2008 Clinical Practice Guidelines - Canadian Diabetes Association

More documents

Recommendations

Info

2008 CLINICAL PRACTICE GUIDELINES S140 Neuropathy Canadian Diabetes Association Clinical Practice Guidelines Expert Committee The initial draft of this chapter was prepared by Vera Bril MD FRCPC and Bruce Perkins MD MPH FRCPC KEY MESSAGES • Exposure to higher levels of glycemia, elevated triglycerides, high body mass index, smoking and hypertension are risk factors for neuropathy. • Intensive glycemic control is effective for primary prevention or secondary intervention of neuropathy in people with type 1 diabetes. • In people with type 2 diabetes, lower blood glucose levels are associated with reduced frequency of neuropathy. INTRODUCTION Detectable sensorimotor polyneuropathy will develop within 10 years of the onset of diabetes in 40 to 50% of people with type 1 or type 2 diabetes (1). Although
Table 1. Oral medications for the management of neuropathic pain* Medication Suggested starting dose † Suggested titration † Common or serious side effects Tricyclic antidepressants Amitriptyline (17,18) Anticonvulsants 10 mg QHS Increase weekly by 10 mg/day to a maximum of 150 mg/day Gabapentin (19) ‡ 300 mg TID Increase weekly by 300 mg/day to a maximum of 3600 mg/day Pregabalin (20) 75 mg BID May double weekly to a maximum of 300 mg BID Opioid analgesics ‡ Sustained-release oxycodone (21) 10 mg BID Increase every 3 days by 10 mg to a maximum of 60 mg BID Dry mouth Blurred vision Constipation Urinary retention Dizziness Drowsiness Cardiac arrhythmias (particularly in the elderly) Dizziness Somnolence Ataxia Fatigue Peripheral edema Weight gain Peripheral edema Dizziness Somnolence Constipation Nausea Somnolence *Clinically important outcomes in the clinical trial setting are generally defined by a 30 to 50% decrease in pain (as assessed by visual analogue scores). Few patients achieve complete pain relief in these clinical trials. † Dose ranges are for adults and are generalized from clinical trials – smaller starting doses and slower titration schedules may be indicated. Optimal doses are the lowest doses required for maximum efficacy without significant side effects. Although required for some agents, dose adjustments for renal and liver dysfunction are not shown here. Physicians should refer to the most current edition of the Compendium of Pharmaceuticals and Specialties (Canadian Pharmacists Association, Ottawa, Ontario, Canada) for product monographs and complete prescribing information. ‡ Combination therapy with gabapentin and an opioid has been shown to achieve better analgesia at lower doses of each drug (22). RECOMMENDATIONS 1. In people with type 2 diabetes, screening for peripheral neuropathy should begin at diagnosis of diabetes and occur annually thereafter. In people with type 1 diabetes, annual screening should commence after 5 years’ postpubertal duration of diabetes [Grade D, Consensus]. 2. Screening for peripheral neuropathy should be conducted by assessing loss of sensitivity to the 10-g monofilament or loss of sensitivity to vibration at the dorsum of the great toe [Grade A, Level 1 (10)]. 3. People with diabetes should be treated with intensified glycemic control to prevent the onset and progression of neuropathy [Grade A, Level 1A, for type 1 diabetes (3,14); Grade B, Level 2 (16), for type 2 diabetes]. 4.Antidepressants [Grade A, Level 1A (23,25)], anticonvulsants [Grade A, Level 1A (19,20,22,28)], opioid analgesics [Grade A, Level 1A (22)] and topical isosorbide dinitrate [Grade B, Level 2 (31)] should be considered alone or in combination for relief of painful peripheral neuropathy. RELEVANT APPENDIX Appendix 4: Rapid Screening for Diabetic Neuropathy REFERENCES 1. Dyck PJ, Kratz KM, Karnes JL, et al.The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the Rochester Diabetic Neuropathy Study. Neurology. 1993;43:817-824. 2. Partanen J, Niskanen L, Lehtinen J, et al. Natural history of peripheral neuropathy in patients with non-insulin-dependent diabetes mellitus. N Engl J Med. 1995;333:89-94. 3. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329: 977-986. 4. Singleton JR, Smith AG, Bromberg MB. Increased prevalence of impaired glucose tolerance in patients with painful sensory neuropathy. Diabetes Care. 2001;24:1448-1453. S141 COMPLICATIONS AND COMORBIDITIES
Page 1:
Canadian Publication Mail Agreement
Page 4 and 5:
2008 CLINICAL PRACTICE GUIDELINES i
Page 6 and 7:
2008 CLINICAL PRACTICE GUIDELINES i
Page 8 and 9:
2008 CLINICAL PRACTICE GUIDELINES v
Page 10 and 11:
2008 CLINICAL PRACTICE GUIDELINES v
Page 12:
2008 CLINICAL PRACTICE GUIDELINES x
Page 16 and 17:
2008 CLINICAL PRACTICE GUIDELINES S
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 50 and 51:
Page 52 and 53:
Page 54 and 55:
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74 and 75:
Page 76 and 77:
Page 78 and 79:
Page 80 and 81:
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105: 2008 CLINICAL PRACTICE GUIDELINES S
Page 204 and 205:
Page 206 and 207:
Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
show all

2008 Clinical Practice Guidelines - Canadian Diabetes Association

Create successful ePaper yourself

Delete template?

Save as template?