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Furthermore, while the primary symptoms of neuropathy can be highly unpleasant, the secondary complications (eg, falls, foot ulcers, cardiac arrhythmias, and ileus) are even more serious and can lead to fractures, amputations, and even death in patients with Regadenoson Injection (Lexiscan)- FDA. Since diabetic neuropathy can manifest with a wide variety of sensory, motor, and autonomic symptoms, a structured list of symptoms can be used Regadenoson Injection (Lexiscan)- FDA help screen all diabetic patients for possible neuropathy (see History).

Physical examination of patients with suspected distal sensory motor or focal (ie, entrapment or noncompressive) neuropathies should include assessments for both peripheral and autonomic neuropathy (see Physical Examination). Multiple consensus panels recommend the inclusion of electrophysiologic testing in the evaluation of diabetic neuropathy. An appropriate array of electrodiagnostic tests includes both nerve conduction testing and needle EMG of the most distal muscles usually affected.

The primary care physician needs to be alert for the development of neuropathy-or even its presence at the time of initial diabetes diagnosis-because failure to diagnose diabetic polyneuropathy can lead to serious consequences, including disability and amputation. In addition, the primary care physician is responsible for educating patients la roche spain the acute and chronic complications of diabetes (see Patient Education).

Patients with diabetic peripheral neuropathy require more frequent follow-up, with particular attention to foot inspection to reinforce the need for regular self-care.

Many medications are available for the treatment of diabetic neuropathic pain, although most of them are not specifically approved by the United States Food and Drug Administration for this use.

Nonpharmacologic treatment includes rehabilitation, which may comprise physical, occupational, speech, and recreational therapy. Peripheral neurons can be categorized broadly as motor, sensory, or autonomic. Motor neurons originate in the central nervous system (CNS) and extend to the anterior horn of the spinal cord. From the anterior horn, they exit the spinal cord (via ventral roots) and combine with other fibers in the brachial or lumbar plexuses and innervate their target organs through peripheral nerves.

Sensory neurons originate at the dorsal root ganglia (which lie outside the spinal cord) and follow a similar course Regadenoson Injection (Lexiscan)- FDA motor neurons. Sensory neurons are subdivided into categories according to the sensory modality they convey (see Regadenoson Injection (Lexiscan)- FDA Table below). Autonomic neurons consist of sympathetic and parasympathetic types.

In the periphery, preganglionic fibers leave Regadenoson Injection (Lexiscan)- FDA CNS and synapse on postganglionic neurons in the sympathetic abbott laboratories or in sympathetic ganglia.

The smaller fibers are affected first in DM. With continued exposure to hyperglycemia, the larger fibers become affected. Fibers of different size mediate different types of sensation, as shown in the table below.

Subdivisions buttock and lower back pain Sensory Neurons (Open Table in a new window)The factors leading to the development of diabetic neuropathy are not understood completely, and multiple hypotheses have been advanced. Development of symptoms depends on many factors, ei compendex as total hyperglycemic exposure and other risk factors such as elevated lipids, blood pressure, smoking, increased height, and high exposure to other potentially neurotoxic agents such as ethanol.

Genetic factors may also play a role. For more information, see Type 2 Diabetes and TCF7L2. Hyperglycemia causes increased levels of intracellular glucose in nerves, leading to saturation of the normal glycolytic pathway.

Extra glucose is shunted into the polyol pathway and converted to sorbitol and fructose by the enzymes aldose reductase and sorbitol dehydrogenase. This is the rationale for the use of aldose reductase inhibitors to improve nerve conduction. These include direct damage to blood vessels leading to nerve ischemia Regadenoson Injection (Lexiscan)- FDA facilitation of AGE reactions. Despite the incomplete understanding of Regadenoson Injection (Lexiscan)- FDA processes, use of the antioxidant alpha-lipoic acid may hold promise for improving neuropathic symptoms.

With future refinements, however, pharmacologic intervention targeting one or more of these mechanisms may prove successful. In the case of focal or asymmetrical diabetic neuropathy syndromes, vascular injury or autoimmunity may play more important roles. T1DM patients with autonomic neuropathy showed differences in gene methylation compared with T1DM patients without neuropathy. For example, in the NINJ2 gene, which is involved in nerve regeneration, patients with autonomic neuropathy had significantly greater methylation in the first axon than did the other patients with type 1.

The Regadenoson Injection (Lexiscan)- FDA of hyperglycemia has received strong support from the Diabetes Control and Complications Trial (DCCT). Using the coefficient of variation (CV) for fasting plasma glucose, the investigators found that, after consideration of HbA1c, the odds ratios for the development of painful diabetic peripheral neuropathy were 4. After modifications had been made for established risk factors measured over time, the odds ratio for peripheral neuropathy in patients with type 2 diabetes versus those with type 1 was 2.

More than half of cases are distal symmetric polyneuropathy. Solid prevalence data for the latter 2 less-common syndromes is lacking.

The wide variability in symmetric diabetic polyneuropathy prevalence data is due to lack of consistent criteria for diagnosis, variable methods of selecting patients for study, and differing assessment techniques. In addition, because many patients with diabetic polyneuropathy are initially asymptomatic, detection is extremely dependent on careful neurologic examination by the primary care clinician.

The use of additional Regadenoson Injection (Lexiscan)- FDA techniques, such as autonomic or quantitative sensory testing, might result in a higher recorded prevalence. The investigators found that the annual prevalence rose from 24. The value then gradually fell, declining to 20.

However, members of minority groups (eg, Maxillofacial surgeon, African Americans) have more secondary complications from diabetic neuropathy, such as lower-extremity amputations, than whites.

DM affects men and women Regadenoson Injection (Lexiscan)- FDA equal frequency. Diabetic neuropathy can occur at any age but is more common with increasing age and severity and duration of diabetes.

Patients with untreated or inadequately treated Regadenoson Injection (Lexiscan)- FDA have higher morbidity and complication rates related to neuropathy than patients with tightly controlled diabetes.

Repetitive trauma to affected areas may cause skin breakdown, progressive ulceration, and infection. Amputations and death may result. Treating diabetic neuropathy is a difficult task for the physician and patient. Most of the medicines mentioned in the Medication section do not lead to complete symptom relief.



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