Neuropathy Practice Exam: Diabetes Chapter 31

Diabetic neuropathy is the most common complication of diabetes in North America, often developing within 10 years of diagnosis in up to 50% of patients. The 2018 Clinical Practice Guidelines stress that while there is no cure, the progression of neuropathy can be significantly delayed with early detection and optimal glycemic control.

This practice exam tests your ability to apply screening protocols, differentiate between peripheral and autonomic neuropathies, and select appropriate pharmacologic treatments for neuropathic pain.

Key Concepts Covered in This Exam:

Screening Protocols: Mastering the different screening timelines for Type 1 diabetes (starting 5 years post-diagnosis) versus Type 2 diabetes (at diagnosis) and the use of the 10 g monofilament or 128 Hz tuning fork.
Prevention Strategies: Understanding that intensive glycemic control is effective for preventing neuropathy in Type 1 diabetes and reducing its frequency in Type 2 diabetes.
Pain Management: Identifying evidence-based pharmacotherapies for painful diabetic neuropathy, including anticonvulsants (pregabalin, gabapentin) and antidepressants (duloxetine, venlafaxine), while recognizing that opioids are second-line or last-resort agents.
Autonomic Neuropathy: Recognizing the signs of cardiac autonomic neuropathy (CAN), gastroparesis, and erectile dysfunction, and the risks associated with them, such as resting tachycardia and postural hypotension.
Diagnostic Limitations: Knowing that simple screening tests like the monofilament are excellent for identification but that diagnosis requires excluding other causes (e.g., B12 deficiency, alcohol use).

1. A patient with type 2 diabetes and peripheral neuropathy has been found to have abnormal heart rate variability testing. Why is this finding clinically significant?

It confirms the diagnosis of distal symmetric polyneuropathy
It indicates the patient has a pacemaker
It is used to identify cardiac autonomic neuropathy
It has no clinical significance

2. What is the prevalence of erectile dysfunction in men with diabetic autonomic neuropathy?

Up to 10%
Up to 25%
Up to 60%
Up to 40%

3. What is the suggested starting dose for pregabalin in the treatment of painful diabetic neuropathy?

75 mg twice daily
300 mg twice daily
25 mg once daily
150 mg twice daily

4. A 55-year-old with type 1 diabetes for 25 years has painful neuropathy and symptoms of orthostatic hypotension. You want to initiate duloxetine for pain management. What additional consideration is important regarding orthostatic hypotension treatment?

Orthostatic hypotension resolves spontaneously with pain treatment
Duloxetine will improve orthostatic hypotension
Care must be taken to monitor for supine hypertension when using fludrocortisone or midodrine
Duloxetine is contraindicated with orthostatic hypotension

5. For treatment of postural hypotension in diabetic autonomic neuropathy, which of the following is a specific pharmacologic therapy?

Metformin
Metoclopramide
Midodrine
Metoprolol

6. Conservative measures for postural hypotension management include all of the following EXCEPT:

Restricting fluid intake
Increasing fluid and salt intake
Sleeping with the head of bed elevated
Compression stockings

7. A patient with diabetic gastroparesis is currently on a GLP-1 receptor agonist. What is the recommended approach regarding this medication?

Consider withdrawal of the GLP-1 RA as an exacerbating medication
Switch to a different GLP-1 RA formulation
Continue the GLP-1 RA as it has no effect on gastroparesis
Half the dose of the GLP-1 RA to improve gastric emptying

8. What is the maximum tolerated dose of gabapentin for painful diabetic neuropathy?

2,400 mg/day
3,600 mg/day
1,200 mg/day
1,800 mg/day

9. According to the DCCT/EDIC study, what is the prevalence of cardiac autonomic neuropathy (CAN) after 20 years of type 1 diabetes?

At least 20%
At least 10%
At least 50%
At least 30%

10. Which of the following is NOT a recognized risk factor for diabetic neuropathy?

Aspirin use
Elevated triglycerides
High body mass index
Hypertension

11. Which type of neuropathy can be distinguished from polyneuropathy by electrophysiological studies and is common in diabetes?

Carpal tunnel syndrome and ulnar neuropathy at the elbow
Thoracic radiculopathy
Cranial neuropathy
Diabetic radiculoplexus neuropathy

12. According to the guideline, what is the relationship between neuropathy and prediabetes?

Neuropathy only occurs after 10 years of diabetes
Prediabetes is protective against neuropathy
People with type 2 diabetes may have neuropathy even in the prediabetes stage
Neuropathy never occurs in prediabetes

13. A patient presents with excessive sweating in the head and neck triggered by food consumption. What type of diabetic autonomic neuropathy manifestation does this represent?

