The resolution of the expert council is devoted to discussing aspects of the use of ipidacrine for the treatment of mononeuropathies, polyneuropathies and radiculopathies of various etiologies. Specialists prepared recommendations for ipidacrine's application in treating peripheral nervous system disorders.

The expert consensus is aimed to develop an algorithm for the diagnosis and treatment of mononeuropathies for outpatient neurologists. Leading experts in the field of neurology have suggested workup options for certain types of tunnel mononeuropathies based on current data on the effectiveness and safety of various types of conservative and surgical treatment.

ЦЕЛЬ: описание и анализ двух клинических случаев ЭМ у пациентов с СД1. МАТЕРИАЛЫ И МЕТОДЫ: обследованы 2 пациента с СД1 и эритромелалгией (ЭМ) в сочетании с по- линейропатией (ПНП). Проведено клинико-лабораторное и инструментальное обследование пациентов и их динамическое наблюдение. РЕЗУЛЬТАТЫ: в первом случае ЭМ развилась вторично в рамках острой болевой диабетической по- линейропатией (ДПН) с преимущественным поражением тонких нервных волокон (ТНВ) и сопровождалась выраженными жгучими болями, не переносимостью тепла, аллодинией, выраженными нейропатическими отеками. В дебюте пациентка имела нормальные показатели ЭНМГ с их резким ухудшением к 9 месяцу наблюдения – аксонально-демиелинизирующая ПНП с поражением ног и рук. При контроле через 2 года частичная положительная динамика по амплитуде моторного ответа. Прогрессирующее снижение пери- ферической чувствительности по смешанному паттерну поражения. Динамический провал к 9 месяцу наблюдения с последующим частичным восстановлением температурной и болевой чувствительности. Длительность комбинированной противоболевой терапии составила 8 месяцев. Данный клинический вариант характеризуется хорошим ответом на терапию и без рецидивным течением при условии адек- ватного гликемического контроля. Однако у пациентки был зафиксирован рецидив, с вновь развившейся клинической картиной вторичной ЭМ и невропатической болью, потребовавшей дополнительно 12 ме- сяцев терапии. В настоящее время длительность без рецидивного периода наблюдения превысила 2 года после отмены противоболевой терапии. В втором случае ЭМ носила первичный характер. Острая болевая ПНП с преимущественным пораже- нием ТНВ развилась на 2м месяце после дебюта СД1 и была расценена как индуцированная лечением СД (снижение HbA1c за 4 месяца более 8%), в дальнейшем превалировала резистентная НБ в сочетании с вы- раженными вегетативными нарушениями. ПНП интерпретирована как идиопатическая тонковолоконная ПНП с первичной ЭМ. Уже в дебюте ПНП при ЭНМГ было выявлено выраженное демиелинизирующее по- ражение сенсорных и моторных нервных волокон ног с признаками вторичной аксонопатии. В клиниче- ской картине превалировали симптомы поражения ТНВ (жжение, непереносимость тепла – требовалось постоянное охлаждение, как результат травматизация и развитие вторичных некрозов в области стоп и голеней), отмечался выраженный ортостаз, периферические нейропатические отеки и выраженная тахикардия. Противоболевая терапия не прекращалась (габапентин+дулоксетин). Направлен на генети- ческое тестирование. Нейрохирургическое лечение (стимуляция спинного мозга) в тестовом периоде продемонстрировало частичную эффективность. В обоих случаях ЭМ и ПНП сопровождались развитием язвенной патологии стоп и рецидивирующим течением.

