Diabetic peripheral neuropathic pain is a stronger predictor of depression than other diabetic complications and comorbidities

Antidepressant effect of carvedilol on streptozotocin-induced diabetic peripheral neuropathy mice by altering gut microbiota

RATIONALE

Although diabetic peripheral neuropathic pain (DPNP) and depression have been recognized for many years, their co-morbidity relationship and effective treatment choices remain uncertain.

OBJECTIVES

To evaluate the antidepressant effect of carvedilol on streptozotocin-induced DPNP mice, and the relationship with gut microbiota.

METHODS

The hyperalgesia and depressive behaviors of mice with comorbidity of DPNP and depression were confirmed by pain threshold of the mechanical sensitivity test (MST), immobility time of the tail suspension test (TST) and the forced swimming test (FST). The anti-depressive effect and fecal gut microbiota composition were studied in DPNP mice treated with carvedilol (10 mg/kg/day), and the relationships between them were analyzed by Spearman's correlation.

RESULTS

Depression was successfully induced in DPNP mice. Carvedilol can reverse the decreased mechanical pain threshold and relieve the depressive behaviors of DPNP mice, while increasing the abundance of Prevotella, Ruminococcus, Helicobacter and Desulfovibrio, and decreasing the abundance of Akkermansia and Allobaculum.

CONCLUSIONS

Carvedilol can alleviate the mechanical hyperalgesia and alter gut microbiota to ameliorate the depression-like behaviors which induced by DPNP.

Development and Progression of Polyneuropathy Over 5 Years in Patients With Type 2 Diabetes

BACKGROUND AND OBJECTIVES

There is a need for knowledge regarding the natural course of diabetic polyneuropathy (DPN), a complication in type 2 diabetes (T2D). The aim of this study was to examine the development of DPN over time.

METHODS

Patients with newly diagnosed T2D, recruited from a national cohort, and controls without diabetes of similar age and sex, underwent sensory phenotyping in 2016-2018. The Toronto consensus criteria were used to classify patients into possible, probable, and confirmed DPN. For this 5-year, observational, follow-up, cohort study, all participants were invited to a reexamination combining bedside sensory examination, quantitative sensory testing (QST), nerve conduction studies (NCSs), and skin biopsies measuring intraepidermal nerve fiber density (IENFD) in order to compare phenotypic and diagnostic changes over time.

RESULTS

Of the baseline 389 patients and 97 controls, 184 patients (median [interquartile range] diabetes duration 5.9 [4.1-7.4] years, mean hemoglobin A1c [HbA1c] 51 ± 11 mmol/mol at baseline) and 43 controls completed follow-up (46.9%). Confirmed DPN was present in 35.8% and 50.3%, probable DPN in 27.2% and 14.6%, possible DPN in 17.2% and 16.6%, and no DPN in 15.2% and 17.9% at baseline and follow-up, respectively. The estimated prevalence (95% CI) of confirmed DPN was 33.5% (24.9-42.1) compared with 22.7% (17.5-28.0) at baseline. During the follow-up period, 43.9% of patients with probable DPN developed confirmed DPN. Progression of neuropathy occurred in 16.5% and 24.7% and regression in 5.9% and 18.6% of patients based on NCS and IENFD, respectively. Progression based on NCS and/or IENFD was associated with higher baseline waist circumference and triglycerides, and regression with lower baseline HbA1c. Patients with at least probable DPN at baseline but neither patients without DPN nor controls developed increased spread of hyposensitivity, more hyposensitivity on QST and lower NCS z-scores at follow-up, and worsening of nerve parameters at follow-up correlated with higher baseline triglycerides.

DISCUSSION

In patients with well-regulated T2D, the proportion of patients with confirmed DPN increased over 5 years driven by progression from probable DPN. A large proportion of patients progressed, and a smaller proportion regressed on nerve parameters. Higher triglycerides correlated with this progression and may constitute a risk factor.

Depression and type 2 diabetes: A causal relationship and mechanistic pathway

Depression is a mood disorder that may increase risk for the development of insulin resistance (IR) and type 2 diabetes (T2D), and vice versa. However, the mechanistic pathway linking depression and T2D is not fully elucidated. The aim of this narrative review, therefore, was to discuss the possible link between depression and T2D. The coexistence of T2D and depression is twice as great compared to the occurrence of either condition independently. Hyperglycaemia and dyslipidaemia promote the incidence of depression by enhancing inflammation and reducing brain serotonin (5-hydroxytryptamine [5HT]). Dysregulation of insulin signalling in T2D impairs brain 5HT signalling, leading to the development of depression. Furthermore, depression is associated with the development of hyperglycaemia and poor glycaemic control. Psychological stress and depression promote the development of T2D. In conclusion, T2D could be a potential risk factor for the development of depression through the induction of inflammatory reactions and oxidative stress that affect brain neurotransmission. In addition, chronic stress in depression may induce the development of T2D through dysregulation of the hypothalamic-pituitary-adrenal axis and increase circulating cortisol levels, which triggers IR and T2D.

Therapeutic potential of orally applied KB-R7943 in streptozotocin-induced neuropathy in rats

Both peripheral neuropathy and depression can be viewed as neurodegeneration's consequences of diabetes, at least in part coexisting with or resulting from sodium-calcium dysbalance. This study aims to assess the therapeutic potential of the orally applied reverse-mode inhibitor of the sodium-calcium exchanger (NCX) KB-R7943 in the streptozotocin (STZ) diabetes model in rats. A pilot pharmacokinetic (PK) study with high-performance liquid chromatography with high-resolution tandem mass spectrometric detection revealed higher drug exposure (AUC), lower volume of distribution (Vd) and clearance (Cl), and faster decline of the plasma concentration (ƛ) in rats with diabetes vs. controls. Brain and heart accumulation and urinary excretion of the unmetabolized KB-R7943 at least 24 h were also demonstrated in all rats. However, heart and hippocampus KB-R7943 penetration (AUCtissue/AUCplasma) was higher in controls vs. diabetic rats. The development of thermal, mechanical, and chemical-induced allodynia was assessed with the Cold plate test (CPT), Randall-Stiletto (R-S) test, and 0.5% formalin test (FT). Amitriptyline 10 mg/kg, KB-R7943 5 mg/kg, or 10 mg/kg p.o once daily was applied from the 28th to the 49th day. The body weight, coat status, CPT, R-S, and FT were evaluated on days (-5), 0, and 42. On day 41, a forced swim test and 24-h spontaneous physical activities were assessed. The chronic treatment effects were calculated as % of the maximum. A dose-depended amelioration of neuropathic and depression-like effects was demonstrated. The oral application of KB-R7943 for potentially treating neurodegenerative consequences of diabetes merits further studies. The brain, heart, and kidneys are essential contributors to the PKs of this drug, and their safety involvement needs to be further characterized.

Perineural injections of incobotulinumtoxin-A for diabetic neuropathic pain of the lower extremities: protocol for a phase II, single-centre, double-blind, randomised, placebo-controlled trial (the PINBOT study)

INTRODUCTION

Diabetic neuropathic pain (DNP) is a debilitating complication affecting 15-20% of people with diabetes and is a predictor of depression, poor sleep and decreased quality of life. Current pharmacological treatments are often insufficient and have significant side-effects. Subcutaneous or intradermal botulinumtoxin-A (BonT-A) is an effective and safe treatment for neuropathic pain but is limited by the need to cover the entire affected area with injections. For large cutaneous areas, infiltration of the sensory nerve supply with BonT-A could provide similar effects, with a single injection. We aim to investigate the safety, efficacy, and effects on quality of life, physical activity, depressive symptoms and activities of daily living of perineural injections of BonT-A in patients with DNP of both lower extremities.

METHODS

This study is a double-blind, randomised, placebo-controlled clinical trial. 80 participants with moderate to severe DNP of both legs will be randomised 1:1 to receive injections of either 100 units incobotulinumtoxin-A or a saline placebo around each distal sciatic nerve for two cycles of 12 weeks. Average daily pain scores will be recorded once a day from 1 week prior to the first treatment and through the entire study period. Primary outcomes are differences between groups in daily and weekly mean pain scores. Secondary outcomes are levels of physical activity, depression scores, health-related quality of life, activities of daily living, sensory profiles and motor function, recorded at baseline, 4, 12, 16 and 24 weeks. The use of rescue medication and adverse events will be recorded throughout the study period.

