В обзорной статье рассмотрены современные представления о распространенности, клинической картине, подходах к диагностике и лечению одного из наиболее частых неврологических осложнений сахарного диабета – диабетической полиневропатии, как соматические, так и вегетативные ее проявления. Развитие невропатии имеет высокую распространенность среди больных диабетом, а клинически выраженные ее формы отражают тяжелое течение сахарного диабета и служат неблагоприятным прогностическим признаком, сопряженным с увеличением смертности примерно в 5 раз. В то же время своевременное выявление и адекватная коррекция ее проявлений могут существенно улучшать качество жизни больных. Рассмотрены возможности патогенетической терапии диабетической полиневропатии, связанные с применением бенфотиамина и α-липоевой кислоты, а также симптоматической терапии ее отдельных проявлений.
In the review article, modern concepts of prevalence, clinical picture, approaches to diagnosis and treatment of one of the most frequent neurological complications of diabetes mellitus – diabetic polyneuropathy, both somatic and vegetative manifestations thereof – are considered. The development of neuropathy has a high prevalence of angry diabetic patients, and its clinically expressed forms reflect the severe course of diabetes and serve as an unfavorable prognostic sign associated with an increase in mortality of about 5 times. At the same time, timely detection and adequate correction of its manifestations can significantly improve the quality of life of patients. The possibilities of pathogenetic therapy of diabetic polyneuropathy associated with the use of benfotiamine and α-lipoic acid, as well as symptomatic therapy of its individual manifestations, are considered.
1. Верткин А.Л., Ткачева О.Н., Подпругина Н.Г. и др. Диабетическая автономная нейропатия: диагностика и метаболическая нейропатия. Клин. фармакология и терапия. 2004; 4–8. / Vertkin A.L., Tkacheva O.N., Podprugina N.G. i dr. Diabeticheskaia avtonomnaia neiropatiia: diagnostika i metabolicheskaia neiropatiia. Klin. farmakologiia i terapiia. 2004; 4–8. [in Russian]
2. Левин О.С. Полиневропатия. М.: МИА, 2006. / Levin O.S. Polinevropatiia. M.: MIA, 2006. [in Russian]
3. Строков И.А., Баринов А.Н. Клиника, патогенез и лечение болевого синдрома при диабетической полиневропатии. Неврол. журн. 2001; 6: 47–54. / Strokov I.A., Barinov A.N. Klinika, patogenez i lechenie bolevogo sindroma pri diabeticheskoi polinevropatii. Nevrol. zhurn. 2001; 6: 47–54. [in Russian]
4. Штульман Д.Р., Левин О.С. Неврология: справочник практического врача. М.: Медпресс-информ, 2008. / Shtul'man D.R., Levin O.S. Nevrologiia: spravochnik prakticheskogo vracha. M.: Medpress-inform, 2008. [in Russian]
5. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2009; 32 (Suppl. 1): S62–S67.
6. Ametov AS, Barinov A, Dyck PJ et al. The sensory symptoms of diabetic polyneuropathy are improved with alpha-lipoic acid. Diabetes Care 2003; 26: 770–6.
7. Androne L, Gavan NA, Veresiu IA, Orasan R. In vivo effect of lipoic acid on lipid peroxidation in patients with diabetic neuropathy. In Vivo 2000; 14: 327–30.
8. Boulton AJ, Vinik AI, Arezzo JC et al. Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care 2005; 28 (4): 956–62.
9. Boulton A, Tesfaye S (eds). Diabetic neuropathy. Oxford, 2009; p.98.
10. Dyck PJ, Karnes JL, O’Brien PC et al. The Rochester Diabetic Neuropathy study: reassessment of tests and criteria for diagnosis and staged severity. Neurology 1992; 42: 1164-70.
11. Dyck PJ, Thomas PK (eds). Diabetic neuropathy. 2nd ed. Philadelphia: WB Saunders, 1999.
12. Dyck PJB. Diabetic Radiculoplexus Neuropathies. In. Neurological therapeutics: principles and practice. J.H.Noseworthy (ed). Martin Dunitz, 2003; p. 2007–10.
13. Dyck PJ, Karnes JL, O’Brien PC et al. The Rochester Diabetic Neuropathy Study: reassessment of tests and criteria for diagnosis and staged severity. Neurology 1992; 42: 1164–70.
14. Gries FA, Cameron NE, Low PA (eds). Textbook of Diabetic Neuropathy. Stuttgart: Thieme, 2003.
15. Han D, Handelman G, Marcocci L et al. Lipoic acid increases de novo synthesis of cellular glutathione by improving cystine utilization. Biofactors 1997; 6 (3): 321–38.
16. Heitzer T, Finckh B, Albers S et al. Benefficial effects of alpha-lipoic acid and ascorbic acid on endothelium-dependent, nitric oxide-mediated vasodilation in diabetic patients: relation to parameters of oxidative stress. Free Radic Biol Med 2001; 31: 53–61.
