eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy
Diabetic Lumbosacral Plexopathy: Treatment & Medication
Updated: Oct 10, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Rehabilitation Program
Physical Therapy
Neurologic recovery is slow for patients with diabetic lumbosacral plexopathy. A physical therapist (PT) can assist in improving a patient's functional mobility (eg, transfers, ambulation). The PT instructs the patient in the use of assistive devices when necessary. An exercise and range-of-motion program supervised by the PT also is helpful to maintain and improve function and avoid contractures.
Occupational Therapy
The occupational therapist can recommend appropriate adaptive equipment (eg, a reacher, an elevated toilet seat, a tub bench), depending on the amount of weakness, so that the patient can be independent in activities of daily living and perform self-care tasks in a seated position.
Medical Issues/Complications
Good glycemic control through the adjustment of diabetes medication (eg, oral agents, insulin) is of paramount importance. Education on proper diet and exercise also is essential.
Surgical Intervention
No surgical intervention is needed for diabetic lumbosacral plexopathy.
Consultations
Consider consultation with an endocrinologist (eg, with a diabetologist) to assist with the management of diabetes mellitus.
Medication
Intravenous human immunoglobulin (IVIg) may hasten recovery in patients with diabetic lumbosacral plexopathy (DLP), although this treatment has not been proven in controlled studies and remains controversial.23,24,25 Other immunosuppressant agents, such as cyclophosphamide and methylprednisolone, also are thought to improve recovery. Two double-blinded, placebo-controlled trials of subjects with DLP have been initiated, one with intravenous methylprednisolone and the other with IVIg. The results of these studies have not yet been published.
Blood products
The administration of human immunoglobulins may improve the clinical and immunologic aspects of the disease. Blood products may decrease autoantibody production and increase solubilization and removal of immune complexes.
Immunoglobulins (Gamimune, Gammagard S/D, Sandimmune)
Immunoglobulin neutralizes circulating myelin antibodies through anti-idiotypic antibodies. It down-regulates proinflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T-cells and B-cells and augments suppressor T-cells; blocks complement cascade; promotes remyelination; and may increase CSF IgG (10%).
Adult
2 g/kg IV qmo for 3 mo
Pediatric
Not established
Increases toxicity of live virus vaccine (MMR); do not administer within 3 mo of vaccine
Documented hypersensitivity; IgA deficiency; anti-IgE/IgG antibodies
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Check serum IgA before intravenous immune globulin; use an IgA-depleted product (eg, Gammagard S/D); infusions may increase serum viscosity and thromboembolic events; infusions may increase risk of migraine attacks, aseptic meningitis (10%), urticaria, pruritus, or petechiae (2-5 d postinfusion to 30 d); increases risk of renal tubular necrosis in elderly patients and in patients with diabetes, volume depletion, and preexisting kidney disease; lab result changes associated with infusions include elevated antiviral or antibacterial antibody titers for 1 mo, 6-fold increase in ESR for 2-3 wk, and apparent hyponatremia
Tricyclic antidepressants
These drugs have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin.
Amitriptyline (Elavil)
Analgesic for certain chronic pain.
Adult
30-150 mg/d PO
Pediatric
Not established
Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; patients who have taken MAOIs in past 14 d; patients with history of seizures, cardiac arrhythmias, glaucoma, and urinary retention
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiac conduction disturbances and history of hyperthyroidism, renal or hepatic impairment; avoid using in elderly patients
Nortriptyline (Aventyl, Pamelor)
Has demonstrated effectiveness in the treatment of chronic pain. By inhibiting the reuptake of serotonin and/or norepinephrine by the presynaptic neuronal membrane, this drug increases the synaptic concentration of these neurotransmitters in the CNS. Pharmacodynamic effects, such as the desensitization of adenyl cyclase and the down-regulation of beta-adrenergic receptors and serotonin receptors, also appear to play a role in its mechanisms of action.
Adult
25-150 mg/d PO in divided doses
Pediatric
Not established
Cimetidine may increase levels when used concurrently; may increase prothrombin time in patients stabilized with warfarin
Documented hypersensitivity; narrow-angle glaucoma; do not administer to patients who have taken MAOIs in past 14 d
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiac conduction disturbances and history of hyperthyroidism and renal or hepatic impairment; due to pronounced effects in cardiovascular system, best to avoid in elderly patients
Doxepin (Sinequan, Adapin)
This agent inhibits histamine and acetylcholine activity and has proven useful in the treatment of various forms of depression associated with chronic and neuropathic pain.
Adult
10-150 mg/d PO hs or divided bid/tid
Pediatric
Not established
Decreases antihypertensive effects of clonidine but increases effects of sympathomimetics and benzodiazepines; effects increase with phenytoin, carbamazepine, and barbiturates
Documented hypersensitivity; urinary retention; acute recovery phase following myocardial infarction; glaucoma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, and patients receiving thyroid replacement
Desipramine (Norpramin)
May increase the synaptic concentration of norepinephrine in the CNS by inhibiting reuptake by presynaptic neuronal membrane. The drug may have effects in the desensitization of adenyl cyclase and in the down-regulation of beta-adrenergic receptors and serotonin receptors.
Adult
25-100 mg/d PO; not to exceed 150 mg/d
Pediatric
Not established
Decreases antihypertensive effects of clonidine but increases effects of sympathomimetics and benzodiazepines; effects of desipramine increase with phenytoin, carbamazepine, and barbiturates
Documented hypersensitivity; narrow-angle glaucoma, recent myocardial infarction; patients who currently are taking MAOIs or fluoxetine or who have taken them in the past 2 wk
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, and patients receiving thyroid replacement
Antiepileptic drugs
These agents are used for the neuropathic type of pain.
Gabapentin (Neurontin)
Has anticonvulsant properties and antineuralgic effects; however, its exact mechanism of action is unknown. The drug is structurally related to GABA but does not interact with GABA receptors. Titration to effect can take place over several days (300 mg on day 1, 300 mg bid on day 2, and 300 mg tid on day 3).
Adult
300-3600 mg/d PO in 3-4 divided doses
Pediatric
Not established
Antacids may reduce bioavailability significantly (administer at least 2 h following antacids); may increase norethindrone levels significantly
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with severe renal disease
More on Diabetic Lumbosacral Plexopathy |
| Overview: Diabetic Lumbosacral Plexopathy |
| Differential Diagnoses & Workup: Diabetic Lumbosacral Plexopathy |
 Treatment & Medication: Diabetic Lumbosacral Plexopathy |
| Follow-up: Diabetic Lumbosacral Plexopathy |
| References |
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References
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Further Reading
Keywords
diabetic lumbosacral plexopathy, diabetes mellitus, diabetes mellitus type 1, diabetes mellitus type 2, type 1 diabetes, diabetes type 1, type 2 diabetes, diabetes 1, diabetes 2, diabetic neuropathy, neuropathy, lumbosacral, lumbar sacral, plexopathy, lumbosacral plexopathy, proximal neuropathy, amyotrophy, diabetic amyotrophy, distal symmetrical polyneuropathy, DSPN, polyneuropathy, Bruns-Garland syndrome, diabetic proximal neuropathy, diabetic lumbosacral polyradiculopathy, polyradiculopathy, diabetic lumbosacral radiculoplexus neuropathy(DLRPN), diabetic femoral neuropathy, ischemic mononeuropathymultiplex associated with diabetes mellitus, proximal lower limb motor neuropathy