ETHICS AND DISSEMINATION

The study is approved by the Danish Committee on Health Research Ethics and the Danish Medicines Agency. EU-Clinical Trial Information System (EU: 2022-500727-68-01), clinicaltrials.gov (ID: NCT05623111). Results will be published in peer-reviewed journals in open-access formats and data made available in anonymised form.

TRIAL REGISTRATION NUMBER

NCT05623111.

Psychosocial Care for People With Diabetic Neuropathy: Time for Action

Psychological factors and psychosocial care for individuals with diabetic neuropathy (DN), a common and burdensome complication of diabetes, are important but overlooked areas. In this article we focus on common clinical manifestations of DN, unremitting neuropathic pain, postural instability, and foot complications, and their psychosocial impact, including depression, anxiety, poor sleep quality, and specific problems such as fear of falling and fear of amputation. We also summarize the evidence regarding the negative impact of psychological factors such as depression on DN, self-care tasks, and future health outcomes. The clinical problem of underdetection and undertreatment of psychological problems is described, together with the value of using brief assessments of these in clinical care. We conclude by discussing trial evidence regarding the effectiveness of current pharmacological and nonpharmacological approaches and also future directions for developing and testing new psychological treatments for DN and its clinical manifestations.

The Hidden Burden-Exploring Depression Risk in Patients with Diabetic Nephropathy: A Systematic Review and Meta-Analysis

INTRODUCTION

Diabetic nephropathy is a common complication among patients with diabetes mellitus, and it has been linked to a higher risk of depression. However, the magnitude of this association remains unclear. This study aimed to systematically review and meta-analyse the risk of depression in patients with diabetic nephropathy compared to diabetes patients without nephropathy.

METHODS

We conducted a systematic literature review, searching multiple databases from January 1964 to March 2023, and included randomized controlled trials, non-randomized controlled trials, and observational studies. We assessed the risk of bias using the Newcastle Ottawa scale for observational studies. The statistical analysis was performed using STATA version 14.2, and pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated. A total of 60 studies were included.

RESULTS

The pooled OR for the risk of depression among patients with diabetic nephropathy was 1.78 (95% CI 1.56-2.04; I² = 83%; n = 56), indicating a significantly higher risk compared to diabetes patients without nephropathy (p < 0.001). Pooling the effect size across these studies showed that the pooled OR was 1.15 (95% CI 1.14-1.16; I² = 88%; n = 32). Subgroup analyses based on the type of diabetes and study region revealed no significant differences in the pooled estimates.

CONCLUSION

This study demonstrates that patients with diabetic nephropathy have a significantly higher risk of depression compared to diabetes patients without nephropathy. These findings highlight the importance of assessing and addressing the mental health of patients with diabetic nephropathy as part of their overall healthcare management.

Prevalence of painful diabetic peripheral neuropathy in type 2 diabetes mellitus and diabetic peripheral neuropathy: A nationwide cross-sectional study in mainland China

AIM

The study aimed to assess the prevalence and risk factors of painful diabetic peripheral neuropathy (PDPN) in patients with type 2 diabetes mellitus (T2DM) and diabetic peripheral neuropathy (DPN) in mainland China.

METHODS

This nationwide cross-sectional study enrolled T2DM patients with DPN from 25 provinces in China between July 2017 and December 2017. The prevalence, characteristics, and risk factors of PDPN were analyzed.

RESULTS

Among 25,710 patients with T2DM and DPN, 14,699 (57.2%) had PDPN. The median age was 63 years old. Age over 40 years old, education level, hypertension, myocardial infarction, duration of diabetes of over five years, diabetic retinopathy and nephropathy, moderate total cholesterol, moderate and higher low-density lipoprotein (LDL) increased uric acid (UA) and decreased estimated glomerular filtration rate (eGFR) were independently associated with PDPN (all P < 0.05). Compared with low levels of C-peptide, moderate levels were independently associated with a higher risk of PDPN, while high levels were associated with a lower risk (all P < 0.001).

CONCLUSIONS

In mainland China, more than half of the patients with DPN have neuropathic pain. Patients with older age, lower education level, longer duration of diabetes, lower LDL, increased UA, decreased eGFR, and comorbidities had an increased risk of PDPN.

Alpha-Lipoic Acid and Glucose Metabolism: A Comprehensive Update on Biochemical and Therapeutic Features

Alpha-lipoic acid (ALA) is a natural compound with antioxidant and pro-oxidant properties which has effects on the regulation of insulin sensitivity and insulin secretion. ALA is widely prescribed in patients with diabetic polyneuropathy due to its positive effects on nerve conduction and alleviation of symptoms. It is, moreover, also prescribed in other insulin resistance conditions such as metabolic syndrome (SM), polycystic ovary syndrome (PCOS) and obesity. However, several cases of Insulin Autoimmune Syndrome (IAS) have been reported in subjects taking ALA. The aim of the present review is to describe the main chemical and biological functions of ALA in glucose metabolism, focusing on its antioxidant activity, its role in modulating insulin sensitivity and secretion and in symptomatic peripheral diabetic polyneuropathy. We also provide a potential explanation for increased risk for the development of IAS.

Bidirectional association between depression and diabetic nephropathy by meta-analysis

BACKGROUND

Studies suggested that the association between depression and diabetic nephropathy may be bi-directional, but this hypothesis remains investigating. In this meta-analysis, the bi-directional relationship between depression and diabetic nephropathy was investigated.

METHODS

A search for the publications on depression and diabetic nephropathy in the databases of PubMed, Web of science, and Embase from the earliest available to August 2022 was conducted. Two sets of pooled risk estimates were calculated using random effects models: diabetic nephropathy predicting depression and depression predicting diabetic nephropathy. Cross-sectional studies were assessed using Agency for Healthcare Research and Quality (AHRQ), cohort and case-control studies were assessed using Newcastle-Ottawa Scale (NOS).

RESULT

Of the 974,121 patients in 30 clinical studies, 24 studies met eligibility for diabetic nephropathy predicting onset of depression, representing 28,438 incident cases. The other 6 studies met criteria for depression predicting onset of diabetic nephropathy, representing 945,683 incident cases. The pooled odds ratio (OR) of diabetic nephropathy predicting depression was 1.46 (95% CI 1.27-1.67). The OR of depression predicting diabetic nephropathy was 1.22 (95% CI 1.13-1.31).

CONCLUSION

This meta-analysis shows that the relationship between depression and diabetic nephropathy may be bidirectional. Diabetic nephropathy may be a predictor of depression, and depression may also be an indicator of diabetic nephropathy. The mechanisms underlying the bidirectional relationship need to be further investigated and interventions of the comorbidity of depression and diabetic nephropathy need be studied in clinical practice.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

A higher incidence of diabetic peripheral neuropathy may be associated with decreased sleep and increased depression in older adults

Aim: Diabetes mellitus (DM) tends to increase with aging. Nearly half of the patients with DM develop neuropathy (DPN). Despite its high burden and morbidity, the conditions that DPN may be associated with have not been adequately studied in older adults. We aimed to identify sleep duration and comprehensive geriatric assessment components that may be associated with DPN. Material and Method: This is a cross-sectional retrospective study. DPN diagnosed with a medical history, neurologic examination, and electromyography (EMG). 125 diabetic older patients were included. All comprehensive geriatric assessment tests and questions about sleep quality and time were performed. We divided the patients into two groups those without neuropathy and with neuropathy and compared them. Results: The median age of 125 patients was 72 (min-max; 64-94). 58.8% of them were women. The percentage of married people and living with their spouse and slept for 6 hours or more had a lower percentage in the DPN group. Polypharmacy and the percentage of heart failure were significantly higher in the DPN group. Lawton-Brody score, which shows instrumental daily living activities (IADL) and geriatric depression score (GDS) was higher in the DPN group. In logistic regression, we found that depression scores were higher and sleep duration was shorter in the DPN group (respectively, odd ratio:265 p:.012; odd ratio:.1.917 p:.045) Conclusions: DPN in older adults may affect the functionality and be associated with fewer sleep hours and depression. Not only blood glucose regulation but also other factors such as sleep duration and depressed mood may be associated with DPN in older adults.

