TATALAKSANA

POLINEUROPATI
DIABETES MELLITUS
Fokus Pada Nyeri Neuropatik Diabetikum

Andy Tampubolon
Eka HospitalPekanbaru
KRITERIA DIAGNOSTIK DM
Gejala klasik + GDS ≥ 11.1 mmol (200 mg/dL)
atau
Gejala klasik + GDP ≥ 7.0 mmol (126 mg/dL)
atau
Kadar GD 2 jam PP saat TTGO ≥ 11.1 mmol (200 mg/dL)  Glukosa
Anhydrous terlarut dalam air 75 mg
atau
HbA1C ≥ 6.5 %
Mekanisme Neuropati
• Faktor metabolik (kadar GD tinggi, durasi DM, Dislipidemia, dan kadar
insulin rendah)
• Faktor Neurovaskuler  gangguan suplai oksigen dan nutrisi ke sel
saraf
• Faktor autoimun  inflamasi sel saraf
• Cedera mekanikal (contoh : CTS)
• Sel saraf rentan secara genetik
• Faktor gaya hidup (merokok, alkohol)
Definisi Neuropati Diabetikum
• Possible DPN (Diabetic Peripheral Neuropathy)
Hipestesia, gejala positif neuropati sensorik (baal/tebal, nyeri) kebanyakan pada tungkai ; atau
gejala neuropati simetris ; atau penurunan reflex fisiologi pada tungkai
• Probable DPN
2 atau lebih gejala berikut :
• Gejala neuropati
• Hipestesia distal (gloves and stockings hypesthesia)
• Penurunan refleks fisiologi
• Confirmed DPN
Hasil pemeriksaan Elektromiografi / Nerve Conduction Study abnormal disertai gejala dan tanda
neuropati
19th Annual Diabetic Neuropathy Study Group of the European Association for the Study of Diabetes (NEURODIAB) and the Eighth
International Symposium on Diabetic Neuropathy (Toronto, 2019).
Klasifikasi Neuropati Diabetikum
•Polineuropati Simetrik
•Neuropati Otonom
•Poliradikulopati
•Mononeuropati
Polineuropati Simetrik
•Gloves – Stockings Hypesthesia
•Pain
•Paresthesia
•Dysesthesia
Neuropati Otonom
Simptomatik Abnormal Subklinis
Hipotensi postural Refleks pupil abnormal
Gastroparesis Disfungsi esofagus
Diare diabetikum Refleks kardiovaskuler
Neuropathic bladder abnormal
Disfungsi ereksi Blunted counter-regulatory
responses to hypoglycemia
Edema neuropatik
Tekanan darah perifer
Charcot arthropathy meningkat
Gustatatory sweating
Poliradikulopati
• Poliradikulopati Lumbal
Nyeri tungkai disertai kelemahan dan atrofi otot tungkai
• Poliradikulopati Thorakal
Nyeri abdomen, seperti diikat
• Diabetic neuropathic cachexia
• Poliradikulopati + Neuropati perifer
• Berat badan turun dan depresi
Mononeuropati
•Entrapment Neuropathy
•Mononeuropati kranialis
•Mononeuropati multipel
Tatalaksana
Neuropati  morbiditas
Tiga elemen utama :
•Pengendalian kadar glukosa dalam darah
•Foot care
•Penanganan nyeri
Painful Diabetic Neuropathy
•Nyeri  20 % pasien DM
•Terapi sistematik, stepwise approach
•Nyeri berhubungan dengan neuropati
Konsekuensi Nyeri
•Nyeri hebat, polifarmasi
•Disabilitas fisik
•Kualitas hidup rendah
Painful Diabetic Neuropathy, Diagnosis
•Nyeri  neuropati EMG/NCS
•Peripheral Vascular Disease ?
•Lokasi, kualitas, onset (timbul saat istirahat,
berkurang saat aktivitas)
 Management of Painful DPN

Neurostimulatory Interventional
Pharmacotherapy Regional
Anesthesia

Treatment Approaches
Physical
Rehabilitation
Complementary/
Alternative

Psychological Lifestyle

Bril et al, Neurology 2011

Farmakoterapi
(Rekomendasi American Academy of Neurology)
 Dose

Drug Class Agent Common AEs Major AEs

Initial Effective

Anticonvulsants

25-75 300-600 • Somnolence  Angioedema

• Dizziness  Hepatotoxicity
Pregabalin mg, mg/day
• Peripheral edema  Rhabdomyolysis
1-3x/day • Headache  Suicidal
• Ataxia thoughts and
• Fatigue behaviour
• Xerostomia  Seizures after
• Weight gain rapid
discontinuation
 Thrombocytope
nia
 Dose

Drug Class Agent Common AEs Major AEs

Initial Effective

Antidepressants- SNRI

20-30 60-120  Nausea  Stevens-Johnson

 Somnolence syndrome
Duloxetine mg/day mg/day  Dizziness  Hepatotoxicity
 Constipation  Hypertensive
 Dyspepsia crisis
 Diarrhea  GI hemorrhage
 Xerostomia  Delirium
 Anorexia  MI
 Headache  Arrhythmias
 Diaphoresis  Glaucoma
 Insomnia  Suicidal thoughts
 Fatigue Shift to mania
 Decreased libido  Seizures
Tricyclic Antidepressants:
Adverse Effects
• Commonly reported AEs
(generally anticholinergic):
Fewest
AEs • Desipramine
• blurred vision
• cognitive changes
• Nortriptyline
• constipation
• dry mouth
• Imipramine
• orthostatic hypotension
• sedation
• Doxepin
• sexual dysfunction
• tachycardia
• Amitriptyline
• urinary retention Most
AEs
AEs = adverse effects.
TERIMA KASIH