I.I. Bilous, L.B. Pavlovych, N.I. Bytsko
Bukovinian State Medical
University, Chernivtsi, Ukraine
COCARNIT
IN THE MULTIMODALITY TREATMENT OF DIABETIC POLYNEUROPATHY
Summary: The work is dedicated to researching of the effect of cocarnit on the
functional state of the peripheral nerves based on the findings of stimulation
electroneuromyography in multimodality treatment of diabetic polyneuropathy.
The most positive influence on the amplitude of M-response of the nerves of the
upper and lower extremities has been detected in case of use of cocarnit in
comparison with the basic treatment.
Introduction.
Diabetic
neuropathy (DPN) is a set of clinical and sub clinical syndromes, each of which
is characterized by diffuse or focal lesions of peripheral and/ or autonomic
nervous fibers as a result of diabetes mellitus (DM). This is one of the most
common chronic complications of diabetes that is diagnosed in almost half of
patients. The clinical manifestations of DPN are very diverse and occur in
practice of specialists in various specialties. It is known that diabetic
polyneuropathy increases the danger of amputation by 1.7 times, the danger of
feet deformation increases by 12 times, and the danger of feet ulcers increases
by 39 times.
A significant
prevalence of this pathology determines the importance of practical and
theoretical perspectives. The most informative method of diagnosing lesions of
the peripheral nervous system in patients with DPN is electroneuromyography. It
is registration of oscillations of electric potentials in skeletal muscles that
allows examining the state of peripheral lesions of neuromotor apparatus
effectively.
Thus, when using
this method, lesions detection frequency of functions of peripheral nerves increases
up to 70-90%.
Purpose and objectives of the research. Prove the expediency of application of cocarnit (CDF) in treatment of
patients with DPN, depending on the duration of diabetes by studying the
functional state of peripheral nerves according to finding of stimulation electroneuromyography.
Research objectives.
Examine the indicators of stimulation electroneuromyography in patients with
DPN, depending on the duration of diabetes mellitus before and after treatment.
Materials and methods. We explored 86 patients with type II diabetes mellitus who were
hospitalized in Chernivtsy Regional Clinical Endocrinological Dispensary. Among
the patients there were 36 women and 50 men; the age of the patients ranged
from 36 to 65 years. Diabetes mellitus
(DM) of moderate severity was observed in 82 patients, 4 patients were in a critical
state; 12 patients were in position to compensate for the disease, 74 patients
had subcompensation. Patients were divided into 3 groups: Gr.1 - patients who
had diabetes up to 1 year (29 patients);
Gr.2-
patients with diabetes up to 10 years (30 patients); Gr.3 - patients with
diabetes for over 10 years (27 patients). Additionally patients were divided
into two subgroups. Subgroup I - patients who have received basic therapy that
included Diet number 9, maninil to 5 mg twice daily or insulin (2/3 of daily
dose in the morning and 1/3 of dose in the evening, the rate of 0.7 - 1.0 U /
kg body weight), pentoxifylline intravenously 5 ml per 250 ml isotonic sodium chloride,
vitamin B (42 patients). Subgroup II - patients that along with basic treatment
received CDF (1 ampoule intramuscularly 1 time per day for two weeks) (44
patients). The control group consisted of 20 healthy individuals. The study of
the functional state of peripheral nerves was performed by stimulation electroneuromyoraphy
(ENMG) on the apparatus Neuro-refraction-4 (Neurosoft, Russia).
Discussion
of research results
Determine
the amplitude of M-response of peripheral nerves of upper extremities through
stimulation ENMG.
While
assessing the dynamics of the M-response amplitude n. medianus it was found out
that group 1 patients with diabetes duration up to 1 year M-response amplitude
n. medianus tended to decrease by 24.3% compared with the control. Amplitude
decreases with increasing of disease duration. Thus, in the second group of
patients, M- response amplitude decreased by 28.1%, and the patients who had
diabetes for over 10 years showed decrease of M- response amplitude n. medianus
by 32% compared to the control (p <0.05), indicating the axonal lesions of
peripheral nerves. Patients of group 1 manifested increase of M- response amplitude
after basic treatment by 7%; after additional prescription of CDF along with
the basic therapy M-response amplitude n. medianus significantly increased by
20.5%. In the second group, M-response amplitude n. medianus almost did not
change after basic treatment (by 0.82%); after additional prescription of CDF there
was a tendency to increase by 17.1% (p> 0.05). In the third group of
patients, a slight increase in the amplitude of M-response by 3.4% (p> 0.05)
was noted after basic treatment; after the additional appointments of CDF
M-response amplitude increased by 20.2% (p> 0.05).
We
investigated the indicators of M-response amplitude n. ulnaris (m. abductor
digiti minimi) before and after the conducted treatment in diabetic patients
with DPN. In group 1 patients with diabetes up to 1 year, decrease in
M-response amplitude n. ulnaris by 18.1% was noted compared to the control
(p> 0.05). Amplitude decreases with increasing of disease duration. Thus, in
the second group of patients M-response amplitude decreased by 26.3% (p>
0.05), and patients with diabetes over 10 years showed likely decrease in the
M-response amplitude n. medianus by 29.2%
compared with the control. Thus, even in patients with diabetes up to 1 year
decrease in the amplitude of M-response was noted, indicating a predominantly
axonal lesion of peripheral nerves. M-response amplitude decreases depending on
the duration of diabetes.
