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Diabetic neuropathy Classification and external resources ICD-10 E10.4, E11.4, E12.4, E13.4, E14.4 ICD-9 250.6 MedlinePlus 000693 MeSH D003929 Diabetic neuropathies are neuropathic disorders that are associated with diabetes mellitus. These conditions are thought to result from diabetic microvascular injury involving small blood vessels that supply nerves (vasa nervorum) in addition to macrovascular conditions that can culminate in diabetic neuropathy. Relatively common conditions which may be associated with diabetic neuropathy include third nerve palsy; mononeuropathy; mononeuropathy multiplex; diabetic amyotrophy; a painful polyneuropathy; autonomic neuropathy; and thoracoabdominal neuropathy. Contents 1 Signs and symptoms 2 Pathogenesis 2.1 Microvascular disease 2.2 Advanced glycated end products 2.3 Protein kinase C 2.4 Polyol pathway 2.5 Effects on nerve types 2.5.1 Sensorimotor polyneuropathy 2.5.2 Autonomic neuropathy 2.5.3 Cranial neuropathy 3 Diagnosis 4 Treatment 4.1 Tricyclic antidepressants 4.2 Serotonin-Norepinephrine reuptake inhibitors 4.3 Selective Serotonin reuptake inhibitor 4.4 Antiepileptic drugs 4.5 Classical Analgesics 4.6 Other treatments 4.7 Tight glucose control 5 Prognosis 6 Epidemiology 7 Footnotes 8 References 9 External links // Signs and symptoms Diabetic neuropathy affects all peripheral nerves: pain fibers, motor neurons, autonomic nerves. It therefore necessarily can affect all organs and systems since all are innervated. There are several distinct syndromes based on the organ systems and members affected, but these are by no means exclusive. A patient can have sensorimotor and autonomic neuropathy or any other combination. Symptoms vary depending on the nerve(s) affected and may include symptoms other than those listed. Symptoms usually develop gradually over years. Symptoms may include: Numbness and tingling of extremities Dysesthesia (abnormal sensation to a body part) Diarrhea Erectile dysfunction Urinary incontinence (loss of bladder control) Impotence Facial, mouth and eyelid drooping Vision changes Dizziness Muscle weakness Difficulty swallowing Speech impairment Fasciculation (muscle contractions) Anorgasmia Burning or electric pain Pathogenesis There are four factors thought to be involved in the development of diabetic neuropathy: Microvascular disease Main article: Microangiopathy Vascular and neural diseases are closely related and intertwined. Blood vessels depend on normal nerve function, and nerves depend on adequate blood flow. The first pathological change in the microvasculature is vasoconstriction. As the disease progresses, neuronal dysfunction correlates closely with the development of vascular abnormalities, such as capillary basement membrane thickening and endothelial hyperplasia, which contribute to diminished oxygen tension and hypoxia. Neuronal ischemia is a well-established characteristic of diabetic neuropathy. Vasodilator agents (e.g., ACE inhibitors, α1-antagonists) can lead to substantial improvements in neuronal blood flow, with corresponding improvements in nerve conduction velocities. Thus, microvascular dysfunction occurs early in diabetes, parallels the progression of neural dysfunction, and may be sufficient to support the severity of structural, functional, and clinical changes observed in diabetic neuropathy. Advanced glycated end products Main article: Advanced glycation end product Elevated intracellular levels of glucose cause a non-enzymatic covalent bonding with proteins, which alters their structure and inhibits their function. Some of these glycosylated proteins have been implicated in the pathology of diabetic neuropathy and other long term complications of diabetes. Protein kinase C Main article: Protein kinase C PKC is implicated in the pathology of diabetic neuropathy. Increased levels of glucose cause an increase in intracellular diacylglycerol, which activates PKC. PKC inhibitors in animal models will increase nerve conduction velocity by increasing neuronal blood flow. Polyol pathway Main article: Polyol pathway Also called the sorbitol/aldose reductase pathway, the