neuropathy

Management of Peripheral Neuropathy

Primary care can effectively manage typical peripheral neuropathies, and pattern recognition is key in identifying patients who should be referred to specialty care.

This was the topic of discussion at this afternoon’s session presented by Kelsey Barrell, MD, who is an assistant professor in the Department of Neurology at the University of Utah and the program director at the Neuromuscular Medicine Fellowship. 

She began with an overview of peripheral neuropathy and why it is so important for clinicians to be informed about. Peripheral neuropathy is one of the most common neurologic disorders seen in primary care, she said, especially with the growing prevalence of diabetes.

The symptoms of the disorder depend on the nerves affected, and can include pain, burning, orthostatic hypotension, sexual dysfunction, numbness, imbalance, weakness, and muscle atrophy.

“In reality, often people will have a combination of the above, often beginning with the small fiber symptoms and progressing on.”

Clinical Approach

“The approach all starts with history,” she explained. Clinicians should ask about when symptoms first presented, the distribution of symptoms, whether they involve pain, and whether any risk factors, such as diabetes, obesity, family history, or social factors are present. History should be followed by a neurologic exam using a safety pin, tuning fork, and reflex hammer.

Diagnostics should include a glucose tolerance test, vitamin B12 levels, serum protein electrophoresis with immunofixation, a lipid panel, and CMP and TSH.

Pattern Recognition

  • The most common pattern is distal sensory polyneuropathy, which begins in the toes, moves to the knees and the hands, and should be symmetric.
  • Mononeuropathies, which are also very common, include Carpal Tunnel and Cubital Tunnel syndromes.
  • “Autonomic Neuropathies are tricky, because they are often underreported.” In this neuropathy, the autonomic nervous system is affected.
  • Mononeuritis Multiplex is an uncommon but aggressive and treatable form of neuropathy. It includes patchy, asymmetric weakness and numbness that begins quite rapidly.
  • Neuronopathy affects the dorsal root ganglion which leads to profound sensory loss.
  • Polyradiculoneuropathies involve inflammation of nerve roots and peripheral nerves which leads to reduction of reflexes.
  • Motor Predominant neuropathy involves significant muscle weakness and atrophy with limited or no sensory loss.

Treatment

She went on to examine the 3 tenets of treatment, including targeting/preventing the underlying disease course, targeting symptoms, and mitigating further harm. Topicals, she explained, are normally not strong enough for use as a monotherapy. These include lidocaine ointment, capsaicin, compounded ointment, and CBD ointments and tinctures. The mainstay treatment, she said, is the oral neuropathic pain modulators, including gabapentin, amitriptyline, pregabalin, duloxetine, and oxycodone.

chart

Figure 1.

When to Refer

Patients should be referred to a neurologist when patients do not fit the typical pattern of length-dependent, sensory-predominant neuropathy. Clinical characteristics of atypical pattern include asymmetric or multifocal symptoms, acute progression, motor predominant, non-length dependent, young onset, prominent autonomic features, and significant functional limitations.

—Michael Potts

Reference:
Barrell K. Management of Peripheral Neuropathy. Talk presented at: Practical Updates in Primary Care 2020 Virtual Series; October 9-10, 2020; virtual.