Neuropati Diabetes

Diabetes & Neuropati

Makroangipati Ulkus pedis (luka di kaki)

Diabetes
Melitus Fraktur/trauma/jatuh
Mikroangiopati
Amputasi
Kecacatan
Neuropati
Biaya perawatan >>>
Diabetes
Mortalitas >>>
Kualitas hidup <<<
Focal/
Diffuse
Multifocal

Polineuropati DM Mononeuropati
Autonom Radikulopati/Poliradikulopati
(ADA, 2017; Jia, 2014; Busui, 2017;
Vinik, 2008, Saha, 2014)
Kriteria Diabetes Melitus

Kadar HbA1C ≥6,5% 5,7 – 6,4%

Prediabetes
Kadar Glukosa Darah Puasa (GDP) ≥ 126 mg/dL 100 -125 mg/dL

Kadar Glukosa Darah 2 jam setelah makan ≥ 200 mg/dL 140 – 199 mg/dL

Gejala klasik hiperglikemia atau krisis hiperglikemia, disertai kadar glukosa darah acak ≥ 200
mg/dL

Neuropati
Diabetes
Adanya tanda dan/atau gejala disfungsi saraf perifer pada pasien
dengan diabetes setelah penyebab lain dieksklusi
Neuropati Diabetes

Neuropati Diabetes
• salah satu komplikasi Diabetes Melitus (DM) yg paling sering terjadi & cukup serius

Polineuropati DM Distal symmetric polyneuropathy (DSPN)

• bentuk yang paling banyak ditemukan pada neuropati diabetes (sekitar 75%)
• berkontribusi terhadap kejadian fraktur dan trauma (jatuh) akibat disfungsi serabut saraf ->ketidakstabilan posisi
pasien, trauma minor berulang, dan peningkatan resiko jatuh

Ulkus pedis dan CN Komplikasi Lanjut

• meningkatkan resiko amputasi dan biaya perawatan pada polineuropati DM dan juga sekaligus angka mortalitasnya
Neuropati Diabetes

Neuropati diabetes dapat asimtomatis (Up to 50% (ADA 2017)), tidak adanya
gejala bukan berarti tidak ada neuropati.

Diabetes neuropati sulit diterapi

Identifikasi & kontrol faktor resiko  mencegah neuropati

Deteksi dini penting  mencegah progesifitas

Deteksi dan tata laksana yang baik dapat memperbaiki keluhan/gejala,

meminimalkan sekuel, & meningkatkan kualitas hidup
Neuropati Diabetes

• Prosentase neuropati pada penderita DM berkisar 50-75%

• CDC (Center of Disease Control)  60-70%
• Sebagian besar dg gejala nyeri
Tipe Neuropati Diabetes

Neuropati DM

Polineuropati
Poli-/
DM/ DSPN Autonom Mononeuropati
Radikulopati
(75%)

Subklinis
Faktor Resiko

HbA1C/kadar
Usia Durasi Tinggi Badan
gula darah

Hipertensi Profil lemak Berat Badan

Sindroma
metabolik

Alkohol Merokok
• Anamnesa
 Keluhan sensoris, tipe nyeri, durasi, lokasi nyeri
 Penyakit penyerta
 Faktor resiko

• Pemeriksaan fisik

• Pemeriksaan tambahan
Keluhan

• Tebal, kesemutan, kesetrum,

gangguan keseimbangan

• Nyeri: terbakar,
ditusuk-tusuk, seperti disilet

• Hiperalgesia
Pemeriksaan
Subyektif
• Pin prick
• Garpu tala
• Monofilamen
• Diskriminasi panas dan
dingin

Obyektif
• Reflek ankle/pergelangan kaki
• Tes Kuantitas Sensoris (QST)
• Biopsi kulit dan densitas intraepidermal nerve fiber (IENF)
• Corneal confocal microscopy
• Contact heat evoked potential
• Fungsi sudomotor
• Pemeriksaan konduksi saraf (ENMG)
 Penyakit
Lain ??