polyol pathway may be implicated in diabetic complications that result in microvascular damage to nervous tissue, and also to the retina and kidney. Glucose is a highly reactive compound, and it must be metabolized or it will find tissues in the body to react with. Increased glucose levels, like those seen in diabetes, activates this alternative biochemical pathway, which in turn causes a decrease in glutathione and an increase in reactive oxygen radicals. The pathway is dependent on the enzyme aldose reductase. Inhibitors of this enzyme have demonstrated efficacy in animal models in preventing the development of neuropathy. While most body cells require the action of insulin for glucose to gain entry into the cell, the cells of the retina, kidney and nervous tissues are insulin-independent. Therefore there is a free interchange of glucose from inside to outside of the cell, regardless of the action of insulin, in the eye, kidney and neurons. The cells will use glucose for energy as normal, and any glucose not used for energy will enter the polyol pathway and be converted into sorbitol. Under normal blood glucose levels, this interchange will cause no problems, as aldose reductase has a low affinity for glucose at normal concentrations. However, in a hyperglycemic state, the affinity of aldose reductase for glucose rises, meaning much higher levels of sorbitol and much lower levels of NADPH, a compound used up when this pathway is activated. The sorbitol can not cross cell membranes, and when it accumulates, it produces osmotic stresses on cells by drawing water into the cell. Fructose does essentially the same thing, and it is created even further on in the chemical pathway. The NADPH, used up when the pathway is activated, acts to promote nitric oxide and glutathione production, and its conversion during the pathway leads to reactive oxygen molecules. Glutathione deficiencies can lead to hemolysis caused by oxidative stress, and we already know that nitric oxide is one of the important vasodilators in blood vessels. NAD+, which is also used up, is necessary to keep reactive oxygen species from forming and damaging cells. Furthermore, the high levels of sorbitol are believed to reduce the cellular uptake of another alcohol, myoinsitol, decreasing the activity of the plasma membrane Na+/K+ ATPase pump required for nerve function, further contributing to the neuropathy. In summary, excessive activation of the polyol pathway leads to increased levels of sorbitol and reactive oxygen molecules and decreased levels of nitric oxide and glutathione, as well as increased osmotic stresses on the cell membrane. Any one of these elements alone can promote cell damage, but here we have several acting together. Effects on nerve types Different nerves are affected in different ways Sensorimotor polyneuropathy Longer nerve fibers are affected to a greater degree than shorter ones, because nerve conduction velocity is slowed in proportion to a nerve's length. In this syndrome, decreased sensation and loss of reflexes occurs first in the toes on each foot, then extends upward. It is usually described as glove-stocking distribution of numbness, sensory loss, dysesthesia and night time pain. The pain can feel like burning, pricking sensation, achy or dull. Pins and needles sensation is common. Loss of proprioception, the sense of where a limb is in space, is affected early. These patients cannot feel when they are stepping on a foreign body, like a splinter, or when they are developing a callous from an ill-fitting shoe. Consequently, they are at risk of developing ulcers and infections on the feet and legs, which can lead to amputation. Similarly, these patients can get multiple fractures of the knee, ankle or foot, and develop a Charcot joint. Loss of motor function results in dorsiflexion, contractures of the toes, loss of the interosseous muscle function and leads to contraction of the digits, so called hammer toes. These contractures occur not only in the foot but also in the hand where the loss of the musculature makes the hand appear gaunt and skeletal. The loss of muscular function is progressive. Autonomic neuropathy