糖尿病痛性神经病变的发病机制和治疗.ppt
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1、 糖尿病痛性神糖尿病痛性神病病的的病机制和治病机制和治糖尿病在世界范糖尿病在世界范的流行的流行: :1. Zimmet P, et al. 1. Zimmet P, et al. NatureNature 2001; 2001;414414:7827. :7827. 2. www.idf.org/node/1049?unode=3B96844A-C026-2FD3-87E85FD2293F42E9. 2. www.idf.org/node/1049?unode=3B96844A-C026-2FD3-87E85FD2293F42E9. 30301351351711712202201 130030
2、01 1Patients With Diabetes (Millions)Patients With Diabetes (Millions)YearYear5005002 2366 million people with DM in 2011366 million people with DM in 2011近年来在儿童或青少年中2型糖尿病的流行呈引人注目地增高2型糖尿病成年人日益增的威 糖尿病并症糖尿病眼底病适成人失明的主要原因糖尿病病末期病的主要原因糖尿病外周神病非性下肢截肢的主要原因心血管疾病 中增加2-4倍的心血管死亡和中Diabetes Care 2010; 33: 2285-93末
3、梢、称性、多神病 (DSPN) 50% of DM与网膜病和病相关格血糖控制可以防微血管并症慢性高糖的暴露是脑血管病变的危险因素足足 和和 截肢截肢最最强强的危的危因素因素称性、称性、度依度依性、性、 感感- -运运性神性神病病糖尿病伴疾病 (IHD, CVD, PVD, obesity, Nephropathy, DR,BP, LDL, A1c神神病病疼痛疼痛 灼感 /刺痛 深部痛 感 麻木 末梢、称性 夜加重自主神自主神病病 体位性低血 心自主神病 胃 腹泻 便秘 尿失禁 性功能障碍 出汗感感 足 感染 截肢 跌倒 上肢症状. 运症状.Diabetes UK “Putting feet f
4、irst” http:/www.diabetes.org.uk/Documents/Professionals/Education%20and%20skills/Footcare-pathway.0212.pdf英国糖尿病学会推荐每年进行足部检查足部脱鞋和袜子足部畸形的部位出胼胝的部位找的征象以往是否有足背动脉波动外周神的(10g 或振)鞋袜是否出神痛“阳性”症状持续性烧灼样痛或钝痛阵发性电击样刺痛 感觉异常(痛性感觉异常)诱发痛 (痛觉过敏, 痛觉超敏)“阴性” 症状 (感觉或痛觉缺失)麻木痛觉减退, 痛觉丧失感觉迟钝, 感觉缺失DPN的诊断: 病史床估: 病史体征感症状运症状功能障碍估排除
5、其它原因致的神病原因感觉神经反射检查振触刺10g 尼估鞋袜 DPN的诊断疑似DPN DPN的症状或体征可能DPNDPN的症状和体征确诊DPNDPN 的症状或体征及和神经传导检查异常多伦多糖尿病神经病变专家共识 Tesfaye et al. Diabetes Care 2010; 33: 2285-93NC-stat DPN 检查 检测步骤和临床用途 检测时间少于1分钟 包括4个步骤 临床益处早期检测协助诊断评估病变程度强化血糖控制的意义改善足部护理为医生提供参考加强患者教育鉴别诊断% NGT i-IFG i-IGT IFG+IGT New DM Known DM n=577 n=55 n=18
6、3 n=46 n=62 n=177MONICA/KORA Augsburg Survey F4 (Age: 61-82 yr; n=1100)MONICA/KORA Augsburg Survey F4 (Age: 61-82 yr; n=1100)NGTNGT= normal glucose tolerance= normal glucose tolerancei-IFG= isolated impaired fasting glucosei-IFG= isolated impaired fasting glucosei-IGT= isolated impaired glucose tole
7、rancei-IGT= isolated impaired glucose tolerance vibration and/or pressure sensationvibration and/or pressure sensationBongaerts et al., Diabetes Care 2012; 35: 1891-3糖尿病神病在糖尿病前期和糖尿病的流行情况% Unawarei-IFG i-IGT IFG+IGT New DM Known DM n=55 n=183 n=46 n=62 n=177i-IFG = isolated impaired fasting glucosei-
8、IFG = isolated impaired fasting glucosei-IGT = isolated impaired glucose tolerancei-IGT = isolated impaired glucose tolerance% with PNP6%15%24%16%22%Question: HQuestion: Has a physician ever told you that you suffer from nerve damage, neuropathy as a physician ever told you that you suffer from nerv
