QuestionSBA
QuestionChoice
Low strength capsaicin cream can be used for the treatment of localised neuropathic pain. This patient's pain is more widespread and so topical treatment is unlikely to be beneficial. A patch containing 8% capsaicin is an option for peripheral neuropathic pain and could be considered under specialist supervision
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Start 0.075% capsaicin cream
QuestionChoice
Neuropathic pain may be responsive to treatment with opioids such as morphine. However, it should be reserved for persistent symptoms refractory to treatment with anti-depressants (e.g. amitriptyline or duloxetine) and anti-epileptics (pregabalin or gabapentin)
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Start modified-release morphine sulphate
QuestionChoice
Regular paracetamol would not be particularly useful for the treatment of neuropathic pain
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Start regular paracetamol
QuestionChoice
This patient has signs and symptoms of diabetic neuropathy. Other symptoms of neuropathic pain include tingling, sensitivity to touch and electric-like sensations. NICE guidelines suggest using amitriptyline, duloxetine, pregabalin or gabapentin as the first-line treatment for neuropathic pain
32388
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Start duloxetine
QuestionChoice
Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) and is not particularly useful for treating neuropathic pain. It would also not be appropriate in this case, given the history of a duodenal ulcer, as NSAIDs are a major cause of gastric and duodenal ulceration
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Start ibuprofen
QuestionComment
All Diabetics Get Peripheral (Neuropathy) -->
Amitriptyline, Duloxetine, Gabapentin, Pregabalin
22279
User
subscriber
Fever Juice
QuestionComment
duloxetine increases bleeding risk (like NSAID) so would potentially not give in Hx of peptic ulcer disease 
23552
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subscriber
RNA Haemophilus
Concept
Chapter
# Summary

Diabetic peripheral neuropathy (DPN) refers to a variety of peripheral nerve disorders as a result of diabetes. The primary causative factor is chronic hyperglycaemia, which leads to several distinct types of DPN, including Distal Symmetrical Sensory Neuropathy, Small-fibre Predominant Neuropathy, Diabetic Amyotrophy, Mononeuritis Multiplex, Autonomic Neuropathy and Charcot Arthropathy. Symptoms vary according to the subtype of DPN but usually involve sensory loss and/or pain in a glove and stocking distribution or proximal weakness. Key investigations focus on assessing the extent of neuropathy and rule out other potential causes of neuropathy. Management is primarily symptomatic and emphasises good glycaemic control. This section covers DPN broadly, with a later focus on Charcot arthropathy.

# Definition

Diabetic peripheral neuropathy (DPN) represents a spectrum of peripheral nerve disorders stemming from diabetes. The central driver behind their development is believed to be chronic hyperglycaemia.

# Epidemiology

DPN is a common complication of both type 1 and type 2 diabetes, with approximately 50% of long-term diabetic patients developing the condition. The risk increases with the duration of diabetes and poor glycemic control.

# Aetiology

Chronic hyperglycaemia in diabetes is the primary cause of DPN, leading to damage to peripheral nerves through various mechanisms, including accumulation of advanced glycation end products, oxidative stress, and inflammatory pathways.

# Clinical Features

DPN can be categorised into several types, each presenting with distinct clinical features:

## Distal Symmetrical Sensory Neuropathy

- Most common form of DPN.
- Resulting from loss of large sensory fibres.
- Presents with sensory loss in a 'glove and stocking' distribution, typically affecting touch, vibration and proprioception.

## Small-fibre Predominant Neuropathy

- Due to the loss of small sensory fibres.
- Manifests as deficits in pain and temperature sensation in a 'glove and stocking' distribution, often accompanied by episodes of burning pain.

## Diabetic Amyotrophy

- Originates from inflammation of the lumbosacral plexus or cervical plexus.
- Characterised by severe pain around the thighs and hips, along with proximal weakness.

## Mononeuritis Multiplex

- Typically painful.
- Defined as neuropathies involving two or more distinct peripheral nerves.

## Autonomic Neuropathy

- Presents with postural hypotension, gastroparesis, constipation, urinary retention, arrhythmias, and erectile dysfunction.

# Differential Diagnosis

The differential diagnosis for DPN includes:

- **Vitamin B12 deficiency**: Can present with peripheral neuropathy, typically in a glove and stocking distribution. May also feature megaloblastic anemia and glossitis.
- **Alcohol-induced peripheral neuropathy**: Presents similarly to DPN but may also have accompanying signs of chronic alcohol misuse.
- **Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)**: Often presents with both sensory loss and motor weakness, typically in a proximal and distal distribution.
- **Hypothyroidism**: Can present with neuropathy, usually accompanied by other symptoms such as fatigue, weight gain, and cold intolerance.