The autonomic nervous system is composed of nerves serving the heart, gastrointestinal system and genitourinary system. Autonomic neuropathy can affect any of these organ systems. The most commonly recognized autonomic dysfunction in diabetics is orthostatic hypotension, or fainting when standing up. In the case of diabetic autonomic neuropathy, it is due to the failure of the heart and arteries to appropriately adjust heart rate and vascular tone to keep blood continually and fully flowing to the brain. This symptom is usually accompanied by a loss of the usual change in heart rate seen with normal breathing. These two findings suggest autonomic neuropathy. GI tract manifestations include gastroparesis, nausea, bloating, and diarrhea. Because many diabetics take oral medication for their diabetes, absorption of these medicines is greatly affected by the delayed gastric emptying. This can lead to hypoglycemia when an oral diabetic agent is taken before a meal and does not get absorbed until hours, or sometimes days later, when there is normal or low blood sugar already. Sluggish movement of the small intestine can cause bacterial overgrowth, made worse by the presence of hyperglycemia. This leads to bloating, gas and diarrhea. Urinary symptoms include urinary frequency, urgency, incontinence and retention. Again, because of the retention of urine, urinary tract infections are frequent. Urinary retention can lead to bladder diverticula, stones, reflux nephropathy. Cranial neuropathy When cranial nerves are affected, oculomotor (3rd) neuropathies are most common. The oculomotor nerve controls all of the muscles that move the eye with the exception of the lateral rectus and superior oblique muscles. It also serves to constrict the pupil and open the eyelid. The onset of a diabetic third nerve palsy is usually abrupt, beginning with frontal or periorbital pain and then diplopia. All of the oculomotor muscles innervated by the third nerve may be affected, but those that control pupil size are usually well-preserved early on. This is because the parasympathetic nerve fibers within CNIII that influence pupillary size are found on the periphery of the nerve (in terms of a cross sectional view), which makes them less susceptible to ischemic damage (as they are closer to the vascular supply). The sixth nerve, the abducens nerve, which innervates the lateral rectus muscle of the eye (moves the eye laterally), is also commonly affected but fourth nerve, the trochlear nerve, (innervates the superior oblique muscle, which moves the eye downward) involvement is unusual. Mononeuropathies of the thoracic or lumbar spinal nerves can occur and lead to painful syndromes that mimic myocardial infarction, cholecystitis or appendicitis. Diabetics have a higher incidence of entrapment neuropathies, such as carpal tunnel syndrome. Diagnosis Diabetic peripheral neuropathy is the most likely diagnosis for someone with diabetes who has pain in a leg or foot, although it may also be caused by vitamin B12 deficiency or osteoarthritis. A recent review in the Journal of the American Medical Association's "Rational Clinical Examination Series" evaluated the usefulness of the clinical examination in diagnosing diabetic peripheral neuropathy.[1] While the physician typically assesses the appearance of the feet, presence of ulceration, and ankle reflexes, the most useful physical examination findings for large fiber neuropathy are an abnormally decreased vibration perception to a 128-Hz tuning fork (likelihood ratio (LR) range, 16–35) or pressure sensation with a 5.07 Semmes-Weinstein monofilament (LR range, 11–16). Normal results on vibration testing (LR range, 0.33–0.51) or monofilament (LR range, 0.09–0.54) make large fiber peripheral neuropathy from diabetes less likely. Combinations of signs do not perform better than these 2 individual findings.