17. Kishi Y, Schmelzer JD, Yao JK et al. Alpha-lipoic acid: effect on glucose uptake, sorbitol pathway, and energy metabolism in experimental diabetic neuropathy. Diabetes 1999; 48: 2045–51.
18. Kramer H, Rolke R, Hecht M et al. Follow-up of advanced diabetic neuropathy. J Neurol 2005: 315–20.
19. Low PA, Benrud-Larsen LM, Sletten DM et al. Autonomic symptoms and diabetic neuropathy: a population-based study. Diabetes Care 2004; 27: 2942–7.
20. Reljanovic M, Reichel G, Rett K et al. The ALADIN II Study Group: Treatment of diabetic polyneuropathy with the antioxidant thioctic acid (alpha-lipoic acid): a two-year mylticenter randomized double blind placebo contorolled trial (ALADIN II). Free Radic Res 1999; 31: 171–9.
21. Said G, Baudoin D, Toyooka K. Sensory loss, pains, motor deficit and axonal regeneration in length-dependent diabetic polyneuropathy. J Neurol 2008; 255: 1693–702.
22. Shaw JE, Zimmet PZ, Gries FA, Ziegler D. Epidemiology of diabetic neuropathy. In: Gries FA, Cameron NE, Low PA (eds). Textbook of Diabetic Neuropathy. New York: Thieme, 2003; p. 64–82.
23. Stracke H, Gaus W, Achenbach U et al. Benfotiamine in Diabetic Polyneuropathy (BENDIP): Results of a randomised, double-blind, placebo-controlled clinical study. Exp Clin Endocrinol Diabetes 2008; 116: 600 – 5.
24. Tesfaye S, Stevens LK, Stephenson JM et al. Prevalence of diabetic peripheral neuropathy and its relation to glycaemic control and potential risk factors: the EURODIAB IDDM Complications Study. Diabetologia 1996; 39: 1377–84.
25. Trence DL. Peripheral neuropathy in diabetes: is it diabetic neuropathy? Clin Diabetes 2002; 20: 103–4.
26. Vinik AI, Maser RE, Mitchell BD et al. Diabetic autonomic neuropathy. Diabetes Care 2003; 26: 53–81.
27. Vinik AI, Mehrabyan A. Diabetic neuropathies. Med Clin North Am 2004; 88: 947–99.
28. Ziegler D. Treatment of diabetic neuropathy and neuropathic pain. Diabetes Care 2008; 31: 255–61.
29. Ziegler D, Hanefeld M, Ruhnau RJ et al. The ALADIN III Study group. Treatment of symptomatic diabetic peripherial neuropathy with antioxidant alpha-lipoic acid. Diabetes Care 1999; 22: 1296–1301.
30. Ziegler D, Ametov A, Barinov A et al. Oral treatment with alpha-lipoic acid improves symptomatic diabetic polyneuropathy. The SYDNEY 2 trial. Diabetes Care 2006; 29: 2365–70.
31. Ziegler D. Thioctic acid for patients with symptomatic diabetic neuropathy: a critical review. Treat Endocrinol 2004; 3 (3): 173–89.
32. Ziegler D, Nowak H, Kempler P et al. Treatment of symptomatic diabetic polyneuropathy with the antioxidant alpha-lipoic acid: a meta-analysi. Diabet Med 2004; 21 (2): 114–21.
________________________________________________
1. Vertkin A.L., Tkacheva O.N., Podprugina N.G. i dr. Diabeticheskaia avtonomnaia neiropatiia: diagnostika i metabolicheskaia neiropatiia. Klin. farmakologiia i terapiia. 2004; 4–8. [in Russian]
2. Levin O.S. Polinevropatiia. M.: MIA, 2006. [in Russian]
3. Strokov I.A., Barinov A.N. Klinika, patogenez i lechenie bolevogo sindroma pri diabeticheskoi polinevropatii. Nevrol. zhurn. 2001; 6: 47–54. [in Russian]
4. Shtul'man D.R., Levin O.S. Nevrologiia: spravochnik prakticheskogo vracha. M.: Medpress-inform, 2008. [in Russian]
5. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2009; 32 (Suppl. 1): S62–S67.
6. Ametov AS, Barinov A, Dyck PJ et al. The sensory symptoms of diabetic polyneuropathy are improved with alpha-lipoic acid. Diabetes Care 2003; 26: 770–6.
7. Androne L, Gavan NA, Veresiu IA, Orasan R. In vivo effect of lipoic acid on lipid peroxidation in patients with diabetic neuropathy. In Vivo 2000; 14: 327–30.
8. Boulton AJ, Vinik AI, Arezzo JC et al. Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care 2005; 28 (4): 956–62.
9. Boulton A, Tesfaye S (eds). Diabetic neuropathy. Oxford, 2009; p.98.
10. Dyck PJ, Karnes JL, O’Brien PC et al. The Rochester Diabetic Neuropathy study: reassessment of tests and criteria for diagnosis and staged severity. Neurology 1992; 42: 1164-70.