Diabetic Neuropathic Cachexia: A Clinical Case and Review of Literature

A 46-year-old man was admitted to the surgical department because of abdominal pain and anemia, with the radiological finding of a perforated duodenal ulcer, and underwent laparoscopic surgical treatment. Type 2 diabetes mellitus (T2DM) had been diagnosed 5 years earlier and treated with diet. At clinical investigation, the patient was depressed and anorexic; moreover, he complained of lower extremity weakness and bilateral feet pain, burning in nature and accompanied by allodynia. This painful sensation had been preceded by an 8-month history of fatigue and anorexia with profound weight loss of 35 kg. After clinical evaluation and a nerve conduction study, diagnosis of diabetic cachectic neuropathy was made based on the rapid onset of severe neuropathic pain in the context of diabetic neuropathy, marked weight loss, and depressed mood. The therapy with pregabalin and duloxetine had scarce effect and was gradually discontinued. The patient, however, obtained progressive relief and amelioration of neuropathic lower-limb pain concomitant with weight gain. This clinical trend also confirmed the diagnosis of this rare form of diabetic neuropathy. A few cases of diabetic neuropathic cachexia have been reported in the literature and are briefly reviewed here.

The characteristics of pain and dysesthesia in patients with diabetic polyneuropathy

Introduction/aims

Patients with diabetic polyneuropathy (DPN) may experience paresthesia, dysesthesia, and pain. We aimed to characterize the predictors, symptoms, somatosensory profile, neuropathy severity, and impact of painful DPN and dysesthetic DPN.

Methods

This study was a cross-sectional study of type 2 diabetes patients with confirmed DPN, diagnosed using widely accepted methods including a clinical examination, skin biopsy, and nerve conduction studies.

Findings

Of 126 patients with confirmed DPN, 52 had DPN without pain or dysesthesia, 21 had dysesthetic DPN, and 53 painful DPN. Patients with painful DPN were less physically active and suffered from more pain elsewhere than in the feet compared to patients with DPN without pain. Patients with painful DPN had the largest loss of small and large sensory fiber function, and there was a gradient of larger spatial distribution of sensory loss from DPN without dysesthesia/pain to dysesthetic DPN and to painful DPN. This could indicate that patients with dysesthesia had more severe neuropathy than patients without dysesthesia but less than patients with painful DPN. Patients with dysesthetic and painful DPN had higher symptom scores for depression and fatigue than those without dysesthesia/pain with no difference between dysesthetic and painful DPN.

Conclusions

There was a gradient of increasing sensory loss from DPN without dysesthesia/pain to dysesthetic DPN and to painful DPN. Pain and dysesthesia are common in DPN and both interfere with daily life. It is therefore important to consider dysesthesia when diagnosing and treating patients with neuropathy.

An Insight into Potential Pharmacotherapeutic Agents for Painful Diabetic Neuropathy

Diabetes is the 4th most common disease affecting the world's population. It is accompanied by many complications that deteriorate the quality of life. Painful diabetic neuropathy (PDN) is one of the debilitating consequences of diabetes that effects one-third of diabetic patients. Unfortunately, there is no internationally recommended drug that directly hinders the pathological mechanisms that result in painful diabetic neuropathy. Clinical studies have shown that anticonvulsant and antidepressant therapies have proven fruitful in management of pain associated with PDN. Currently, the FDA approved medications for painful diabetic neuropathies include duloxetine, pregabalin, tapentadol extended release, and capsaicin (for foot PDN only). The FDA has also approved the use of spinal cord stimulation system for the treatment of diabetic neuropathy pain. The drugs recommended by other regulatory bodies include gabapentin, amitriptyline, dextromethorphan, tramadol, venlafaxine, sodium valproate, and 5 % lidocaine patch. These drugs are only partially effective and have adverse effects associated with their use. Treating painful symptoms in diabetic patient can be frustrating not only for the patients but also for health care workers, so additional clinical trials for novel and conventional treatments are required to devise more effective treatment for PDN with minimal side effects. This review gives an insight on the pathways involved in the pathogenesis of PDN and the potential pharmacotherapeutic agents. This will be followed by an overview on the FDA-approved drugs for PDN and commercially available topical analgesic and their effects on painful diabetic neuropathies.

Painful Diabetic Peripheral Neuropathy Study of Chinese Outpatients (PDNSCOPE): A Multicentre Cross-Sectional Registry Study of Clinical Characteristics and Treatment in Mainland China

INTRODUCTION

This aim of this study was to delineate current clinical scenarios of painful diabetic peripheral neuropathy (PDN) and associated anxiety and depression among patients in Mainland China, and to report current therapy and clinical practices.

METHODS

A total of 1547 participants were enrolled in the study between 14 June 2018 and 11 November 2019. Recruitment was conducted using a multilevel sampling method. Participants' demographics, medical histories, glucose parameters, Douleur Neuropathique 4 Questionnaire (DN4) scores, visual analogue scale (VAS) pain scores, Patient Health Questionnaire 9 (PHQ-9) scores, Generalised Anxiety Disorder 7 (GAD-7) scores and therapies were recorded.

RESULTS

The male-to-female ratio was 1.09:1 (807:740), and the mean age at onset was 61.28 ± 11.23 years. The mean DN4 score (± standard deviation) was 4.91 ± 1.88. The frequencies of DN4 sub-item phenotypes were: numbness, 81%; tingling, 68.71%; pins and needles, 62.90%; burning, 53.59%; hypoaesthesia to touch, 50.16%; electronic shocks, 43.31%; hypoaesthesia to pinprick, 37.94%; brushing, 37.82%; painful cold, 29.61%; and itching, 25.86%. Age, diabetic duration, depression history, PHQ-9 score and GAD-7 score were identified as risk factors for VAS pain score. Peripheral artery disease (PAD) was a protective factor for VAS pain score. For all participants currently diagnosed with PDN and for those previously diagnosed PDN, fasting blood glucose (FBG) was a risk factor for VAS; there was no association between FBG and VAS pain score for PDN diagnosed within 3 months prior to recruitment. Utilisation rate of opium therapies among enrolled participants was 0.71% , contradiction of first-line guideline recommendation for pain relief accounted for 9.43% (33/350) and contradiction of second-line guideline recommendation for opium dosage form was 0.57% (2/350).

CONCLUSION

Moderate to severe neuropathic pain in PDN was identified in 73.11% of participants. Age, diabetic duration, depression history, PHQ-9 score, GAD-7 score and FBG were risk factors for VAS pain scores. PAD was protective factor. The majority of pain relief therapies prescribed were in accordance with guidelines.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT03520608, retrospectively registered, 2018-05-11.

Incidence of antiepileptic drug therapy and factors associated with their prescribing in outpatients with diabetic polyneuropathy

AIMS

The goal of this retrospective cohort study was to analyze the incidence of, and factors associated with the antiepileptic drug (AED) therapy in the five years following the diagnosis of diabetic polyneuropathy in patients followed in Germany.

METHODS

The study included patients aged 18-80 years with an initial diagnosis of diabetic polyneuropathy in 1238 general and diabetologist practices in Germany between January 2008 and December 2017 (index date). The main outcome of the study was the incidence of the AED therapy in the five years following the diagnosis of diabetic polyneuropathy. Adjusted Cox regression analyses were conducted to investigate the association between study covariates and the incidence of the AED therapy.

RESULTS

The present study included 48,324 patients (mean [standard deviation] age 65.8 [10.6] years, 55.6% male). Within five years of the diagnosis of diabetic polyneuropathy, 16.4% of patients were prescribed at least one AED. The three most frequent drugs were pregabalin, gabapentin, and carbamazepine. Female sex (HR = 1.22), private health insurance coverage (HR = 1.22), follow-up in a general practice (HR = 1.85), HbA1c ≥10% (HR = 1.36), previous referral to a neurological practice (HR = 1.47), previous hospital admission (HR = 1.51) and depression (HR = 1.15) were positively associated with the incidence of the AED therapy.

CONCLUSIONS

The incidence of the AED therapy was low in patients recently diagnosed with diabetic polyneuropathy in Germany. More research is warranted to understand the infrequent use of AEDs in diabetic polyneuropathy patients from this country.

