Diabetes and pain

Diabetic neuropathy is an important complication with high morbidity and mortality and reducing the quality of life of diabetic patients. Diabetic neuropathy forms a heterogeneous clinical picture by affecting proximal or distal nerves and sensory, motor or autonomic nerves in different forms.

 Epidemiology

The prevalence of diabetes mellitus in Turkey was found to be 8% for females and 6.2% for males. Another study found that the incidence of neuropathic pain in diabetic patients in Turkey was 16% in adult diabetics

.Diagnosis and Approach to the Patient

Diabetic patients have thick fiber neuropathy, decreased vibra- tion and position, muscle weakness, decreased tendon reflexes, and ataxia. Pain may be deeper and more prominent than thin fiber neuropathy. An increase in the leg blood flow occurs and Charcot arthropathy may develop in the later period. Damage to the fine fibers can result in pain, resulting in dysesthesia, hyperesthesia, hyperalgesia, allodynia and loss of sensation. Influence of fine fibers that are effective in controlling skin blood flow can also lead to dry skin, foot ulcers, gangrene and ultimately loss of extremity. It is known that it stays in the same patient and thin fibers can be affected at different grades in different nerves. 

Treatment

Provision of normoglycemia is accepted as the first step of treatment, regardless of the form or cycle of diabetic neuropathy. Tricyclic antidepressants such as gabapentin, pregabalin and amitriptyline may be used in the treatment of symptomatic diabetic neuropathic pain. Opioids, SNRIs, lamotrigine, and tramadol are among the second- or third-line agents to be considered. The use of nonsteroidal anti-inflammatory drugs should be avoided because of the ineffective efficacy of pharmacological treatment of diabetic peripheral neuropathic pain and the risk of bleeding, gastrointestinal toxicity and cardiovascular risks. In the same way, paracetamol, B6 vitamins are drugs used in clinical practice, but they should not be used in this indication. Amitriptyline should be avoided due to safety problems above 60 years of age.

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Prof. Dr. Altan Şahin, 2018