OBJECTIVE:The purpose of the present double-blind, placebo-controlled, randomized clinical trial was to evaluate the efficacy and safety of Cytoflavin in patients with diabetic polyneuropathy (DPN).MATERIAL AND METHODS:Investigational therapy was administered in two steps: intravenous infusions of experimental drug/placebo for 10 days followed by oral administration for 75 days. In 10 clinical centers, 216 patients aged 45-74 years with a diagnosis of type 2 diabetes mellitus, symptomatic distal sensorimotor DPN, confirmed no earlier than 1 year before screening, on stable therapy (no change of drugs and doses) by oral hypoglycemic drugs, intermediate-acting, long-acting or extra-long-acting insulin, and/or GLP-1 receptor agonists.RESULTS:By the end of treatment, the change of the Total Symptom Score (TSS) in the experimental group was -2.65 points, in the placebo group -1.73 points (p<0.001). Improvement of symptoms in the experimental group was achieved regardless of the degree of compensation for type 2 diabetes (both in those with Hb1Ac <8.0% and in those with Hb1Ac ≥8.0%), but demonstrated better results in patients with less severe baseline symptoms (TSS <7.5). Improvement in the components of the TSS scale «paresthesia» and «numbness» occurred as early as on day 11 of therapy; by the end of treatment, a significant decrease in the «burning» component was also demonstrated. The experimental drug had a positive safety profile.CONCLUSION:Cytoflavin, intravenous solution and enteric-coated tablets (SPTF Polysan Ltd.) is indicated for the symptomatic treatment of DPN.

The leading cause of systemic vascular complications in diabetes mellitus (DM) is partial damage to the vascular wall and hemorheological changes in the lumen of blood vessels against the background of chronic hyperglycemia. Vasoconstriction, edema, ischemia and tissue hypoxia develop as a result of these processes, which, in addition to increasing the risk of cardiovascular diseases, lead to impaired endoneural circulation. The use of a drug with an antihypoxant effect as a pathogenetic therapy in patients with type 2 diabetes mellitus (T2DM) and a subclinical stage of diabetic peripheral neuropathy (DPN1) makes it possible to slow down the progression of micro- and macrovascular complications, along with achieving sustainable compensation for diabetes.Aim. To assess the effect of a drug with antihypoxic effects (Actovegin®) on the parameters of macro- and microcirculation of the capillary bed, arterial stiffness and endothelial function in patients with T2DM and DPN1.Material and methods. A comparative study of macro- and microcirculation parameters, arterial stiffness and endothelial function in patients with T2DM and DPN1 before and after treatment with Actovegin® (group “A”, n = 20), and a group of patients with T2DM and DPN1 without Actovegin® treatment (group “B”, n = 20).Results. An improvement in the parameters of microcirculation was revealed: expansion of the arterial section of the capillaries during treatment with Actovegin®. In patients with reduced endothelial function during treatment with Actovegin®, there is a significant increase in its function, as well as a decrease in perivascular edema. Treatment with Actovegin® does not affect the indicators of central hemodynamics and indicators of arterial stiffness in patients with T2DM and DPN1.Conclusion. The results of the study clearly demonstrated that the use of a drug with an antihypoxic effect (Actovegin®) in patients with T2DM and DPN1 significantly improves the parameters of microcirculation, and, therefore, can be recommended as pathogenetic therapy at the earliest stages of diabetes development. Integral assessment of microcirculation parameters, as well as a new technology for determining the pulse wave velocity and endothelial function allows to identify patients in need of more intensive monitoring. Conducting this examination before the start of drug therapy can serve as a guideline in assessing the effectiveness of the treatment.

ОРИГИНАЛЬНЫЕ ИССЛЕДОВАНИЯЦель исследования -оценить эффективность курсовой терапии препаратом альфа-липоевой кислоты (АЛК) диабетической полиневропатии (ДПН) у пациентов с сахарным диабетом (СД) 2-го типа.Материал и методы.В исследовании принял участие 31 человек в возрасте 51 года -70 лет с диагнозом СД 2-го типа с дистальной сенсомоторной ДПН.Пациентам была назначена курсовая терапия препаратом АЛК 600 мг внутривенно в течение 10 дней (10 инфузий) с 6-месячным интервалом.Результаты и обсуждение.На старте исследования наблюдалось снижение уровня антиоксидантных ферментов у 1/4 пациентов.На фоне курсовой терапии ДПН препаратом АЛК отмечалось статистически достоверное уменьшение клинических проявлений ДПН по шкалам TSS и NIS-LL ( p<0,05).Также наблюдалось улучшение электрофизиологических показателей сенсорных и моторных нервов нижних конечностей.Применение АЛК способствовало статистически достоверному увеличению уровня антиоксидантного фермента глутатионпероксидазы (p<0,05).Заключение.Курсовая терапия ДПН препаратом АЛК способствует увеличению уровня антиоксидантных ферментов, уменьшению клинических проявлений ДПН и нормализации электрофизиологических показателей сенсорных и моторных нервов нижних конечностей.