9、e damage, neuropathy or diabetic foot?or diabetic foot?Bongaerts et al., Diabetes Care 2013; 36: 1141-6无感知的糖尿病神病在糖尿病前期和糖尿病患者非常流行Sheffield 调查: 精神情感障碍Galer et al., Diabetes Res Clin Pract, 2000Galer et al., Diabetes Res Clin Pract, 2000Enjoymentof lifeSleepMobilityNormalworkRecreationalactivitiesSocia
10、lactivitiesGeneralactivityMoodRelationsSelf-carePercentage with substantial interference out of n=105 with pain Percentage with substantial interference out of n=105 with pain Modified Brief Pain Inventory (BPI) score Modified Brief Pain Inventory (BPI) score 5 5%糖尿病痛性神病影响日常活慢性疼痛可导致睡眠障碍,而睡眠障碍也可对疼痛造成
11、不利影响心理症状和慢性疼痛显著相关慢性疼痛中常见的恶性三角关系Argoff. Clin J Pain. 2007;23:15-22; Nicholson and Verna. Pain Med. 2004; 5(S1):S9-S27; 睡眠障碍心理症状功能损伤疼痛相关的Tesfaye et al. N Engl J Med 2005; 352: 341-50胆固醇甘油三BMI糖尿病病程HbA1c化HbA1c吸烟高血1.571.571.381.381.481.481.361.361.401.401.271.271.211.211.151.15Model 1:Model 1:without CVD
12、without CVDand retinopathyand retinopathyOdds ratios (95% CI)n=1101 with type 1 DM; FU: 7.30.6 yrs 初诊的2型糖尿病患者表皮内的神经纤维密度和腓感觉神经传导速度(SNCV)(SNCV)和腓感觉神经动作电位(SNAP)(SNAP)IENFD (fibers/mm)*Diabetic (n=86)Diabetic (n=86)Control (n=48)Control (n=48)*P0.001*P0.001皮肤活皮肤活腓感觉神经传导速度 (SNCV) (SNCV)*Sural SNCV (m/s)S
13、ural SNCV (m/s)腓感觉神经动作电位(SNAP)(SNAP)Sural SNAP (V)Sural SNAP (V)*P0.001*P0.001*P=0.006*P=0.006Ziegler et al., ADA, 2012糖尿病神病的病因脉脉静脉静脉外周神的解剖毛毛血管血管ControlDPN1. Tesfaye S, et al. Diabetologia. 1993;36:126674在糖尿病神病中有髓鞘的神缺失通过显微镜观察糖尿病患者:神经活检显示毛细血管呈闭塞状态糖尿病神病微血管受DPNDiabetic Control1. Cameron NA, et al. Diab
14、etologia. 2001;44:197388BMEndo.ControlDPN1. Tesfaye S, et al. Diabetologia. 1993;36:126674糖尿病神病微血管异常VeinArteryArtery脉脉静脉静脉毛血管塞致静脉分流毛毛血管血管已确诊DPN的血流受损正常确诊DPN1. Tesfaye S, et al. Diabetologia. 1993;36:126674.脉脉静脉糖尿病神病的病机制外周的外周的害害中枢中枢害害1. Eaton S, et al. Lancet. 2001;358:356.糖尿病受可能更多的原因d+NNDPPL周围灰质体积 (m
15、l)Control vs. Neuropathy (p=0.016)Diabetic Control vs. Neuropathy (p=0.07)脊髓萎缩40455055606570交叉区域 (mm2)HVNo DNPainless DN健康对照组 vs.伴有DSP的糖尿病患者(p=0.016)不伴有DSP的糖尿病患者vs.伴有DSP的糖尿病患者(p=0.07)Eaton S, et al. Lancet. 2001;358:35-6191010Eaton S, et al. Lancet. 2001;358:35-6健康对照组不伴有DSP的糖尿病患者伴有DSP的糖尿病患者Diabetic
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- 关 键 词:
- 糖尿 病痛 神经 病变 发病 机制 治疗