11. Dyck PJ, Thomas PK (eds). Diabetic neuropathy. 2nd ed. Philadelphia: WB Saunders, 1999.
12. Dyck PJB. Diabetic Radiculoplexus Neuropathies. In. Neurological therapeutics: principles and practice. J.H.Noseworthy (ed). Martin Dunitz, 2003; p. 2007–10.
13. Dyck PJ, Karnes JL, O’Brien PC et al. The Rochester Diabetic Neuropathy Study: reassessment of tests and criteria for diagnosis and staged severity. Neurology 1992; 42: 1164–70.
14. Gries FA, Cameron NE, Low PA (eds). Textbook of Diabetic Neuropathy. Stuttgart: Thieme, 2003.
15. Han D, Handelman G, Marcocci L et al. Lipoic acid increases de novo synthesis of cellular glutathione by improving cystine utilization. Biofactors 1997; 6 (3): 321–38.
16. Heitzer T, Finckh B, Albers S et al. Benefficial effects of alpha-lipoic acid and ascorbic acid on endothelium-dependent, nitric oxide-mediated vasodilation in diabetic patients: relation to parameters of oxidative stress. Free Radic Biol Med 2001; 31: 53–61.
17. Kishi Y, Schmelzer JD, Yao JK et al. Alpha-lipoic acid: effect on glucose uptake, sorbitol pathway, and energy metabolism in experimental diabetic neuropathy. Diabetes 1999; 48: 2045–51.
18. Kramer H, Rolke R, Hecht M et al. Follow-up of advanced diabetic neuropathy. J Neurol 2005: 315–20.
19. Low PA, Benrud-Larsen LM, Sletten DM et al. Autonomic symptoms and diabetic neuropathy: a population-based study. Diabetes Care 2004; 27: 2942–7.
20. Reljanovic M, Reichel G, Rett K et al. The ALADIN II Study Group: Treatment of diabetic polyneuropathy with the antioxidant thioctic acid (alpha-lipoic acid): a two-year mylticenter randomized double blind placebo contorolled trial (ALADIN II). Free Radic Res 1999; 31: 171–9.
21. Said G, Baudoin D, Toyooka K. Sensory loss, pains, motor deficit and axonal regeneration in length-dependent diabetic polyneuropathy. J Neurol 2008; 255: 1693–702.
22. Shaw JE, Zimmet PZ, Gries FA, Ziegler D. Epidemiology of diabetic neuropathy. In: Gries FA, Cameron NE, Low PA (eds). Textbook of Diabetic Neuropathy. New York: Thieme, 2003; p. 64–82.
23. Stracke H, Gaus W, Achenbach U et al. Benfotiamine in Diabetic Polyneuropathy (BENDIP): Results of a randomised, double-blind, placebo-controlled clinical study. Exp Clin Endocrinol Diabetes 2008; 116: 600 – 5.
24. Tesfaye S, Stevens LK, Stephenson JM et al. Prevalence of diabetic peripheral neuropathy and its relation to glycaemic control and potential risk factors: the EURODIAB IDDM Complications Study. Diabetologia 1996; 39: 1377–84.
25. Trence DL. Peripheral neuropathy in diabetes: is it diabetic neuropathy? Clin Diabetes 2002; 20: 103–4.
26. Vinik AI, Maser RE, Mitchell BD et al. Diabetic autonomic neuropathy. Diabetes Care 2003; 26: 53–81.
27. Vinik AI, Mehrabyan A. Diabetic neuropathies. Med Clin North Am 2004; 88: 947–99.
28. Ziegler D. Treatment of diabetic neuropathy and neuropathic pain. Diabetes Care 2008; 31: 255–61.
29. Ziegler D, Hanefeld M, Ruhnau RJ et al. The ALADIN III Study group. Treatment of symptomatic diabetic peripherial neuropathy with antioxidant alpha-lipoic acid. Diabetes Care 1999; 22: 1296–1301.
30. Ziegler D, Ametov A, Barinov A et al. Oral treatment with alpha-lipoic acid improves symptomatic diabetic polyneuropathy. The SYDNEY 2 trial. Diabetes Care 2006; 29: 2365–70.
31. Ziegler D. Thioctic acid for patients with symptomatic diabetic neuropathy: a critical review. Treat Endocrinol 2004; 3 (3): 173–89.
32. Ziegler D, Nowak H, Kempler P et al. Treatment of symptomatic diabetic polyneuropathy with the antioxidant alpha-lipoic acid: a meta-analysi. Diabet Med 2004; 21 (2): 114–21.
Авторы
О.А.Ганькина, О.С.Левин*
ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Минздрава России. 125993, Россия, Москва, ул. Баррикадная, д. 2/1
*oslevin@mail.ru
________________________________________________
O.A.Gankina, O.S.Levin*
Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation. 125993, Russian Federation, Moscow, ul. Barrikadnaia, d. 2/1
*oslevin@mail.ru