ЦЕЛЬ РАБОТЫ Анализ и описание существующих методов первичной диагностики диабетической полиневропатии (ДПН), включая шкалы и опросники. МАТЕРИАЛ И МЕТОДЫ Проведен поиск и анализ рекомендаций по диагностике ДПН, методик оценки периферической чувствительности, шкал и опросников, применяемых для диагностики ДПН. Поиск публикаций осуществлялся в базах данных eLibrary, PubMed, Web of Science, Springer, Google Scholar, ClinicalKey. Глубина поиска — 20 лет; также включались публикации, имеющие исторический интерес. РЕЗУЛЬТАТЫ Всего в настоящий обзор включено 79 публикаций. В большинстве публикаций с целью первичной диагностики ДПН предлагается проводить сбор жалоб и анамнеза больного, оценку температурной и/или болевой чувствительности (оценку функции тонких нервных волокон), оценку вибрационной и тактильной чувствительности (оценку функции толстых нервных волокон). Для первичной диагностики ДПН возможно использование валидизированных диагностических опросников, таких как Мичиганский инструмент скрининга невропатии (Michigan Neuropathy Screening Instrument — MNSI), Невропатический дисфункциональный счет (модифицированный вариант) (Neuropathy Disability Score modified — NDSm). Для оценки выраженности болевой симптоматики рекомендованы Шкала симптомов невропатии (Neuropathy Symptom Score — NSS) и визуально-аналоговая шкала боли (ВАШ), для подтверждения невропатического характера боли — опросник DN4. Большинству пациентов с помощью методов первичной диагностики удается поставить диагноз, расширенная диагностика используется в случаях, требующих дифференциальной диагностики, и может включать электронейромиографию (ЭНМГ), конфокальную микроскопию тонких нервов роговицы, интраэпидермальную панч-биопсию, количественное сенсорное тестирование. ЗАКЛЮЧЕНИЕ Использование предложенных алгоритмов позволит объективизировать диагноз и улучшить своевременность и качество оказываемой медицинской помощи пациентам с ДПН.

The increase in the number and life expectancy of patients with diabetes mellitus (DM) worldwide determines the high prevalence of late complications of diabetes, including diabetic polyneuropathy (DPN), the most common type of polyneuropathy. Oxidative stress is considered the main reason for the cellular pathology development in diabetes mellitus, which determines the use of antioxidants for the DPN treatment. Alpha-lipoic acid (ALA), a natural fat-soluble antioxidant, is the most effective drug for reducing DPN symptoms. Furthermore, the symptom-modifying effect of ALA has been shown in numerous randomized controlled trials. The article discusses the possible disease-modifying effect of ALA.

The article presents a clinical case of an elderly patient who had consulted a neurologist due to rapidly developed various complications of diabetes in the form of damage to the peripheral and central nervous systems. The debut of diabetic amyotrophy two years ago in our patient was mistakenly considered as a manifestation of osteochondrosis of the lumbosacral spine. The recommended drug therapy did not reduce symptoms and caused gastrointestinal disorders, which led to the independent withdrawal of all drugs. Polypharmacy reduced the patient’s adherence to therapy and reduced the frequency of regular visits to the doctor.The article deals with the pathogenesis of the main neurological complications of diabetes (diabetic neuropathy and cognitive disorders) in elderly people with arterial hypertension. The possibility of their therapeutic correction to reduce the number of medications taken by patients is discussed. Tactics of polymorbid patients taking into account concomitant chronic diseases should include normalization of glucose levels, correction of vascular risk factors, non-pharmacological methods of treatment - lifestyle changes, diet therapy, regular moderate physical activity. The use of alpha-lipoic (thioctic) acid (Berlithion) as a lipophilic antioxidant will help to slow down the development of complications.