Analgesic and Antidepressant Effects of the Clinical Glutamate Modulators Acetyl-L-Carnitine and Ketamine

Pain and depression are leading causes of disability and of profound social and economic burden. Their impact is aggravated by their chronicity and comorbidity and the insufficient efficacy of current treatments. Morphological and functional metabolism studies link chronic pain and depressive disorders to dysfunctional neuroplastic changes in fronto-limbic brain regions that control emotional responses to painful injuries and stressful events. Glutamate modulators are emerging new therapies targeting dysfunctional brain areas implicated in the generation and maintenance of chronic pain and depression. Here, we report the effects of two clinically approved glutamate modulators: acetyl-L-carnitine (ALCAR) and S, R(±)ketamine (KET). ALCAR is a natural neurotrophic compound currently marketed for the treatment of neuropathies. KET is the prototypical non-competitive antagonist at N-methyl-D-aspartate glutamate receptors and a clinically approved anesthetic. Although they differ in pharmacological profiles, ALCAR and KET both modulate aminergic and glutamatergic neurotransmissions and pain and mood. We assessed in rats the effects of ALCAR and KET on cerebral metabolic rates for glucose (rCMRglc) and assessed clinically the effects of ALCAR in chronic pain and of KET in post-operative pain. ALCAR and KET increased rCMRglc at similar degrees in prefrontal, somatosensory, and cingulate cortices, and KET increased rCMRglc at a different, much larger, degree in limbic and dopaminergic areas. While rCMRglc increases in prefrontal cortical areas have been associated with analgesic and antidepressant effects of ALCAR and KET, the marked metabolic increases KET induces in limbic and dopaminergic areas have been related to its psychotomimetic and abuse properties. In patients with chronic neuropathic pain, ALCAR (1,000 mg/day) yielded to a fast (2 weeks) improvement of mood and then of pain and quality of life. In day-surgery patients, KET improved dischargeability and satisfaction. In obese patients undergoing bariatric surgery, a single, low dose of KET (0.5 mg/kg) at induction of anesthesia determined a very fast (hours) amelioration of post-operative depression and pain and an opioid-sparing effect. These findings indicate that ALCAR and KET, two non-selective glutamate modulators, still offer viable therapeutic options in comorbid pain and depression.

Diabetic peripheral neuropathy: Person-centered care

ABSTRACT

Patients with diabetes mellitus may experience painful and nonpainful diabetic peripheral neuropathy (DPN). This article offers an overview of DPN and the clinical assessment and management of patients with DPN, as well as the nurse's role in supporting these patients.

Diabetic polyneuropathy and pain, prevalence, and patient characteristics: a cross-sectional questionnaire study of 5,514 patients with recently diagnosed type 2 diabetes

Supplemental Digital Content is Available in the Text.

Diabetic polyneuropathy and painful diabetic polyneuropathy are frequent in early type 2 diabetes, associated with modifiable risk factors, and have major impact on mental health.

Most studies of diabetic polyneuropathy (DPN) and painful DPN are conducted in persons with longstanding diabetes. This cross-sectional study aimed to estimate the prevalence of DPN and painful DPN, important risk factors, and the association with mental health in recently diagnosed type 2 diabetes. A total of 5514 (82%) patients (median diabetes duration 4.6 years) enrolled in the Danish Centre for Strategic Research in Type 2 Diabetes cohort responded to a detailed questionnaire on neuropathy and pain. A score ≥4 on the MNSI questionnaire determined possible DPN, whereas pain presence in both feet together with a score ≥3 on the DN4 questionnaire determined possible painful DPN. The prevalence of possible DPN and possible painful DPN was 18% and 10%, respectively. Female sex, age, diabetes duration, body mass index, and smoking were associated with possible DPN, whereas only smoking showed a clear association with possible painful DPN (odds ratio 1.52 [95% confidence interval: 1.20-1.93]). Possible DPN and painful DPN were independently and additively associated with lower quality of life, poorer sleep, and symptoms of depression and anxiety. Possible DPN itself had greater impact on mental health than neuropathic pain. This large study emphasizes the importance of careful screening for DPN and pain early in the course of type 2 diabetes.

Prospects for the application of transcranial magnetic stimulation in diabetic neuropathy

Encouraging results have been reported for the use of transcranial magnetic stimulation-based nerve stimulation in studies of the mechanisms of neurological regulation, nerve injury repair, and nerve localization. However, to date, there are only a few reviews on the use of transcranial magnetic stimulation for diabetic neuropathy. Patients with diabetic neuropathy vary in disease progression and show neuropathy in the early stage of the disease with mild symptoms, making it difficult to screen and identify. In the later stage of the disease, irreversible neurological damage occurs, resulting in treatment difficulties. In this review, we summarize the current state of diabetic neuropathy research and the prospects for the application of transcranial magnetic stimulation in diabetic neuropathy. We review significant studies on the beneficial effects of transcranial magnetic stimulation in diabetic neuropathy treatment, based on the outcomes of its use to treat neurodegeneration, pain, blood flow change, autonomic nervous disorders, vascular endothelial injury, and depression. Collectively, the studies suggest that transcranial magnetic stimulation can produce excitatory/inhibitory stimulation of the cerebral cortex or local areas, promote the remodeling of the nervous system, and that it has good application prospects for the localization of the injury, neuroprotection, and the promotion of nerve regeneration. Therefore, transcranial magnetic stimulation is useful for the screening and early treatment of diabetic neuropathy. Transcranial magnetic stimulation can also alleviate pain symptoms by changing the cortical threshold and inhibiting the conduction of sensory information in the thalamo-spinal pathway, and therefore it has therapeutic potential for the treatment of pain and pain-related depressive symptoms in patients with diabetic neuropathy. Additionally, based on the effect of transcranial magnetic stimulation on local blood flow and its ability to change heart rate and urine protein content, transcranial magnetic stimulation has potential in the treatment of autonomic nerve dysfunction and vascular injury in diabetic neuropathy. Furthermore, oxidative stress and the inflammatory response are involved in the process of diabetic neuropathy, and transcranial magnetic stimulation can reduce oxidative damage. The pathological mechanisms of diabetic neuropathy should be further studied in combination with transcranial magnetic stimulation technology.

Protective effects of dihydromyricetin on primary hippocampal astrocytes from cytotoxicity induced by comorbid diabetic neuropathic pain and depression

Activated astrocytes play a key role in diabetic neuropathic pain and depression. We aimed to assess the protective effects of dihydromyricetin (DHM) on primary hippocampal astrocytes cultured with high glucose (HG), substance P (SP), and corticosterone (CORT). Culturing with HG + SP + CORT resulted in damage to primary hippocampal astrocytes, which simulates the clinical damage caused by comorbidity of diabetic neuropathic pain and depression. Western blot, qPCR, and immunofluorescence analyses revealed that HG + SP + CORT increased P2X₇ receptor expression in primary hippocampal astrocytes, which was reversed by DHM treatment. Further, HG + SP + CORT elevated TNF-α, IL-1β, free Ca²⁺, and ERK1/2 phosphorylation levels, which was inhibited by DHM or P2X₇ shRNA treatment. Moreover, DHM significantly reduced the P2X₇ agonist-activated currents in HEK293 cells transfected with the P2X₇ receptor. These findings suggest that DHM can protect primary hippocampal astrocytes cultured with HG + SP + CORT from P2X₇ receptor-mediated damage. Culturing cells with HG + SP + CORT might be a viable cell model for cellular injury exploration of diabetic comorbid pain and depression.

Evaluation of the relationship among foot wound risk, foot self-care behaviors, and illness acceptance in patients with type 2 diabetes mellitus

AIMS

Due to insufficient data in primary care, this study was designed to assess the influence of patient's foot self-care behaviors and illness acceptance on the risk of developing diabetic foot ulcers (DFU) in adults diagnosed with type 2 diabetes mellitus (DM).

METHODS

This is a descriptive study with a clinical assessment element. Data were collected using a number of validated psychometric questionnaires that assess the participant's foot self care behavior, acceptance of Illness, symptoms and neuropathy. The study included 246 patients diagnosed with type 2 DM attending a designated family health center in Konya, Turkey.

RESULTS

In the present study, there was a significant difference between DFSBS scores and gender and whether the patients resided in urban or rural areas (p < 0.05). A significant difference between AIS score and gender, educational status, social security, place of residence, and economic status of the participants was observed (p < 0.05). According to the results of regression analysis, gender, frequency of physician control visit (monthly), and foot care training predicted the DFSBS score, whereas gender, education, economic status, presence of other non-infectious diseases, hospitalization in the previous year, and OTNS results predicted the AIS score. Furthermore, the AIS and OTNS scores predicted the MNSI-Q score.

CONCLUSIONS

In the family health centers, individuals who are at risk must be initially identified and efforts should be made to prevent complications and increase illness acceptance.