(American Diabetes Association, 2017)

Pengobatan

Farmakologi Non Farmakologi

 Background, cont.
• Pharmacologic Agents:
 Anticonvulsants, antidepressants, opioids, antiarrhythmics, cannabinoids,
aldose reductase inhibitors, protein kinase C beta inhibitors, antioxidants (α-
lipoic acid), transketolase activators (thiamines and allithiamines), topical
medications (analgesic patches, anesthetic patches, capsaicin cream,
clonidine), and others
• Nonpharmacologic Modalities:
 Infrared therapy, shoe magnets, exercise, acupuncture, external stimulation
(transcutaneous electrical nerve stimulation), spinal cord stimulation,
biofeedback and behavioral therapy, surgical decompression, and intrathecal
baclofen

© 2011 AMERICAN ACADEMY OF NEUROLOGY

 Conclusions/Recommendation

Conclusions:
• Based on consistent Class I evidence, pregabalin is established as effective in lessening the pain of
PDN .
• Pregabalin also improves QOL and lessens sleep interference, though the effect size is small.

Recommendation:
• If clinically appropriate, pregabalin should be offered for the treatment of PDN (Level A).

© 2011 AMERICAN ACADEMY OF NEUROLOGY

 Conclusions/Recommendation

Conclusions:
• Based on 1 Class I study, gabapentin is probably effective in lessening the pain of PDN.
• Based on 2 Class II studies, sodium valproate is probably effective in treating PDN.

Recommendation:
• Gabapentin and sodium valproate should be considered for the treatment of PDN (Level B).

© 2011 AMERICAN ACADEMY OF NEUROLOGY

 Conclusions/Recommendations

Conclusions:
• Based on 3 Class I and 5 Class II studies, the antidepressants amitriptyline, venlafaxine, and
duloxetine are probably effective in lessening the pain of PDN .
• Venlafaxine and duloxetine also improve QOL.
• Venlafaxine is superior to placebo in relieving pain when added to gabapentin.

Recommendations:
• Amitriptyline, venlafaxine, and duloxetine should be considered for the treatment of PDN (Level B).
Data are insufficient to recommend one of these agents over the others.
• Venlafaxine may be added to gabapentin for a better response (Level C).

© 2011 AMERICAN ACADEMY OF NEUROLOGY

 Conclusions/Recommendation

Conclusions:
• Based on one Class I study, dextromethorphan is probably effective in lessening the pain of PDN and
improving QOL.
• Based on Class II evidence, morphine sulphate, tramadol, and oxycodone controlled-release are
probably effective in lessening the pain of PDN.
• Dextromethorphan, tramadol, and oxycodone controlled-release have moderate effect sizes, reducing
pain by 27% compared with placebo.

Recommendation:
• Dextromethorphan, morphine sulphate, tramadol, and oxycodone should be considered for the
treatment of PDN (Level B). Data are insufficient to recommend one agent over the other.

© 2011 AMERICAN ACADEMY OF NEUROLOGY

 Conclusions/Recommendation

Conclusions:
• Based on Class I and Class II evidence, capsaicin cream is probably effective in lessening the pain of
PDN.
• Based on Class I evidence, isosorbide dinitrate spray is probably effective for the treatment of PDN.

Recommendation:
• Capsaicin and isosorbide dinitrate spray should be considered for the treatment of PDN (Level B).

© 2011 AMERICAN ACADEMY OF NEUROLOGY

 Conclusions/Recommendations

Conclusions:
• Based on a Class I study, electrical stimulation is probably effective in lessening the pain of PDN and
improving QOL.
• Based on single Class I studies, electromagnetic field treatment, low-intensity laser treatment, and
Reiki therapy are probably not effective for the treatment of PDN.

Recommendations:
• Percutaneous electrical nerve stimulation should be considered for the treatment of PDN (Level B).
• Electromagnetic field treatment, low-intensity laser treatment, and Reiki therapy should probably not be

considered for the treatment of PDN (Level B).

© 2011 AMERICAN ACADEMY OF NEUROLOGY

(American Academy of Neurology, 2011)
Phsycological
support

• Anxietas
• Depresi
• Weight bearing Vs
Non weight bearing
• Foot Exercise
 Pencegahan
Kontrol •Cek kadar gula rutin
Gula •Cek kadar HbA1C Sindrom
Darah • berat badan
a • tekanan darah
metaboli • profil lemak
k

• Keluhan Neuropati
Deteksi • Cek kondisi kaki setiap hari
Dini (luka, goresan, pecah2,
kering), potong kuku • Weight bearing vs
Exercise Non weight bearing
(American Diabetes Association, 2017)
(American Diabetes Association, 2017)
to cure sometimes, to heal often,
to comfort always
Exercise diabetic
foot