The most common form of peripheral nervous system damage in diabetes mellitus is distal symmetric sensorimotor polyneuropathy (DSSMPN). Chronic hyperglycemia, dyslipidemia, and impaired microcirculation are considered to be the key mechanisms for the development of DSSMPN, but its pathogenesis is still unclear and continues to be studied. The paper analyzes the issues of diagnosis of DSSMPN and the effective principles of patient treatment. It also discusses the use of alpha-lipoic acid (ALA) as a drug for the pathogenetic treatment of DSSMPN and describes the results of clinical trials of its treatment with ALA preparations.

When examining a patient with lumbosacral pain, it is necessary to rule out the specific cause of the disease. The diagnosis of discogenic lumbosacral radiculopathy (DLSR) is based on clinical examination; magnetic resonance imaging (MRI) is of informative value in excluding other causes of radiculopathy and in evaluating disk herniation. If the signs of cauda equina and spinal cord compression are absent, and no epidural glucocorticoid injection or urgent surgical treatment is scheduled, there is no reason for early (within the first 4 weeks) MRI.It is recommended to inform the patient with DLSR about the possibility of disk herniation regression and natural recovery and about the advisability of maintaining physical activity. Epidural administration of local anesthetics and glucocorticoids and use of non-steroidal anti-inflammatory drugs are advisable to relieve acute pain. Anticonvulsants (pregabalin and gabapentin), muscle relaxants, and B vitamins can be used as additional methods for acute DLSR; psychological therapies (cognitive behavioral therapy), antidepressants, therapeutic exercises (kinesiotherapy), manual therapy, and acupuncture are effective in chronic DLSR. Consultation with a neurosurgeon for possible microdiscectomy is indicated in the presence of cauda equina syndrome (urgently) and in the absence of medical therapy effects within 4–8 weeks.Therapeutic exercises (kinesitherapy) with an educational program for prevention of strenuous physical activity and static and uncomfortable positions for a long time, as well as for teaching how to lift weights properly, etc. are recommended for preventive purposes.

Laser corneal confocal microscopy (CCM) is a method of objective visualization of thin corneal nerve fibers (CNF), the structure of which changes in patients with diabetes mellitus (DM).PURPOSE:To conduct comparative analysis of the results of CNF assessment using CCM and other known neurological instrumental techniques as well as evaluate their applicability to the early diagnosis of diabetic polyneuropathy (DPN).MATERIAL AND METHODS:We examined a total of 46 patients (85 eyes) with type 1 DM and either subclinical (24 patients), or clinical-stage DPN (22 patients) and 50 patients (87 eyes) with type 2 DM (subclinical DPN in 27 patients and clinical-stage DPN in 23 patients). The control group consisted of 34 healthy volunteers (68 eyes). All patients underwent standard ophthalmological examination, CCM with nerve tortuosity assessment (including calculation of coefficients of CNF orientation anisotropy, KΔL, and symmetry, Ksym) and interocular asymmetry, electroneuromyography (ENMG), and quantitative sensory testing (QST).RESULTS:Analysis of the CCM results revealed a reliable decrease in the average KΔL values in patients with type 1 and type 2 DM compared with the control group. In the group of patients with type 1 DM and subclinical DPN, correlations were revealed between the CNF tortuosity coefficients and a number of ENMG parameters, such as the M-response amplitude of the peroneal nerve (r=0.73, p≤0.02), M-response amplitude of the tibial nerve (r=0.58, p≤0.01), residual latency (r= -0.62, p≤0.05), and peroneal nerve conduction velocity (r=0.57, p≤0.01). Ksym values correlated with the warm sensitivity threshold (r=0.6, p≤0.008). Among patients with type 2 DM and subclinical DPN, the KΔL coefficient correlated with the peroneal nerve conduction velocity (r=0.46, p≤0.02), M-response amplitude of the tibial nerve (r=0.6, p≤0.04), and residual latency of the peroneal nerve (r=-0.56, p≤0.05).CONCLUSION:The state of thin corneal nerves correlates with functional changes in the peripheral nerves. Pathological changes in CNF in patients with DM can be detected at an early (subclinical) stage of DPN using laser CCM and a program for corneal nerve tortuosity analysis.