Management and Treatment of Patients With Major Depressive Disorder and Chronic Diseases: A Multidisciplinary Approach

In patients with physical chronic diseases, the prevalence of major depressive disorder (MDD) is approximately 2- to 3-fold higher than in the general population, and it can reach up to 20-40%. The comorbidity of MDD with chronic medical diseases is associated with poorer quality of life, increased medical symptom burden, poor adherence to self-care regimens, increased risk of functional impairment, morbidity, and mortality, and also higher medical costs. Despite this evidence, in routine practice, psychological issues and concerns are frequently inadequately managed. This consensus document proposes that a proper diagnosis, a multidisciplinary approach, and a personalized treatment plan would allow patients with MDD and chronic comorbidities to be more compliant, to improve the outcomes, to reduce possible relapses in the long term, and to prevent or better manage complications and adverse events. This proposal might be useful for any health professionals who deal with patients with chronic diseases, as it can help to pay more attention to the emotional impact of these conditions, in particular in terms of depressive symptoms.

Managing the multifaceted nature of type 2 diabetes using once-weekly injectable GLP-1 receptor agonist therapy

WHAT IS KNOWN AND OBJECTIVE

As a highly prevalent chronic condition associated with complications and high mortality rates, it is important for pharmacists to have a comprehensive understanding of the impact of type 2 diabetes (T2D) and available treatment options. The use of injectable glucagon-like peptide 1 receptor agonists (GLP-1 RAs) is recommended as an effective and convenient treatment regimen for improving glycaemic control in individuals with T2D, with a good safety profile; however, the wider extent of its potential benefits often are unknown to clinical pharmacists. The objective of this article is to provide an overview of the impact of T2D on individuals and to discuss the multifaceted role of once-weekly (QW) GLP-1 RAs in addressing these challenges.

METHODS

This is a narrative review of the published literature regarding the use of injectable GLP-1 RAs in managing health complications in people with T2D.

RESULTS AND DISCUSSION

Recent findings reveal additional benefits of GLP-1 RAs in managing T2D complications, including atherosclerotic cardiovascular (CV) disease, retinopathy, neuropathy, and nephropathy. Dulaglutide and semaglutide have been shown to provide additional CV benefit in patients at high risk of CV events compared with standard of care/placebo and may offer renal protection in patients with chronic kidney disease. Cost-effectiveness studies, taking into consideration these different complications, have shown that QW GLP-1 RAs were cost-effective compared with other therapies. GLP-1 RAs may also help to improve overall health-related quality of life, reducing the risk of depression and 'diabetes distress', and limiting the risk of hypoglycaemia.

WHAT IS NEW AND CONCLUSION

From the literature, this appears to be the first review of the evidence supporting the multifaceted role of QW GLP-1 RAs in T2D, with particular emphasis on their use in comorbid conditions, as well as associated potential financial and well-being benefits. The results suggest that QW GLP-1 RAs may be an attractive treatment option for improving glycaemic control in T2D, especially in individuals with (or at risk of) additional comorbidities or health complications.

Peripheral neuropathy and depressive symptoms: examining the association in a primary health care setting among persons with and without diabetes mellitus

PURPOSE

The purpose of this study was to measure the association between peripheral neuropathy symptoms and depressive symptoms among a sample of patients with and without diabetes mellitus (DM).

METHODS

Patients were administered the 15-item Michigan Neuropathy Screening Instrument (MNSI) and the patient health questionnaire depression scale (PHQ-8). Patients with an MNSI score ≥ 4 were categorized as having PN and patients with a PHQ-8 score ≥ 10 were considered to have current depression. Log-binomial regression was used to analyze the relationship between PN and depressive symptoms.

RESULTS

406 patients were included in the final analysis. There were no statistically significant differences by diabetes status in PN symptoms (Diabetes = 61.8%; No diabetes = 55.4%; p = .20) or in depression status (Diabetes = 37.6%; No diabetes = 36.6%; p =  .83). After adjustment for covariates, PN was associated with depression (aRR = 4.46; 95% CI 2.91,6.85) independent of diabetes status.

CONCLUSIONS

PN symptoms may be common among aging persons even in the absence of DM. Past literature and our study demonstrate that PN and depression are closely associated. More work is needed to understand the etiology and potential utility of intervention for depression symptoms among patients with neuropathy.

Prevalence of Depression among Type-II Diabetic Patients Attending the Diabetic Clinic at Arar National Guard Primary Health Care Center, Saudi Arabia

Background

Depression is a common comorbidity in type-II diabetic patients, which if undiagnosed leads to poor clinical outcomes.

Objectives

To determine the prevalence and risk factors of depression among type-II diabetic patients attending the National Guard Diabetic Clinic in Arar city. Subjects and methods. This cross-sectional study included every third type-II diabetic patient attending the National Guard Primary Health Care Center between the 1^st of January and 31^st of March 2019. Participants were interviewed using the Patient Health Questionnaire 9 (PHQ-9). Patients who scored ≥5 were considered to have depression. Chi-square test (χ²) was used to compare differences between categorical variables. P ≤ 0.05 was considered statistically significant.

Results

Of the total 422 diabetic patients approached for this study, 397 provided complete responses (94% response rate). Of these, 37% had depression: 23% mild, 9% moderate, and 5% severe. Diabetic patients with low education, poor income, and long duration of diabetes mellitus were found to be at higher risk of depression. Poor compliance with physical activities, diet regimen, family history of DM, and the presence of complications was also significantly associated with depression. On logistic regression analysis, low family income, duration of DM, poor compliance to physical activity, and presence of complications as neuropathy or libido were the main predictors of depression in diabetic patients.

Conclusion

More than one-third of type-II diabetic patients had depression. Regular screening of type-II diabetic patients for depression is a necessity, as it can affect the clinical outcome.

Relationship between diabetic neuropathic pain and comorbidity. Their impact on pain intensity, diabetes complications and quality of life in patients with type-2 diabetes mellitus

OBJECTIVE

To compare cognitive function, mood and sleep status in patients with and without diabetic neuropathic pain (DNP) and their relationship with pain intensity, diabetes complications, and quality of life. To determine whether these relationships differ depending on the sensorial phenotype.

METHODS

Cross-sectional study performed on patients with type-2 diabetes-mellitus and neuropathy. Presence of DNP, pain intensity and phenotype, mood status, sleep characteristics and quality of life were measured.

RESULTS

A total of 130 patients (65 with DNP) were included. DNP was related to poor sleep quality (OR = 1.03;CI95%:1.02-1.05), pain treatment (OR = 3.00,CI95%:1.24-7.29) or previous anxiety (OR = 2.70,CI95%:1.05-6.99). Patients with specific phenotypes or depression (=0.82,CI95%:-0.02-1.67) referred more severe pain. More complications were related to older age (OR = 1.40,CI95%:1.12-1.66), higher pain intensity (OR = 1.51,CI95%:1.00-2.28), lower cognitive performance (OR = 1.25,CI95%:1.09-1.43), previous anxiety (OR = 10.48,CI95%:1.46-75.24) and insulin treatment (OR = 124.50,CI95%:6.64-2335.06). Decrease in mental quality of life was associated with sleep disorders (β = -0.33,CI95%:-0.48,-0.23), physical comorbidities (β = -9.73,CI95%:-18.15, -1.31) and previous anxiety (β = -7.91,CI95%:-13.04, -2.77). Lower scores in physical quality of life were related to sleep disorders (β = -0.12,CI95%:-0.21, -0.18), obesity (β = -8.35,CI95%:-13.16, -3.55), longer time since diagnosis (β = -0.72,CI95%:-1.44;0.01) and disability (β = -14.58,CI95%:-24.69; -4.48).

CONCLUSIONS

The results support the idea that mental comorbidity and sleep disorders are factors associated with DNP and greater pain intensity, more diabetes complications and lower quality of life. Moreover, they highlight the relationship between sensorial phenotypes and pain intensity, and lower cognitive performance and diabetes complications.

Results of Mirogabalin Treatment for Diabetic Peripheral Neuropathic Pain in Asian Subjects: A Phase 2, Double-Blind, Randomized, Placebo-Controlled, Study

INTRODUCTION

Almost one-quarter of Asian patients with diabetes experience diabetic peripheral neuropathic pain (DPNP), which may be associated with moderate or severe levels of pain, insomnia, mood disorders, and worsened quality of life. Current treatments are generally ineffective and may be poorly tolerated. We evaluated mirogabalin as a treatment for DPNP in Asian subjects.

METHODS

This phase 2, randomized, double-blind, controlled study was conducted in Japan, South Korea, and Taiwan. Subjects (n = 450) with DPNP were randomized (1:1:1:1:1) to treatment with 5, 10, or 15 mg twice-daily (BID) mirogabalin, 150 mg BID pregabalin, or placebo. The primary endpoint was change from baseline in average daily pain score (ADPS) at week 7; secondary endpoints included responder rates, Short-Form McGill Pain Questionnaire (SF-MPQ), Patient Global Impression of Change (PGIC), average daily sleep-interference score (ADSIS), and incidence of treatment-emergent adverse events (TEAEs).