[1] Nerve conduction tests may show reduced functioning of the peripheral nerves, but seldom correlate with the severity of diabetic peripheral neuropathy and are not appropriate as routine tests for the condition. [2] Treatment Despite advances in the understanding of the metabolic causes of neuropathy, treatments aimed at interrupting these pathological processes have been limited. Thus, with the exception of tight glucose control, treatments are for reducing pain and other symptoms. Options for pain control include tricyclic antidepressants (TCAs), serotonin reuptake inhibitors (SSRIs) and antiepileptic drugs (AEDs). A systematic review concluded that "tricyclic antidepressants and traditional anticonvulsants are better for short term pain relief than newer generation anticonvulsants."[3] A combination of these medication (gabapentin + nortriptyline) may also be superior to a single agent.[4] The only two drugs approved by the FDA for diabetic peripheral neuropathy are the antidepressant duloxetine and the anticonvulsant pregabalin. Before trying a systemic medication, people with localized diabetic periperal neuropathy might relieve their symptoms with lidocaine patches.[2] Tricyclic antidepressants TCAs include imipramine, amitriptyline, desipramine and nortriptyline. These drugs are effective at decreasing painful symptoms but suffer from multiple side effects that are dosage dependent. One notable side effect is cardiac toxicity, which can lead to fatal arrhythmias. At low dosages used for neuropathy, toxicity is rare, but if symptoms warrant higher doses, complications are more common. Among the TCAs, amitriptyline is most widely used for this condition, but desipramine and nortriptyline have fewer side effects. Serotonin-Norepinephrine reuptake inhibitors The SSNRI duloxetine (Cymbalta) is approved for diabetic neuropathy, while venlafaxine is also commonnly used. By targeting both serotonin and norepinephrine, these drugs target the painful symptoms of diabetic neuropathy, and also treat depression if it exists. On the other hand, selective serotonin reuptake inhibitors are not useful. Selective Serotonin reuptake inhibitor SSRIs include fluoxetine, paroxetine, sertraline and citalopram and are not recommended to treat painful neuropathy because they have been found to be no more efficacious than placebo in several controlled trials. Side effects are rarely serious, and do not cause any permanent disabilities. They cause sedation and weight gain, which can worsen a diabetic's glycemic control. They can be used at dosages that also relieve the symptoms of depression, a common comorbidity of diabetic neuropathy. Antiepileptic drugs AEDs, especially gabapentin and the related pregabalin, are emerging as first line treatment for painful neuropathy. Gabapentin compares favorably with amitriptyline in terms of efficacy, and is clearly safer. Its main side effect is sedation, which does not diminish over time and may in fact worsen. It needs to be taken three times a day, and it sometimes causes weight gain, which can worsen glycemic control in diabetics. Carbamazepine (Tegretol) is effective but not necessarily safe for diabetic neuropathy. Its first metabolite, oxcarbazepine, is both safe and effective in other neuropathic disorders, but has not been studied in diabetic neuropathy. Topiramate has not been studied in diabetic neuropathy, but has the beneficial side effect of causing mild anorexia and weight loss, and is anecdotally beneficial. Classical Analgesics The above three categories of drugs fall under the heading of Atypical, Adjuvant & Potentiators and are often combined with opioids and/or NSAIDs, usually having effects greater than the sum of their parts. Duloxetine + extended release morphine ± naproxen ± hydroxyzine (esp. with oxycodone) ± morphine or hydromorphone immediate release for breakthrough pain is a common recipe in cases where diabetic neuropathy is a complicating factor in a debilitating chronic pain condition — amitryptiline may be more effective than Duloxetine in some. Opioids requiring Cytochrome P-450 activation (e.g. codeine, dihydrocodeine) should perhaps be used with an agent not chemically related to the SSRIs; conversely, they may impact parts of the Liberation, Absorption, Distribution, Metabolism & Elimination profile for morphine, hydromorphone, oxymorphone &c the other way. Other treatments Transcutaneous electric nerve stimulation (TENS) may be effective in treating painful diabetic neuropathy.