The authors present a case-report of Segawa's syndrome. Clinical characteristics, genetic background and treatment options with special emphasis on a differential diagnosis are discussed.

Primary forms of peripheral vegetative insufficiency are relatively rare. This group includes peripheral vegetative insufficiency associated with damage to segmental vegetative structures: sympathetic and parasympathetic nuclei, nodes, peripheral pre- and postganglionic fibers. In the clinical picture of the disease, there are signs of a decrease in the function of the autonomic nervous system, which manifests as cardiovascular, respiratory, genitourinary, gastrointestinal and some other disorders. Since the symptoms are non-specific, autoimmune forms of peripheral vegetative insufficiency are difficult to diagnose. The equipment and methods used in clinical laboratories do not provide reliable diagnostics. Therefore, the identification of new significant diagnostic markers of the diseases, including autoantibodies to acetylcholinesterase, α3-nicotinic acetylcholine receptor and β2-adrenergic receptors, the development on their basis of modern test systems and the introduction of these systems in the practice of neurological medical centers is an important task.

Diabetic polyneuropathy (DPN) is the most common chronic complication of diabetes mellitus and can develop just at the prediabetes stage. As DPN progresses and, in the absence of its adequate treatment, leads to worse quality of life and its shorter expectancy in patients. The paper discusses current clinical guidelines for the examination and management of patients with DPN, diagnostic methods, and pathogenetic treatment of this disease.

Diabetic peripheral neuropathy is a common chronic complication of diabetes mellitus, significantly impairing well-being, quality of life and functioning of patients. The prevalence of diabetic peripheral neuropathy in the Russian Federation ranges from 0.1% to 67.2% in type 1 and from 0.1 to 42.4% in type 2 diabetes mellitus. However, based on the large-scale epidemiological studies, the true prevalence of diabetic peripheral neuropathy is much higher (50 to 70%), with its painful variant occurring in 16% to 30% of patients. Despite the fact that diabetic peripheral neuropathy remains the most common chronic complication of diabetes mellitus, its diagnosis and therapy leave much to be desired. To optimize diagnostic and treatment approaches to painful diabetic peripheral neuropathy, a group of experts representing the leading Russian professional medical associations has developed clinical guidelines for the diagnosis and rational therapy of patients with painful diabetic peripheral neuropathy. This document presents practical aspects of the clinical diagnosis of painful diabetic peripheral neuropathy and an algorithm for differential diagnosis of pain in the lower extremities in patients with diabetes mellitus. The use of symptomatic analgesics with central action, such as anticonvulsants, antidepressants and opioids, is based on the main aspects of neuropathic pain pathophysiology. The characteristics of each drug class are given, with consideration of evidence on their efficacy, tolerability, and the possibility of combination therapy. The data on the first, second, and third lines of agents is presented in accordance with several international clinical guidelines. The need for a tailored drug choice, taking into account the evidence-based data on their efficacy and safety, concomitant drug therapy, tolerability, cost and preferences of the patient, age of the patient and concomitant disorders, is emphasized.

Polyneuropathy in patients with diabetes mellitus is manifested by a lesion of peripheral sensory, motor and autonomic nervous system. Different severity of damage of sensory, motor and autonomic fibers in typical and atypical forms of diabetic polyneuropathy, requires a differentiated approach to therapy, but not the rejection of its implementation. In an interdisciplinary consensus, consultations are held with physicians from different regions of the Russian Federation, and modern methods of diagnosing and assessing the severity of diabetic polyneuropathies, which determine the algorithm for treating patients, are discussed.

Diabetic polyneuropathy (DPN) is the most common chronic complication of diabetes mellitus and can develop just at the prediabetes stage. As DPN progresses and, in the absence of its adequate treatment, leads to worse quality of life and its shorter expectancy in patients. The paper discusses current clinical guidelines for the examination and management of patients with DPN, diagnostic methods, and pathogenetic treatment of this disease.