When
conducting ENMG research in the dynamics it was found out that group 1 patients
had an increase in the amplitude of M-response after basic treatment by 1.57%
(i.e. amplitude almost did not change);
after the additional prescription of CDF it increased by 13.4% (p>
0.05). In patients with diabetes up to 10 years a slight increase by 6.8% in
the amplitude of M-response after basic treatment was noted; after the
additional prescription of CDF it rose 23.5%
(p <0.05). In the third group of patients after basic treatment there was a tendency
to increase the amplitude of M- response by 6.1%; after additional appointments
of CDF it increased by 17.0% (p> 0.05). Thus, patients of all three groups manifested
decrease in the amplitude of M-response, which depended on the duration of
diabetes. After basic treatment, M-response amplitude n. ulnaris almost did not
change in group 1 and tended to increase in the second and third groups of
patients (p> 0.05). Patients of the first and the second groups who along
with the basic treatment received CDF had significant increase of the amplitude
of M- response n. ulnaris compared with patients before treatment. In the third
group of patients who received CDF, a tendency to increase the amplitude of the
M-response was observed (p> 0.05).
We
determined indicators of M-response amplitude n. tibialis (m. abductor
hallucis). In group 1 patients with diabetes up to 1 year decrease in
M-response amplitude n. tibialis by 21.5% was noted compared to the control (p
<0.05). Amplitude decreases with increasing of disease duration. Thus, in
the second group of patients the amplitude of M -response decreased by 38.6% (p
<0.05) and in patients with diabetes over 10 years a likely decrease in the
amplitude M-response n. tibialis by
54.0% was noted compared with the control.
Thus,
even the patients with duration of diabetes up to 1 year had decrease in the
amplitude of M-response n. tibialis, which indicates axonal lesions of
peripheral nerves. M-response amplitude decreases depending on the duration of
diabetes.
Patients
of group 1 had an increase in the amplitude of M- response n. tibialis after
basic treatment by 2.6% (p> 0.05); after the additional prescription of CDF it
increased by 20.7% (p <0.05). In the second group a slight increase by 9.6%
(p> 0.05) in the amplitude of M -response was noted after basic treatment;
after additional appointments of CDF it was by 34.0% (p <0.05). Patients
with diabetes over 10 years only manifested a tendency to increase the amplitude
of M- response after basic treatment by
6.8%; after additional appointments of CDF it increased by 36.1% (p> 0.05).
Thus, after basic treatment in all three groups, a significant increase of the
amplitude of M-response n. tibialis was observed. Patients of the first and the
second groups, who along with the basic treatment received CDF, had an increase
of the amplitude of M-response n. tibialis.
We
estimated the dynamics of amplitude of M-response n. peroneus (m. extensor
digitorum brevis). The results of the study show that patients from group 1
with diabetes up to 1 year had a decrease in the amplitude of M-response by
33.5% (p> 0.05) compared with the control. Amplitude decreases with
increasing of disease duration. Thus, in the second group of patients, the amplitude
of M-response significantly decreased by 42.9%, and in patients with diabetes
duration of more than 10 years a decrease in the amplitude M-response n. peroneus by 46.0% was noted compared to
control (p <0.05). In group 1 patients after basic treatment had a slight
increase in the amplitude of M-response
n. peroneus by 3.1% (p> 0.05);
after the additional prescription of CDF – by 28.1% (p <0.05). In the
second group a slight increase by 7.98% (p> 0.05) in the amplitude of
M-response after basic treatment was noted;
after the additional prescription of CDF – by 30.7% (p <0.05). Patients
with diabetes duration of more than 10 years manifested a marginal increase of the
amplitude of M-response after basic treatment by 3.4% (p> 0.05); after the
addition of CDF- by 20.2% (p> 0.05). Thus, patients of the first and the second groups, who in addition to
background of the basic treatment received CDF, had a considerable increase in
the amplitude of M-response n. peroneus.
Conclusions
1.
Reduction of the amplitude of the M-response of nerves of upper and lower extremities
is observed in the majority of patients of I, II groups and all patients of III
group.
2.
Under the influence of basic treatment M-response amplitude increases insignificantly.
After the addition of Cocarnit a considerable increase in the amplitude of M-response
in patients I and II groups was noted.
Thus,
as a result of instrumental studies it has been found out those even patients
with diabetes at early stage manifest significant changes of neuromotor
peripheral apparatus. They are shown by a decrease in the amplitude of
M-response. The severity and nature of these changes characterize the severity
of the pathological process. This demonstrates a high diagnostic value of ENMG
and the need to include it in a complex examination of patients with DPN.
Severity detected is largely determined by the initial state of the neuromotor
system depending on the duration and severity of diabetes. All this suggests
the need for medical activities at an earlier stage of disease, before the
development of severe structural changes in the peripheral nerves.
Further
research in this area will significantly improve the treatment of patients with
diabetes complicated by polyneuropathy, taking into account the duration of the
underlying disease.
Literature.
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Kaminska Treatment of
diabetes and its
complications: a guide
for physicians. / Balabolkin MI, Klebanov, EM, VM
Kreminskaya - M .: Medicine,
2005. - 512 p.
2.
Burchinsky SG Features of the
antioxidant drug therapy in neurological practice / SG Burchinsky - Ukrainsky
nevrologіchny magazine. - 2007. - №2. - S. 68-73.
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Burchinsky SG Neuroprotective
Pharmacotherapy in Geriatrics from his protection and for what / SG Burchinsky
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4.
Galstyan GR The lesions of the lower
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Аннотация: Статья посвящена изучению влияния кокарнита на функцию периферических
нервов по данным стимуляционной электронейромиографии в комплексном лечении
этой патологии. Наибольший положительный эффект на амплитуду М-ответа нервов
верхних и нижних конечностей выявлено при использовании кокарнита по сравнению
с базисным лечением.