RESULTS

A greater improvement was noted for each mirogabalin treatment group for change from baseline in ADPS at week 7 compared with both placebo and with pregabalin, although these improvements were not statistically significant. The percentage of 30, 50, and 75% responders and subjects with PGIC improvements was greater in each mirogabalin group versus placebo. Mirogabalin 15 mg BID significantly improved the SF-MPQ sensory (p = 0.0313) and visual analog scale scores (p = 0.0093), and ADSIS (p = 0.0002), versus placebo. Treatment was generally well tolerated; the most frequently reported TEAEs in the mirogabalin groups were somnolence (14.7%) and dizziness (11.0%), and most AEs were mild or moderate even at the highest dose.

CONCLUSIONS

In Asian subjects with DPNP, mirogabalin (5, 10, and 15 mg BID) was well tolerated. Although no significant differences were observed in the primary endpoint, there was a tendency toward improvement of pain with mirogabalin treatment, and this trend was also observed in the secondary endpoints.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT01504412.

Multidimensional evaluation is necessary to assess hand function in patients with Charcot-Marie-Tooth disease type 1A

BACKGROUND

Charcot-Marie-Tooth (CMT) disease type 1A (CMT1A) is the most common hereditary neuropathy. Several studies have assessed the relation between axonal loss and grip strength; however, the functional impact on dexterity and health-related quality of life (HRQoL) is unknown. We hypothesized that the severity of axonal loss will be correlated with loss of function and HRQoL.

OBJECTIVE

The purpose of this study was to evaluate the relation between severity of electroneuromyography impairment and its impact on function and HRQoL in adults with CMT1A.

METHODS

Grip and lateral pinch strength were evaluated with specific dynamometers: the Jamar and the Pinch Gauge. Dexterity was explored with the Sollerman, Jebsen, and Nine-hole Peg tests. The CMT impact on well-being was assessed by the validated Medical Outcomes Study Short Form 36 (SF-36), Beck Depression Inventory, and Fatigue Severity Scale, and disease severity by the CMT neuropathy score and Inflammatory Neuropathy Cause and Treatment sensory sum score. Finally, axonal loss and demyelination process was assessed by electroneuromyography.

RESULTS

We included 33 participants with CMT1A (23 females, mean [SD] age 47.0 [4.7] years). We found lack of correlation between severe electroneuromyography impairment (frequency of abnormal results >80%), significant distal amyotrophy (70%) and quality of life (mean [SD] scores for physical and mental SF-36 36.4 [10.0] and 48.4 [11.5]), autonomy for activities of daily living, and hand function that remains relatively preserved. We found a correlation between lateral pinch and dexterity according to the Sollerman test (r=0.52, p<0.05) but a lack of correlation among the other parameters.

CONCLUSIONS

Electrophysiological follow-up seems to be of little relevance to follow HRQoL in individuals with CMT1A and manual function related to functional objectives for everyday physical medicine and rehabilitation practice. The manual function is complex and requires an overall, quantitative, qualitative and multidisciplinary assessment. Each tool (Pinch Gauge, Jamar, Sollerman, Jebsen, Nine-hole Peg) measures a specific element of manual function and is necessary when performing a grip function analysis.

Whole body vibration showed beneficial effect on pain, balance measures and quality of life in painful diabetic peripheral neuropathy: a randomized controlled trial

Purpose

The aim of the study was to determine the efficacy of whole body vibration (WBV) therapy on pain, neuropathy disability score, balance, proprioception and quality of life (QOL) in patients with painful diabetic peripheral neuropathy (PDPN).

Methods

Twenty-six (16 males and 10 females) patients with PDPN were selected on the basis of inclusion and exclusion criteria. Subjects were randomly allocated to an experimental group (n = 13, age = 60.69 ± 5.08) and a control group (n = 13, age = 59.54 ± 4.25). The experimental group was given WBV therapy for six weeks (3 days/week) in addition to standard medical care, dietary advice and lifestyle modifications. Control group was provided only standard medical care, dietary advice and lifestyle modifications. Outcome measures included numeric pain rating scale (NPRS), Leeds assessment of neuropathic symptoms and signs (LANSS), vibration perception threshold (VPT), neuropathy disability score (NDS), proprioception, single-leg stance test (SLST), timed up and go test (TUGT) and short form 36 questionnaire (SF-36).

Results

NPRS, LANSS, NDS, SLST and TUGT showed significant time effect (p ≤ 0.022) and time×group interaction (p ≤ 0.007), whereas group effect was found to be significant only in LANSS (p = 0.001). VPT showed significant group effect (p ≤ 0.045) and time×group interaction (p ≤ 0.007) at great toe, metatarsal head and total average score. SF-36 was found to be significant time effect (p ≤ 0.024) in all domains except limitations due to physical health (p = 0.461). SF-36 average score was found be significant for group effect (p = 0.002) and time×group interaction (p < 0.001).

Conclusion

WBV improves sensory sensations like pain and vibration perception, neuropathy disability score, balance measures and health-related QOL in PDPN.

Diabetic Peripheral Neuropathy Is Associated With Higher Systolic Blood Pressure in Adults With Type 2 Diabetes With and Without Hypertension in the Chinese Han Population

OBJECTIVES

Our aim in this study was to investigate the association between diabetic peripheral neuropathy (DPN) and above-normal blood pressure in nonhypertensive adult patients with type 2 diabetes mellitus (T2DM). We also compared achievement of clinical targets for DPN and non-DPN with T2DM.

METHODS

A retrospective survey was administered to 3,810 patients with T2DM. Cases were grouped according to the Toronto Clinical Scoring System as follows: non-DPN, mild DPN, moderate DPN and severe DPN. A total of 1,835 patients (hypertensive, 1,247; nonhypertensive, 588) also underwent nerve conduction velocity testing, and then was divided into quartile groups.

RESULTS

Irrespective of hypertension, systolic blood pressure (SBP) and glycated hemoglobin levels in the DPN group were higher than those in the non-DPN group (p<0.001). In hypertensive patients, blood pressure goal achievement was lower in the DPN group compared with the non-DPN group (31.1% vs 40.5%, p<0.05). Compared with the nerve conduction velocity Q1 (<P25%) group, optimal SBP of the Q2 (P25% to P50%), Q3 (P50% to P75%) and Q4 (>P75%) groups decreased by 62.2%, 68.2% and 78.0%, respectively. In the nonhypertensive patients, detection of optimal SBP was lower in the DPN group than in the non-DPN group (p<0.05). After adjusting for age, sex and diabetes duration (model 2), a 3-point higher DPN score on the Toronto Clinical Scoring System was associated with an SBP level of 4.2 mmHg higher (95% confidence interval, 0.01 to 0.17; p<0.01) in nonhypertensive patients with diabetes.

CONCLUSIONS

DPN is associated with difficulty in hypertension management in T2DM. It is also associated with elevated systolic blood hypertension, even in nonhypertensive patients with diabetes. Elevated SBP in nonhypertensive T2DM may be also worthy of further attention.

Anxiety, depression and sleep disorders in patients with diabetic neuropathic pain: a systematic review

Introduction: Diabetic neuropathic pain (DNP) is a disabling complication suffered by patients with diabetic neuropathy. DNP coexists with different conditions, especially mental and sleep disorders, which seem to impair the management and course of the disease. However, there is a lack of accurate results about their prevalence. Consequently, the authors analyze the prevalence of anxiety, depression and/or sleep disorders in DND patients.Areas covered: Among the 206 articles found in the search, 8 studies with data from 5 different countries fulfilled the inclusion criteria. The prevalence of anxiety reported ranged between 7.8%-60.4% and that of depression between 13.6%- 50.6%. The two conditions coexist in 26.4%-30.6% in DND patients. A higher prevalence was found when the information was obtained using scales than when it came from medical records. The prevalence of sleep disorders found ranged from 41.6%-43.8%. However, there is lack of information about and the results are often expressed using the mean scores of the scales.Expert opinion: Although the data in the literature vary, a high prevalence of anxiety, depression and sleep comorbidities exists among patients with DNP. These results reaffirm the need to perform systematic evaluations and to identity their presence using validated instruments to obtain more reliable results.