# Investigations

- **Neurological examination**: To assess the extent of sensory and motor deficits.
- **Nerve conduction studies**: To evaluate the nature and extent of neuropathy.
- **Blood tests**: Including glucose levels, HbA1c, B12 levels, thyroid function tests, and liver function tests, to identify potential differential diagnoses or contributory conditions.

# Complications

If uncontrolled, DPN can lead to serious complications such as foot ulcers due to loss of sensation, and autonomic neuropathy can lead to various cardiac, gastrointestinal, and genitourinary disturbances.

# Management

Management strategies for DPN primarily revolve around the control of blood glucose levels to slow the progression of the disease. Symptomatic management may include pain control with medications such as gabapentin or pregabalin, as well as management of complications (e.g., treatment of foot ulcers, management of autonomic disturbances).

# Charcot Arthopathy

## Summary

Charcot arthropathy is a chronic, progressive condition characterised by destructive changes in the bones and joints of patients with neuropathy, most commonly from diabetes. It presents with the '6Ds': Destruction, Deformity, Degeneration, Dense bones, Debris, and Dislocation. Diagnosis often involves imaging, typically with radiographs, and distinguishing it from osteomyelitis. Management focuses on immobilisation, orthotics, medication to manage pain and bone loss, and surgical interventions in advanced or refractory cases.

## Definition

Charcot arthropathy, also known as Charcot joint or neuropathic arthropathy, is a chronic, progressive condition characterised by painful or painless bone and joint destruction in the limbs that have lost sensory innervation. The condition primarily affects patients with peripheral neuropathy.

## Epidemiology

Charcot arthropathy is most commonly seen in patients with long-standing diabetes mellitus, with the prevalence being estimated to be around 0.1-0.9% in this group. It can occur at any age but is more frequently observed in the middle-aged and elderly population.

## Aetiology

The underlying aetiology of Charcot arthropathy is primarily neuropathy. The most common cause of this is diabetes mellitus, which leads to microvascular disease, autonomic neuropathy, and peripheral neuropathy, resulting in cumulative damage to the joints. Other, rarer causes include conditions that cause neuropathy, such as syringomyelia, chronic alcohol abuse, and syphilis.

## Signs and Symptoms

Charcot arthropathy often presents with the '6Ds'(some of which are imaging features):

- Destruction of bone and joint
- Deformity
- Degeneration
- Dense bones
- Debris of bone fragments
- Dislocation

It classically affects the tarsometatarsal joints, but it can involve any joint in a limb that has lost sensation due to neuropathy.

## Differential Diagnosis

The main differential diagnosis to rule out in the context of Charcot arthropathy is osteomyelitis, which also causes bone destruction but is typically associated with systemic symptoms like fever, increased inflammatory markers, and often a preceding or concurrent soft tissue infection.

## Investigations

The diagnosis of Charcot arthropathy is primarily clinical but often involves imaging to assess the extent of the bone and joint involvement:

- X-rays are usually the first-line imaging study. They can demonstrate bone destruction, debris, sclerosis (dense bones), and dislocation.
- MRI can provide more detailed imaging, particularly in early disease or when osteomyelitis is suspected.
- Bone scans may be used in complex cases or when other imaging is inconclusive.

## Management

The management of Charcot arthropathy involves conservative and surgical strategies:

Conservative:
- Prolonged off-loading, often involving special footwear or plaster casts, to allow healing and prevent further damage.
- Use of orthotics for long-term management and prevention of recurrences.

Medications:
- Bisphosphonates can help slow down the process of bone destruction.
- Neuropathic pain agents, such as gabapentin or pregabalin, for pain management.
- Topical anesthetics can also be used to manage pain.

Surgical:
- Resection of bony prominences to prevent ulcers or improve fitting of footwear.
- Correction of severe deformities, usually after the acute phase has settled.
- Amputation may be required in severe cases or when there is a concurrent uncontrolled infection.


# NICE Guidelines

[Click here for NICE CKS on diabetes - type 2](https://cks.nice.org.uk/topics/diabetes-type-2/)

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Diabetic Neuropathy
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Endocrinology
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Duloxetine is an effective first-line treatment for neuropathic pain in patients with diabetic neuropathy.
A 56-year-old man presents to his GP with a history of burning and numbness in his feet and lower legs for the last two months. His past medical history is significant for poorly controlled Type 1 diabetes and a previous duodenal ulcer.

On neurological examination, there is reduced sensation to pin-prick and fine-touch bilaterally from the feet to the knees.

Given the likely diagnosis, which of the following is the next best step in management?
a