Treatment of diabetic polyneuropathy of the lower extremities

Diabetic polyneuropathy of the lower extremities is a complication of type 1 and type 2 diabetes, which can make the patient's life simply unbearable. Burning and baking pains, a sensation of crawling, numbness of the legs, and muscle weakness are the main manifestations of peripheral nerve damage in patients with diabetes mellitus. All this significantly limits the full life of such patients. Virtually no patient with this endocrine pathology can not avoid sleepless nights because of this problem. Sooner or later this problem concerns many of them. And then huge efforts are spent on fighting the disease, since the treatment of diabetic polyneuropathy of the lower extremities is a very difficult task. When treatment does not start on time, the patient may experience irreversible disorders, in particular necrosis and gangrene of the foot, which inevitably leads to amputation. Modern methods of treatment of diabetic polyneuropathy of the lower extremities will be devoted to this article.

To effectively combat the complications of diabetes, it is necessary to comply with the complexity treatment, which means simultaneous impact on all links of pathogenesis (the mechanism of development) disease. And the defeat of the peripheral nerves of the legs is not an exception to this rule. The basic principles of treating the defeat of the peripheral nerves of the legs in this endocrine pathology can be formulated as follows:

• a clear regulation of the sugar concentration in the blood, that is, keeping the values ​​as close as possible to the norm at a constant level, without sudden fluctuations;
• use of antioxidant drugs that reduce the content of free radicals that damage the peripheral nerves;
• the use of metabolic and vascular drugs that help to restore already damaged nerve fibers and prevent damage still intact;
• adequate anesthesia;
• non-pharmacological methods of treatment.

Let's consider in more detail each link of the medical process.

Blood glucose monitoring

Since an increase in the concentration of glucose in the blood is the main cause of the development of diabetic polyneuropathy of the lower extremities, the normalization of this indicator is of paramount importance both for slowing the progress of the process and for reverse development of the already existing symptoms. With type 1 diabetes, insulin therapy is prescribed for this purpose, and for type 2 diabetes mellitus, tablets of various chemical groups (inhibitors of alpha-glucosidase, biguanides and preparations sulfonylureas). The choice of a dose of insulin or a tableted hypoglycemic preparation is a very jewelry process, because it is necessary to achieve not simply reduction of blood sugar, but also to ensure that there are no sharp fluctuations in this indicator (it is more difficult to do this when insulin therapy). And this process is dynamic, that is, the dose of the drug all the time fluctuates. This is influenced by many factors: the patient's eating habits, the experience of the disease, the presence of concomitant pathology.

Even if it turns out to achieve normal glucose levels in the blood, unfortunately, more often than not this is not enough to eliminate the symptoms of peripheral nerves. The defeat of the peripheral nerves at the same time is suspended, but in order to eliminate the existing signs, one has to resort to medicines of other chemical groups. About them and we'll talk below.

Antioxidant therapy

The gold standard among the antioxidants used to treat peripheral nerve damage in diabetes mellitus are preparations of alpha-lipoic (thioctic) acid. These are such drugs as Thiogamma, Espa-lipon, Tyoktatsid, Tiolepta, Neurolephone, Berlition. They all contain the same active substance, differ only in the manufacturer. Preparations of thioctic acid accumulate in nerve fibers, absorb free radicals, improve the nutrition of peripheral nerves. The required dose of the drug should be at least 600 mg. The course of treatment is quite long and ranges from 3 weeks to 6 months, depending on the severity of the symptoms of the disease. The most rational treatment is the following treatment regimen: the first 10-21 day dose of 600 mg is administered intravenously drip on physiological saline solution of sodium chloride, and then the same 600 mg are taken orally for half an hour before meals until the end of the course treatment. It is recommended to periodically repeat courses of treatment, their amount depends on the individual characteristics of the course of the disease.

Metabolic and vascular drugs

In the first place among the metabolic drugs for diabetic polyneuropathy of the lower limbs are vitamins of group B (B1, B6, B12). B1 promotes the synthesis of a special substance (acetylcholine), through which a nerve impulse is transferred from fiber to fiber. B6 prevents the accumulation of free radicals, is involved in the synthesis of several substances-transmitters of the nerve impulse. B12 improves nutrition of the nervous tissue, helps restore the damaged shell of the peripheral nerves, has analgesic action.It's no secret that a combination of these vitamins is considered to be more effective due to the potentiation of each other's effect. It is desirable to use the fat-soluble form of vitamin B1 (benfotiamine), since in this form it penetrates better into the zone of nerve fibers. In the pharmaceutical market, combinations of these drugs are presented quite widely. This is Milgamma, Kompligam V, Neurobion, Kombilipen, Vitagamma. Usually, when the disease is severe, treatment with injectable forms is started, and then switched to tableted. The total duration of application is 3-5 weeks.

Among other metabolic drugs I would like to mention Actovegin. This drug is a calf blood derivative, improves the nutrition of tissues, promotes regeneration processes, including those affected by the diabetic nerves. There are data on the insulin-like action of this drug. Actovegin helps restore sensitivity, reduces pain syndrome. Assign Actovegin in injections of 5-10 ml intravenously for 10-20 days, and then switch to taking a tablet form (1 tablet 3 times a day). The course of treatment is up to 6 weeks.

Of the vascular drugs, Pentaxifylline (Trental, Vasonite) is considered to be the most effective in the defeat of the peripheral nerves of the lower extremities with diabetes mellitus. The drug normalizes blood flow through the capillaries, promotes vasodilation, indirectly improving the nutrition of peripheral nerves. As well as antioxidants, and metabolic drugs, Pentoxifylline is preferable to first inject intravenously and then consolidate the effect with tableted forms. To the drug has a sufficient therapeutic effect, take it at least 1 month.