The effect of exercise therapy combined with psychological therapy on physical activity and quality of life in patients with painful diabetic neuropathy: a systematic review

Background and aims

Approximately 25% of patients with diabetes mellitus type 2 (DMII) develop painful diabetic neuropathy (PDN). PDN is known to affect both mental and physical wellbeing, resulting in anxiety, depression, low quality of life and physical disability. Pharmacological treatment of PDN aims at pain relief and is often ineffective and/or has many side effects. Rehabilitation treatment modalities that are designed to help the patient deal with PDN related complaints, are mostly focussed on either physical (e.g. exercise therapy) or psychological aspects (e.g. cognitive behavioural therapy, CBT). There is emerging evidence that PDN can be approached from a biopsychosocial perspective, in which physical and psychosocial aspects are integrated. From this biopsychosocial approach it is plausible that integrated treatment modalities such as acceptance commitment therapy (ACT) or exposure in vivo (EXP) could be effective in patients with PDN. The objective of this review was to provide an overview of the current evidence on the effects of rehabilitation treatments that combine exercise therapies with psychological therapies in order to improve physical activity (PA) and quality of life (QoL) in patients with PDN.

Methods

Systematic review of the current literature. EMBASE, MEDLINE, Medline In-Process citations and e-Pubs ahead-of-print, Pedro, Web of Science, PsycINFO, CENTRAL, PubMed and Google Scholar were searched. All studies on interventions combining exercise therapy with psychological interventions in patients with PDN, aged >18 years, were included. Outcome measures were PA, QoL.

Results

The search resulted in 1603 records after removing duplicates. After screening on titles and abstracts, 100 records remained. From these, not one study reported on interventions that combined exercise therapy with psychological interventions. Through a secondary hand search, a total of three reviews were identified that described a total of five studies regarding either physical or psychological interventions in patients with PDN. These studies reported moderate effects of (1) mindfulness meditation on QoL, (2) CBT on pain severity, (3) mindfulness-based stress reduction intervention on function, health-related QoL, pain catastrophizing and depression, (4) aerobic exercise on QoL and (5) Tai Chi on glucose control, balance, neuropathic symptoms, and some dimensions of QoL in patients with PDN. All studies were of a moderate quality, and results should be interpreted with caution.

Conclusions

Based on increasing knowledge in the domain of chronic pain, it could be assumed that integrated rehabilitation treatments for patients with PDN are beneficial. There is no literature to support this and more research should be done on integrated biopsychosocial interventions in patients with PDN.

Implications

This empty review highlights the importance that more research should be done on integrated biopsychosocial interventions in patients with PDN. Currently, our research group is performing a study on the effects of EXP treatment in patients with PDN.

Painful Diabetic Peripheral Neuropathy Study of Chinese OutPatiEnts (PDN-SCOPE): protocol for a multicentre cross-sectional registry study of clinical characteristics and treatment in China

INTRODUCTION

Painful diabetic peripheral neuropathy (PDN) is a growing public health problem in China. Despite recent progress in treatment, there has been no nationwide study evaluating current medical practices and compliance with treatment guidelines. The primary aims of this study are to investigate the clinical characteristics and treatment practices for PDN and associated anxiety and depression in China.

METHODS AND ANALYSIS

Painful Diabetic Peripheral Neuropathy Study of Chinese OutPatiEnts is a cross-sectional, multicentre registry study with a target sample size of approximately 1500 people experiencing PDN. People with PDN will be treated according to current guidelines and local practices. The demographics, medical histories, Visual Analogue Scale pain scores, Patient Health Questionnaire-9 results, Generalised Anxiety Disorder-7 scores and therapies will be recorded to evaluate clinical characteristics of PDN and current treatment practices for pain, anxiety and depression.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Peking University Third Hospital Medical Science Research Ethics Committee (2018-182).The results of this study will be disseminated through peer-reviewed publications and scientific presentations.

TRIAL REGISTRATION NUMBER

NCT03520608.

Incidence of Anxiety and Depression Among Patients with Type 2 Diabetes and the Predicting Factors

Introduction

Diabetes mellitus (DM) is a chronic, progressive metabolic illness which is commonly complicated by coexistence of depression and anxiety. This study aimed to assess the prevalence of anxiety and depression among diabetic patients and the factors predicting this coexistence.

Methods

It was a cross-sectional, observational study which included patients of type 2 DM admitted in the hospital due to diabetes-related condition - diabetic foot infections/ulcers, hyperosmotic hyperglycaemic state (HHS), and hypoglycaemic coma/seizure. Anxiety and depression were measured by using the Hospital Anxiety and Depression Scale (HADS). Data was entered and analysed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA).

Results

Mean anxiety score of the participants was 10.88 ± 4.075 and mean depression score was 11.82 ± 4.049. There were 72 (50.7%) patients who had anxiety and 70 (49.2%) patients who had depression. Higher scores of anxiety and depression were statistically significant in female gender, older participants, individuals with longer duration of diabetes, those taking non-insulin treatment, and individuals with painful neuropathy, nephropathy, and foot ulcers.

Conclusion

The incidence of depression and anxiety among hospitalized patients of diabetes mellitus is high. The coexistence of these two chronic debilitating illnesses is worsening the overall quality of life. It is very important to diagnose and manage anxiety and depression in patients with type 2 DM to ensure higher quality of life and life expectancy.

A cross-sectional study investigating frequency and features of definitely diagnosed diabetic painful polyneuropathy

This cross-sectional multicentre study aimed at investigating frequency and features of painful diabetic polyneuropathy. We consecutively enrolled 816 patients attending hospital diabetic outpatient clinics. We first definitely diagnosed diabetic polyneuropathy and pure small-fibre polyneuropathy using clinical examination, nerve conduction study, and skin biopsy or quantitative sensory testing. Adhering to widely agreed criteria, we then identified neuropathic pain and diagnosed painful polyneuropathy using a combined approach of clinical examination and diagnostic tests. Of the 816 patients, 36% had a diabetic polyneuropathy associated with male sex, age, and diabetes severity; 2.5% of patients had a pure small-fibre polyneuropathy, unrelated to demographic variables and diabetes severity. Of the 816 patients, 115 (13%) suffered from a painful polyneuropathy, with female sex as the only risk factor for suffering from painful polyneuropathy. In this large study, providing a definite diagnosis of diabetic polyneuropathy and pure small-fibre polyneuropathy, we show the frequency of painful polyneuropathy and demonstrate that this difficult-to-treat complication is more common in women than in men.

Dihydromyricetin Alleviates Diabetic Neuropathic Pain and Depression Comorbidity Symptoms by Inhibiting P2X7 Receptor

Diabetic neuropathic pain (DNP) and major depressive disorder (MDD) are common complications of diabetes mellitus and mutually affect each other. As a member of the ATP-gated ion channel family, P2X₇ receptor is associated with the transduction of pain signal and the onset of depression. The aim of this study was to investigate the effects of dihydromyricetin (DHM) on rats with comorbid DNP and MDD. After the comorbid model was established, rat behavior changes were monitored by measuring the mechanical withdrawal threshold, thermal withdrawal latency, sugar water preference, immobility time in the forced-swim test, and open-field test parameters. The expressions of P2X₇ receptor in the dorsal root ganglia (DRGs), spinal cord, and hippocampus were assessed by quantitative real-time PCR, Western blotting, and double immunofluorescence. We found that hyperalgesia, allodynia, and depressive behaviors of rats with comorbid DNP and MDD were relieved by treatment with DHM or application of a short-hairpin RNA for P2X₇ receptor. The expression levels of P2X₇, phosphorylated extracellular signal-regulated kinase 1/2, tumor necrosis factor α, and interleukin 1ß were increased in the DRGs, spinal cord, and hippocampus of rats in the model group but restored after DHM or P2X₇ short-hairpin RNA treatment. In conclusion, P2X₇ receptor in the DRGs, spinal cord, and hippocampus participates in the transduction of DNP and MDD signals. DHM seems to relieve comorbid DNP and MDD by reducing the expression of P2X₇ receptor in the DRGs, spinal cord, and hippocampus and may be an effective new drug for the treatment of patients with both DNP and MDD.

Clinical Characteristics of Patients with co-Existent Diabetic Peripheral Neuropathy and Depression: A Systematic Review

Objectives Both diabetic peripheral neuropathy and depression have significant implications on patients’ quality of life, management and outcomes. We aimed to evaluate all available evidence concerning patients with co-existent diabetic peripheral neuropathy and depression, and describe their clinical characteristics, in order to promote early recognition and management.