[5] α-lipoic acid, an anti-oxidant that is a non-prescription dietary supplement has shown benefit in a randomized controlled trial that compared once-daily oral doses of 600 mg to 1800 mg compared to placebo, although nausea occurred in the higher doses.[6] Methylcobalamin, a specific form of Vitamin B-12 found in spinal fluid, has been studied and shown to have significant effect, taken orally or injected, in treating and improving diabetic neuropathy.[7][8] [9] Though not yet commercially available, C-peptide has shown promising results in treatment of diabetic complications, including neuropathies. Once thought to be a useless by-product of insulin production, it helps to ameliorate and reverse the major symptoms of diabetes[10]. In more recent years, Photo Energy Therapy devices are becoming more widely used to treat neuropathic symptoms. Photo Energy Therapy devices emit near infrared light (NIR Therapy) typically at a wavelength of 880 nm. This wavelength is believed to stimulate the release of Nitric Oxide, an Endothelium-derived relaxing factor into the bloodstream, thus vasodilating the capilaries and venuoles in the microcirculatory system. This increase in circulation has been shown effective in various clinical studies to decrease pain in diabetic and non-diabetic patients. [11] Photo Energy Therapy devices seem to address the underlying problem of neuropathies, poor microcirculation, which leads to pain and numbness in the extremities[12], [13]. Sativex, a cannabis based medicince has not been found to be effective for diabetic neuropathy.[14] There has been experimental work testing the efficacy of a drug called sildenafil but this study described itself as an "isolated clinical report" and cited a need for further clinical investigation.[15] Tight glucose control Treatment of early manifestations of sensorimotor polyneuropathy involves improving glycemic control.[16] Tight control of blood glucose can reverse the changes of diabetic neuropathy, but only if the neuropathy and diabetes is recent in onset. Conversely, painful symptoms of neuropathy in uncontrolled diabetics tend to subside as the disease and numbness progress. Prognosis The mechanisms of diabetic neuropathy are poorly understood. At present, treatment alleviates pain and can control some associated symptoms, but the process is generally progressive. As a complication, there is an increased risk of injury to the feet because of loss of sensation (see diabetic foot). Small infections can progress to ulceration and this may require amputation. Epidemiology Diabetes is the leading known cause of neuropathy in developed countries, and neuropathy is the most common complication and greatest source of morbidity and mortality in diabetes patients. It is estimated that the prevalence of neuropathy in diabetes patients is approximately 20%. Diabetic neuropathy is implicated in 50–75% of nontraumatic amputations. The main risk factor for diabetic neuropathy is hyperglycemia. It is important to note that people with diabetes are more likely to develop symptoms relating to peripheral neuropathy as the excess glucose in the blood results in a condition known as Glucojasinogen. This condition is affiliated with erectile dysfunction and epigastric tenderness which in turn results in lack of blood flow to the peripheral intrapectine nerves which govern the movement of the arms and legs. In the DCCT (Diabetes Control and Complications Trial, 1995) study, the annual incidence of neuropathy was 2% per year, but dropped to 0.56% with intensive treatment of Type 1 diabetics. The progression of neuropathy is dependent on the degree of glycemic control in both Type 1 and Type 2 diabetes. Duration of diabetes, age, cigarette smoking, hypertension, height and hyperlipidemia are also risk factors for diabetic neuropathy. Footnotes ^ a b Kanji JN, Anglin RE, Hunt DL, Panju A (April 2010). "Does this patient with diabetes have large-fiber peripheral neuropathy?". JAMA 303 (15): 1526–32. doi:10.1001/jama.2010.428. PMID 20407062. http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=20407062.  ^ a b King SA (October 1, 2008). "Diabetic Peripheral Neuropathic Pain: Effective Management". Consultant 48 (11). http://www.consultantlive.com/pain/article/10162/1337377.  ^ Wong MC, Chung JW, Wong TK (2007). "Effects of treatments for symptoms of painful diabetic neuropathy: systematic review". BMJ 335 (7610): 87. doi:10.1136/bmj.39213.565972.AE. PMID 17562735.  ^ Gilron I, Bailey JM, Tu D, Holden RR, Jackson AC, Houlden RL (October 2009). "Nortriptyline and gabapentin, alone and in combination for neuropathic pain: a double-blind, randomised controlled crossover trial". Lancet 374 (9697): 1252–61. doi:10.1016/S0140-6736(09)61081-3. PMID 19796802.  ^ Dubinsky RM, Miyasaki J (January 2010). "Assessment: efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology". Neurology 74 (2): 173–6. doi:10.1212/WNL.0b013e3181c918fc. PMID 20042705.  ^ Ziegler D, Ametov A, Barinov A, et al. (2006). "Oral treatment with alpha-lipoic acid improves symptomatic diabetic polyneuropathy: the SYDNEY 2 trial". Diabetes Care 29 (11): 2365–70. doi:10.2337/dc06-1216. PMID 17065669.  ^ Ide H, Fujiya S, Asanuma Y, Tsuji M, Sakai H, Agishi Y (1987). ""Clinical usefulness of intrathecal injection of Methylcobalamin in patients with diabetic neuropathy"". Clinical Therapeutics 9 (2): 183–92. PMID 3568063.  ^ Yaqub BA, Siddique A, Sulimani R (1992). "Effects of methylcobalamin on diabetic neuropathy". Clin Neurol Neurosurg 94 (2): 105–11. doi:10.1016/0303-8467(92)90066-C. PMID 1324807.  ^ Kuwabara S, Nakazawa R, Azuma N, et al. (June 1999). "Intravenous methylcobalamin treatment for uremic and diabetic neuropathy in chronic hemodialysis patients". Intern. Med. 38 (6): 472–5. doi:10.2169/internalmedicine.38.472. PMID 10411351. http://joi.jlc.jst.go.jp/JST.Journalarchive/internalmedicine1992/38.472?from=PubMed.  ^ Cotter MA, Ekberg K, Wahren J, Cameron NE (July 2003). "Effects of proinsulin C-peptide in experimental diabetic neuropathy: vascular actions and modulation by nitric oxide synthase inhibition". Diabetes 52 (7): 1812–7. doi:10.2337/diabetes.52.7.1812. PMID 12829651.  ^ Rader A, Barry T (Nov/Dec 2006). "A proposed mechanism for pain relief following NIR or MIRE therapy". Diabetic Microvascular Complications Today: 27–8.  ^ Leonard DR, Farooqi MH, Myers S (January 2004). "Restoration of sensation, reduced pain, and improved balance in subjects with diabetic peripheral neuropathy: a double-blind, randomized, placebo-controlled study with monochromatic near-infrared treatment". Diabetes Care 27 (1): 168–72. doi:10.2337/diacare.27.1.168. PMID 14693984. http://care.diabetesjournals.org/cgi/pmidlookup?view=long&pmid=14693984.  ^ Prendergast JJ, Miranda G, Sanchez M (2004). "Improvement of sensory impairment in patients with peripheral neuropathy". Endocr Pract 10 (1): 24–30. PMID 15251618. http://aace.metapress.com/openurl.asp?genre=article&issn=1530-891X&volume=10&issue=1&spage=24.  ^ Selvarajah D, Gandhi R, Emery CJ, Tesfaye S (January 2010). "Randomized placebo-controlled double-blind clinical trial of cannabis-based medicinal product (Sativex) in painful diabetic neuropathy: depression is a major confounding factor". Diabetes Care 33 (1): 128–30. doi:10.2337/dc09-1029. PMID 19808912. PMC 2797957. http://care.diabetesjournals.org/cgi/pmidlookup?view=long&pmid=19808912.  ^ Sairam, Krishnamurthy, McNicholas, Tom A. (July 2002). "Sildenafil in diabetic peripheral neuropathy" (PDF). The British Journal of Diabetes and Vascular Disease 2 (4): 304. doi:10.1177/14746514020020041202. http://dvd.sagepub.com/cgi/reprint/2/4/304.  ^ "The effect of intensive diabetes therapy on the development and progression of neuropathy. The Diabetes Control and Complications Trial Research Group". Ann. Intern. Med. 122 (8): 561–8. 1995. PMID 7887548.  