Adequate anesthesia

The problem of pain in this disease is almost the most acute among all the symptoms of this disease. Pain syndrome depletes patients, interferes with full sleep and is difficult to treat. Pain in diabetes is neuropathic, which is why simple painkillers, non-steroidal anti-inflammatory drugs have no effect in this situation. Not all patients know about this and often use handfuls of drugs of this kind, it is extremely dangerous development of complications from the stomach, duodenum, intestines, liver and blood system. To relieve pain in such cases, it is advisable to use the following groups of drugs:

• antidepressants;
• anticonvulsants;
• irritant drugs and local anesthetics;
• antiarrhythmic drugs;
• analgesics of the central action of the non-opioid series;
• opioids.

Among antidepressants, Amitriptyline has been used for many years. Begin reception with 10-1, mg for the night, and then the dose of a preparation gradually raises on 10-1, mg before achievement effective. The maximum possible daily dose is 150 mg. If necessary, the entire dose of the drug can be divided into 2-3 doses or completely taken at night. The reception scheme is set individually. Take the drug is not less than -2 months.If, for some reason, Amitriptyline is not suitable for the patient, then they resort to the help of Imipramine, a drug of the same chemical group. If the antidepressants of this chemical group are contraindicated to the patient (for example, if the heart rhythm is disturbed or the angle-closure glaucoma), then it is possible to use selective serotonin and norepinephrine reuptake inhibitors (venlafaxine 150 to 225 mg per day, Duloxetine 60 to 120 mg per day day). The analgesic effect usually comes not earlier than the second week from the beginning of the admission. Other antidepressants (fluoxetine, paroxetine, sertraline and so on) help less with diabetic polyneuropathy of the lower extremities in the sense that they have less pronounced analgesic effect. Their use is advisable with a more pronounced depressive component and poor tolerance of other antidepressants.

Among anticonvulsants, carbamazepine (Finlepsin), Gabapentin (Neurontin, Gabbagamma) and Pregabalin (Lyrics) are used as analgesic. Carbamazepine is a more obsolete drug than others in this group, but it is also much cheaper. The standard treatment regimen is the following: 200 mg in the morning and 400 mg in the evening, if necessary - 600 mg 2 times a day. Both Gabapentin and Pregabalin are the medicines of the current generation of anticonvulsants, which are very effective in combating neuropathic pain.Gabapentin is taken with 300 mg at night, then 300 mg in the morning and in the evening, then 300 mg 3 times a day, and so on, with a gradual increase in the dose. Usually, a sufficient analgesic effect is observed at a dose of 1800 mg per day divided into three doses, in severe cases the dose can be increased to 3600 mg per day. Pregabalin is prescribed 75 mg twice a day. Most often this is enough to reduce pain, but in neglected cases, the dosage can reach 600 mg per day. Usually, the pain syndrome decreases in the first week of treatment, after which it is recommended to reduce the dosage to the minimum effective (75 mg 2 times per day).

Preparations of irritating action (Capsicum, Finalgon, Capsaicin) are rarely used in everyday practice due to the fact that their action is based on the extinction of pain impulses. That is, first when applied to the skin they cause pain, and after a while - a decrease. Many of them cause skin reddening, severe burning, which also does not promote their wide application. From anesthetics, it is possible to use Lidocaine in the form of slow intravenous infusions in a dose of 5 mg / kg, as well as applying to the skin limbs creams, gels and plaster Versasitis with 5% content Lidocaine.

Of antiarrhythmic drugs for treatment, Mexiletine is used at a dose of 450-600 mg per day, although this method of treatment does not apply to popular ones.

Of non-opioid analgesics with a central effect recently used Kadadolon (Flupirtine) in a dose of 100-200 mg 3 times a day.

Opioids are used only in case of ineffectiveness of the above drugs. To this end, use oxycodone (37-60 mg per day) and Tramadol. Tramadol is started with a dose of 25 mg 2 times a day or 50 mg once a night. After a week, the dose can be increased to 100 mg per day. If the condition does not improve, the pain does not decrease by one iota, then a further increase in the dose to 100 mg 2-4 times a day is possible. Treatment with Tramadol continues for at least 1 month. There is a combination of Tramadol with banal Paracetamol (Zaldiar), which allows to reduce the dose of the opioid taken. Zal'diar is used for 1 tablet 1-2 times a day, if necessary, increase the dose to 4 tablets per day. Opioids can develop addiction, which is why these drugs, which are used in the last turn.

And yet there is no medication that could be called the standard of pain treatment for this disease. Quite often in the form of monotherapy, they are ineffective. Then you have to combine them with each other to enhance the effect. The most common combination is an antidepressant with an anticonvulsant or an anticonvulsant with an opioid. It can be said that the strategy of eliminating pain in this disease is a whole art, since there is no standard approach to treatment.

Non-drug therapies

In addition to medicinal ways to combat diabetic polyneuropathy of the lower extremities, physiotherapeutic methods (magnetotherapy, diadynamic currents, percutaneous electrostimulation, electrophoresis, balneotherapy, hyperbaric oxygenation, acupuncture). To treat pain, spinal cord electrical stimulation can be used by implanting stimulant implants. It is indicated to patients with drug-resistant forms of treatment.

If we summarize all of the above, then we can say that the treatment of diabetic polyneuropathy of the lower extremities is a difficult even for an experienced physician, since it is not possible to predict the course of the disease and the possible effect of the prescribed treatment no one. In addition, the duration of the course of treatment in most cases pretty decent, patients have to use drugs for months to achieve at least some changes. And yet the disease can be stopped. An individual approach, taking into account the clinical features of each case, makes it possible to emerge victorious in the battle with the disease.

Report prof. AND. AT. Gurievoy on the topic "Diagnosis and treatment of diabetic neuropathy