Methods Systematic search of PubMed for studies providing data on patients with diabetic peripheral neuropathy and depression. The primary outcome was to evaluate all available evidence related to characteristics of diabetes, diabetic peripheral neuropathy and depression. Secondary study outcomes included comorbid conditions and complications in these patients.

Results Final analysis included 24 studies with data on 205 patients. Most patients were adults between 18–65 years of age. Mean HbA1c value was above 8% and most patients were treated with insulin. Neuropathy was predominantly painful and most patients with available data were considered to have major depressive disorder. In addition to diabetic peripheral neuropathy and depression, diabetes-related complications were recorded in 43 patients, the most common being autonomic neuropathy, retinopathy and nephropathy. The most frequently reported comorbidities were weight loss (72 patients), impotence (60 patients), hypertension (23 patients) and coronary artery disease (22 patients).

Conclusions The present study describes the characteristics of patients with co-existent diabetic peripheral neuropathy and depression, aiming for prompt detection, prevention of further deterioration and improvement of patient outcomes. Available evidence shows that the majority of these patients are adults, with painful peripheral neuropathy and with insulin-treated and inadequately controlled diabetes.

An Assessment of Clinically Important Differences on the Worst Pain Severity Item of the Modified Brief Pain Inventory in Patients with Diabetic Peripheral Neuropathic Pain

Objectives

Using patient global impression of change (PGIC) as an anchor, an approximately 30% reduction on an 11-point numeric pain intensity rating scale (PI-NRS) is considered a clinically important difference (CID) in pain. Our objective was to define the CID for another pain measure, the worst pain severity (WPS) item of the modified Brief Pain Inventory (m-BPI).

Methods

In this post hoc analysis of a double-blind, placebo-controlled, phase 2 study, 452 randomized patients with diabetic peripheral neuropathic pain (DPNP) were followed over 5 weeks, with m-BPI data collected weekly and PGIC at treatment conclusion. Receiver operating characteristic (ROC) curves (via logistic regression) were used to determine the changes in the m-BPI-WPS score that best predicted ordinal clinical improvement thresholds (i.e., "minimally improved" or better) on the PGIC.

Results

Similar to the PI-NRS, a change of -3 (raw) or -33.3% from the baseline on the m-BPI-WPS optimized prediction for the "much improved" or better PGIC threshold and represents a CID. There was a high correspondence between observed and predicted PGIC categories at each PGIC threshold (ROC AUCs were 0.78-0.82).

Conclusions

Worst pain on the m-BPI may be used to assess clinically important improvements in DPNP studies. Findings require validation in larger studies.

Quality of life and time since diagnosis of Diabetes Mellitus among the elderly

Abstract Objectives: To evaluate the quality of life of the elderly with Diabetes Mellitus and to relate the time since diagnosis of diabetes with the quality of life of elderly persons receiving care at a basic health unit. Method: A cross-sectional quantitative study carried out in a Basic Health Unit with 196 elderly persons. For data collection, three instruments were used: one structured (sociodemographic and clinical variables) and the Whoqol-bref and Whoqol-old, with scores ranging from 0 to 100. Descriptive statistical analysis, Student’s T-test and Pearson’s correlation were performed. Results: Of the 196 diabetic patients, the majority were male (54.6%) with a mean age of 67.5 (±6.5) years. The mean time since diagnosis of Diabetes Mellitus was 9.1 years. The domains of the Whoqol-bref with the highest scores, indicating better quality of life, were Social Relations and Psychological, while a worse quality of life was observed in Environment. The facets of the Whoqol-old with the best scores were: Intimacy and Past, Present and Future Activities, and the worst was Death and Dying. The domains associated with one another were Physical and Psychological, Physical and Social Relations, and Psychological and Environmental. The associated aspects were Past, Present and Future Activities and Social Participation. Elderly persons with more than ten years of Diabetes Mellitus had worse quality of life scores in Physical (p=0.001), Social relations (p=0.002), and in the Autonomy (p=0.0012), Social Participation (p=0.041) and Death and Dying (p=0.001) facets. Conclusion: The time of diagnosis of Diabetes Mellitus was negatively associated with the quality of life of the elderly, with worse scores in most domains and facets of the Whoqol.

The Giant Geriatric Syndromes Are Intensified by Diabetic Complications

By 2015, diabetes has affected more than 415 million people over the world. It is anticipated that 640 million adults will suffer from diabetes in 2040. The elongation of the life expectancy, as the result of better general health care, extends also the time when diabetic complications may develop together with other senility-specific problems. The Giant Geriatric Syndromes (Geriatric Giants) have been qualified by the original Nascher's criteria defined more than 100 years ago, but they are becoming more and more relevant in connection with the aging of societies. The criteria comprise the older age, commonness of the health problem, multifactorial etiology, functional or cognitive impairment, worsened outcome, and increased morbidity and mortality. We described the impact of diabetes on Geriatric Giants including cognitive dysfunction, depression, malnutrition, incontinence, falls and fractures, chronic pain, and the loss of senses. The association of diabetes with Geriatric Giants reveals as a vicious circle with the background of neurovascular complications. However, diabetes influence on the incidence of cancer in elderly was also discussed, since neoplastic diseases associate with Geriatric Giants, for example, chronic pain and depression. The knowledge about these aspects of functional decline in geriatric population is crucial to improve patient care.

Depression and Mortality in People with Type 2 Diabetes Mellitus, 2003 to 2013: A Nationwide Population-Based Cohort Study

BACKGROUND

Previous reports have demonstrated a bidirectional relationship between depression and diabetes mellitus (DM), accentuating a need for more intensive depression screening in DM patients. There is a relative paucity of data on the mortality of depressed DM patients in Korea.

METHODS

Retrospective data from January 2003 to December 2013 were collected for adult type 2 diabetes mellitus (T2DM) patients older than 30 years using the National Health Information database maintained by the Korean National Health Insurance Service (NHIS). Demographic characteristics were analyzed with descriptive statistics, and the annual prevalence of depression was estimated. Mortality rates and hazard ratios for each age group (stratified into six age groups) of patients diagnosed with T2DM in 2003 were estimated using a Cox proportional hazard method, with the Kaplan-Meier cumulative survival curve showing the overall survival rates according to the T2DM status until the given year of 2013.

RESULTS

The annual prevalence of depression was consistently higher in T2DM group from 2003 to 2013. The mortality hazard ratio was higher in the depressed in all age groups, and the risk was higher in male groups and in younger-aged groups.

CONCLUSION

Depression was significantly associated with a high mortality risk in T2DM patients; hence, a more systematic surveillance of T2DM patients to identify risk factors for depression might contribute significantly to reducing mortality risk in this group of patients.

Neuropathy and presence of emotional distress and depression in longstanding diabetes: Results from the Canadian study of longevity in type 1 diabetes

AIM

To determine the association of neuropathy and other complications with emotional distress and depression among patients with longstanding type 1 diabetes (T1DM).

METHODS

Canadians with ≥50years of T1DM completed a questionnaire including assessment of distress and depression by the Problem Areas in Diabetes Scale (PAID) and Geriatric Depression Scale (GDS), respectively. Complications were determined using the Michigan Neuropathy Screening Instrument (Questionnaire Component), fundoscopy reports, renal function tests, and self-reported peripheral-(PVD) and cardiovascular (CVD) disease. Associations were analyzed by Poisson regression.

RESULTS

Among 323 participants, 137 (42.4%) had neuropathy, 113 (36.5%) nephropathy, 207 (69.5%) retinopathy, 95 (29.4%) CVD, and 31 (9.8%) PVD. The neuropathy subgroup had higher prevalence of distress (13 (9.5%) vs. 6 (3.3%), p=0.029) and depression (34 (24.9%) vs. 12 (6.5%), p<0.001). Adjusting for diabetes complications, neuropathy was associated with higher PAID (adjusted RR 1.44 (95% CI 1.14-1.82), p=0.003) and GDS scores (adjusted RR1.57 (1.18-2.11), p=0.002). Independent of potential confounders, neuropathy remained associated with higher PAID (adjusted RR 1.39 (1.10-1.76), p=0.006) and GDS scores (adjusted RR 1.37 (1.03-1.83), p=0.032). Associations with neuropathy were not fully explained by neuropathic pain.

CONCLUSION

Compared to other complications, neuropathy had the greatest association with distress and depression in longstanding T1DM, independent of pain. Strategies beyond pain management are needed to improve quality of life in diabetic neuropathy.