References Diabetic Neuropathy at WebMD Diabetic Polyneuropathy at Medscape External links Diabetic Nerve Problems. MedlinePlus' extensive reference list of pertinent sites. Diagnosing Diabetic Autonomic Neuropathy (DAN) v • d • e Diabetes (E10-E14, 250) Types of diabetes Prediabetes (Impaired fasting glucose, Impaired glucose tolerance) Type 1 · Type 2 · MODY · NDM (Transient, Permanent) Diabetes and pregnancy: Gestational diabetes Blood tests Blood sugar · Glycosylated hemoglobin · Glucose tolerance test · Fructosamine Diabetes management Diabetic diet  · Anti-diabetic drugs · Insulin therapy · Glossary of diabetes Complications/prognosis Diabetic comas (Diabetic hypoglycemia, Diabetic ketoacidosis, Nonketotic hyperosmolar) · Diabetic angiopathy · Diabetic myonecrosis · Diabetic nephropathy · Diabetic neuropathy · Diabetic retinopathy · Diabetic cardiomyopathy · Diabetic dermadrome (Diabetic dermopathy, Diabetic bulla, Diabetic cheiroarthropathy, Neuropathic ulcer) M: END anat/phys/devp/horm/cell noco(d)/cong/tumr, sysi/epon proc, drug (A10/H1/H2/H3/H5) v • d • e Endocrine pathology: endocrine diseases (E00–35, 240–259) Pancreas/ glucose metabolism Hypofunction Diabetes mellitus types: (type 1, type 2, MODY 1 2 3 4 5 6) · complications (coma, angiopathy, ketoacidosis, nephropathy, neuropathy, retinopathy, cardiomyopathy) insulin receptor (Rabson–Mendenhall syndrome) · Insulin resistance Hyperfunction Hypoglycemia · beta cell (Hyperinsulinism) · G cell (Zollinger–Ellison syndrome) Hypothalamic/ pituitary axes Hypothalamus gonadotropin (Kallmann syndrome, Adiposogenital dystrophy) · CRH (Tertiary adrenal insufficiency) · vasopressin (Neurogenic diabetes insipidus) · general (Hypothalamic hamartoma) Pituitary Hyperpituitarism anterior (Acromegaly, Hyperprolactinaemia, Pituitary ACTH hypersecretion) · posterior (SIADH) · general (Nelson's syndrome) Hypopituitarism anterior (Kallmann syndrome, Growth hormone deficiency, ACTH deficiency/Secondary adrenal insufficiency) · posterior (Neurogenic diabetes insipidus) · general (Empty sella syndrome, Pituitary apoplexy, Sheehan's syndrome, Lymphocytic hypophysitis) Thyroid Hypothyroidism Iodine deficiency · Cretinism (Congenital hypothyroidism) · Myxedema · Euthyroid sick syndrome Hyperthyroidism Hyperthyroxinemia (Thyroid hormone resistance, Familial dysalbuminemic hyperthyroxinemia) · Hashitoxicosis · Thyrotoxicosis factitia · Graves' disease Thyroiditis Acute infectious · Subacute (De Quervain's, Subacute lymphocytic) · Autoimmune/chronic (Hashimoto's, Postpartum, Riedel's) Goitre Endemic goitre · Toxic nodular goitre · Toxic multinodular goitre Thyroid nodule Parathyroid Hypoparathyroidism Pseudohypoparathyroidism Hyperparathyroidism Primary · Secondary · Tertiary · Osteitis fibrosa cystica Adrenal Hyperfunction aldosterone: Hyperaldosteronism/Primary aldosteronism (Conn syndrome, Bartter syndrome, Glucocorticoid remediable aldosteronism) · AME · Liddle's syndrome · 17α CAH cortisol: Cushing's syndrome (Pseudo-Cushing's syndrome) sex hormones: 21α CAH · 11β CAH Hypofunction/ Adrenal insufficiency (Addison's, WF) aldosterone: Hypoaldosteronism (21α CAH, 11β CAH) cortisol: CAH (Lipoid, 3β, 11β, 17α, 21α) sex hormones: 17α CAH Gonads ovarian: Polycystic ovary syndrome · Premature ovarian failure testicular: enzymatic (5-alpha-reductase deficiency, 17-beta-hydroxysteroid dehydrogenase deficiency) · Androgen receptor (Androgen insensitivity syndrome) general: Hypogonadism (Delayed puberty) · Hypergonadism (Precocious puberty) Height Gigantism · Dwarfism/Short stature (Laron syndrome, Psychosocial) Multiple Autoimmune polyendocrine syndrome (APS1, APS2) · Carcinoid syndrome · Multiple endocrine neoplasia (1, 2A, 2B) · Progeria (Werner syndrome, Acrogeria, Metageria) · Woodhouse-Sakati syndrome M: END anat/phys/devp/horm/cell noco(d)/cong/tumr, sysi/epon proc, drug (A10/H1/H2/H3/H5) v • d • e Drugs used for the treatment of fibromyalgia and neuropathic pain Antidepressants SNRIs Desvenlafaxine • Duloxetine • Milnacipran • Venlafaxine TCAs Amitriptyline • Clomipramine • Desipramine • Imipramine Others Bupropion Anticonvulsants Carbamazepine • Divalproex sodium • Gabapentin • Lacosamide • Lamotrigine • Oxcarbazepine • Phenytoin • Pregabalin • Sodium valproate • Topiramate • Valproic acid Miscellaneous Cannabinoids Nabilone • THC (found in Cannabis) NMDAR antagonists Dextromethorphan • Ketamine Opioids Codeine • Hydrocodone • Hydromorphone • Methadone • Morphine • Oxycodone Topical agents Botulinum toxin • Capsaicin • Glyceryl trinitrate • Lidocaine Others Mexiletine • Tramadol