evaluating and managing foot pain and neuropathy in diabetics dr. leslie goldenberg b.sc., m.d.,...

Evaluating and Managing Foot Pain and Neuropathy in Diabetics

Dr. Leslie GoldenbergB.Sc., M.D., F.R.C.P.(C)., A.B.I.M., F.A.G.S

Medical Director, Walking Mobility ClinicsAssistant Professor, U of T Faculty of Medicine

PRESENTER DISCLOSURE

Dr. Leslie Goldenberg

Relationships with commercial interests: Medical Director of Walking Mobility Clinics

PROGRAM DISCLOSURE OF COMMERCIAL SUPPORT

Dr. Leslie Goldenberg

No commercial support

MITIGATION OF BIAS

Dr. Leslie Goldenberg

Not applicable

NEUROPATHY AND GAIT

NEUROPATHY AND GAIT

NEUROPATHIES

1. Sensory polyneuropathy clinically encompassing a spectrum from subclinical sensory loss to the totally asensate foot (distal symmetric small fiber neuropathy)

2. Autonomic neuropathy with trophic changes, distal hair loss and dry skin

3. Sensory motor polyneuropathy with distal weakness of longer duration (much less common than sensory neuropathy)

NEUROPATHIES

4. Painful distal sensory neuropathy

5.Painful proximal diabetic neuropathy or lumbosacral radiculoplexus neuropathy

6.Femoral neuropathy with diabetic amyotrophy associated with quadriceps wasting

NEUROPATHIES

7. Acute painful diabetic neuropathy (reversible insulin neuritis)

8. Single neuropathy especially of the peroneal and posterior tibialis nerve; third nerve, intercostal nerve roots and median nerve (mononeuropathy)

9. Local pressure palsies and entrapment neuropathies

NEUROPATHIES

10.Part of the syndrome of mononeuritis multiplex

11.Chronic inflammatory demyelinating polyneuropathy

12.Restless leg syndrome associated with diabetes

NEUROPATHIES

13.‘Too tall’ neuropathy

14. Acute quinolone neuropathy

LOCAL PRESSURE PALSIES & ENTRAPMENT NEUROPATHIES

Uni or bilateral peroneal palsy with foot drop

Tibial neuropathy in medial tarsal tunnel

Anterior tarsal tunnel syndrome

Plantar and calcaneal branch entrapments

Buttock sciatica/piriformis syndrome

TOXIC NEURITIS IN DIABETICS

Acute insulin neuritis

Acute Quinolone neuritis

Flagyl neuropathy

Statin induced neuropathy

Pyridoxine (Vitamin B6) neuritis

PROPRIOCEPTION

Role of proprioception and proprioceptive loss in balance

CLINICAL SCREENING ‘QUICKIES’:THE ONE MINUTE NEUROPATHY EXAM

1. Arise without arm recruitment

2. Heel and toe raises

3. Single leg balance

4. Assess sway with eyes closed – static gait

CLINICAL SCREENING ‘QUICKIES’:THE ONE MINUTE NEUROPATHY EXAM

5. Dynamic gait – tandem

6. Turn – Kneel – Deep tendon reflexes

7. Tuning fork – 10 gram pressure – light toe touch

8. Clues from visual inspection (autonomic, claw toes, intrinsic minus, trophic)

BLOOD TESTING SCREEN FOR NEUROPATHY CO-CONSPIRATORS ESR, ANA, ENA-Panel (SSA + Bab)

Serum protein Electrophoresis and Urine for light chains

HIV and Lyme Serology

Anti Hu antibodies

Cryoglobulins, Mercury, HbAIC, B12 and Pyridoxine

Urine porphyrins

NEUTRICEUTICAL THERAPY

B1 – Benfotiamine 600mg

B2 – Riboflavin 8mg

B6 – Pyridoxine 50-100mg

B12 – Methylcobalamine 4000ucg

R – alpha lipoic acid 300 units

Metanx (B6, B12, Folic Acid) combo

Neuropathy Support Formula

Consider B-50’s & B-100’s

Zinc 75mg tid, Vitamin C 500 mg/d

DIABETIC ULCERS – TOPICAL TRANSDERMALS

Clindoxyl gel or BenzaClin

Diltiazem 5%, 15%

Pentoxifyline 10%

Misoprostol 0.0024%, Phenytoin 5%

Timolol 0.5

Humulin 40 units/gram

Santyl collagenase

Iodosorb Inodine Flamazine

Polysporin complete, Ozonol antibiotic

Mupirocin 2% ointment

Metronidazole 1%, 2%

PCCA-PLO, Delivera, Lipoderm

PAINFUL NEUOPATHY – TOPICAL TRANSDERMALS

PCCA-PLO, Delivra, Lipoderm

Diclofenac 15% or Ketoprofen 20%

DMSO 5%

Ketamine 5%, Gabapentin 6%

Amitriptyline 10%

NNT – NUMBERS NEED TO TREAT

TCA’s – 1.4

NMDA antagonists – 1.8

Dilantin – 2.2

Tramadol – 3.3

Neurontin (gabapenin) – 3.7

Lyrica (pregablin) – 4.5

Capsaicin – 5.0

SSRI’s – 6.7