunction that can come with the neuropathy. And typically what occurs is decreased sweating. I, particularly in the hands and in the feet. So when these patients present, they tend to complain of increased sweating rather than the decreased sweating in other parts of their bodies. Again, management is directed at the symptoms. Yeah, there's a few acute diabetic neuropathy is that I wanted toe briefly discuss. The first is limbo sacral ridiculous plexus neuropathy, which is also known as diabetic A my ah TRA fee. And this can be kind of a scary neuropathy to develop. It tends to come on very strong. It's very painful tends to affect the proximal, uh, lower extremities, the upper leg. It can progress to a lot of atrophy, actually, pretty fast and make people non ambulatory. It's thought that this may be a form of microvascular itis. Eso, sometimes high dose steroids were used in the short term with it, but management really comes down to aggressive management of their pain. So they're able to continue Thio work with physical therapy, um, in assistance with ambulance ation because they may require, uh, assistive devices during that time another form of an acute diabetic neuropathy that can occur. It's called a treatment induced neuropathy. Unfortunately, this happens when patients, uh, improve their glyphs seem in control again. This one is a very painful neuropathy that develops. It tends to affect a lot of the small nerve fibers, um, and kind of autonomic symptoms with it. Um, And again, we're addressing the symptomatic control, which is usually the pain, uh, and hoping for glucose stabilization. Okay, further complications that we'll see in patients with diabetes or stroke. Um, something that we check for in any of our patients who present with acute ischemic stroke or even hemorrhagic strokes to work on modifications. And in fact, when someone presents with a focal neurological deficit even concerning for stroke, before we administer T p A or considering the intervention, we must check a glucose level as hyperglycemia can actually cause focal neurological deficit, which are reversible. We can see seizures when the glucose levels drop, or even hyperkinetic movement disorders. or large flailing limb movements Associate ID with hyperglycemia. I'm at this point, we don't have any disease modifying agents Thio treat the neuropathy or these more focal complications that come with diabetes. Eso it really all comes down Thio treating the underlying disease and education and minimization of the effects of it. Thank you very much.