Gastroparesis
Diabetic bladder dysfunction
Cardiac autonomic neuropathy
Gustatory sweating

14. Bladder dysfunction in diabetic autonomic neuropathy can include all of the following EXCEPT:

Detrusor dysfunction with overflow incontinence
Increased bladder contractility with urge incontinence
Loss of bladder sensation
Predisposition to urinary tract infections

15. Based on the DCCT and its follow-up studies, for how long do the benefits of intensive insulin treatment persist for the primary prevention of neuropathy in type 1 diabetes?

Over a decade
5 years
2 years
Benefits do not persist after the trial ends

16. A patient asks about surgical release of distal lower limb nerves for diabetic neuropathy. What is the recommendation?

Recommended only in severe cases
Recommended after failure of two medications
Recommended as first-line treatment
Not recommended due to lack of evidence

17. The most common early symptoms of diabetic neuropathy from small fibre involvement include:

Muscle weakness and atrophy
Numbness and loss of protective sensation
Loss of ankle reflexes only
Pain (sharp, shooting) and dysesthesias (burning)

18. A diabetes educator is counseling a patient about why underdiagnosis of neuropathy is a problem. According to the guideline, which statement best summarizes the clinical impact of underdiagnosis?

Underdiagnosis is not a recognized problem in primary care
Underdiagnosis impedes the benefits of early identification, and management
Underdiagnosis only affects medication selection
Underdiagnosis has no significant clinical impact

19. A patient with type 2 diabetes has symptoms of asymmetric neuropathy with greater motor than sensory impairment. What is the recommended approach?

Refer for additional neurological evaluation to rule out nondiabetic causes
Reassure the patient this is typical diabetic neuropathy
Increase diabetes medications only
Start pregabalin immediately

20. Which two screening tools are recommended for rapid, reliable asymptomatic screening for peripheral neuropathy?

Nerve conduction studies and electromyography
10 g Semmes-Weinstein monofilament and 128 Hz tuning fork
Ankle-brachial index and pulse palpation
Skin biopsy and quantitative sensory testing

21. How does the 10 g monofilament test for annual DSPN screening differ from testing to assess risk for foot ulceration?

Testing for ulceration risk uses a 1 g monofilament
Testing for ulceration risk generally requires testing of 3 sites on each foot
There is no difference in technique
Annual screening requires more sites than ulceration risk assessment

22. What percentage of people with type 1 or type 2 diabetes will develop detectable sensorimotor polyneuropathy within 10 years of diabetes onset?

10% to 20%
60% to 70%
40% to 50%
25% to 35%

23. When performing monofilament screening for diabetic neuropathy, where should the 10 g monofilament be applied?

Lateral malleolus bilaterally
Plantar surface of the heel bilaterally
Dorsal aspect of the great toe bilaterally
Plantar surface of metatarsal heads only

24. When treating painful diabetic neuropathy, what degree of pain reduction is considered a clinically meaningful response?

Complete resolution of pain
60% to 80% reduction in baseline pain
30% to 50% reduction in baseline pain
10% to 20% reduction in baseline pain

25. A 48-year-old patient with newly diagnosed type 2 diabetes presents with bilateral burning pain in both feet. Physical examination and nerve conduction studies are normal. Which statement best explains this presentation?

The patient cannot have diabetic neuropathy with a normal examination
Nerve conduction studies are not valid for diabetic neuropathy
Pain may be present with normal clinical examination and normal nerve conduction studies
The patient’s symptoms are psychosomatic

26. A 22-year-old patient was diagnosed with type 1 diabetes at age 14 (post-pubertal). When should annual screening for neuropathy have commenced or should commence?

At age 19
At age 24
Only when symptoms develop
At age 14

27. A patient with painful diabetic neuropathy asks about treatment options. Which medications have received Health Canada approval specifically for neuropathic pain in diabetes?

Valproate and venlafaxine
Gabapentin and amitriptyline
Pregabalin and duloxetine
Carbamazepine and nortriptyline

28. Why is the primary use of opioids NOT recommended as first-line therapy for painful diabetic neuropathy, despite clinical trial evidence for pain efficacy?

Potential for dependency, tolerance, dose escalation and diversion
They worsen glycemic control
They are not effective for neuropathic pain
They are contraindicated with all diabetes medications

29. A patient with severe gastroparesis requires temporary pharmacologic treatment with a prokinetic agent. Which medication may be used, but with limited duration due to risk of extrapyramidal side effects?

Metoclopramide
Domperidone
Ondansetron
Erythromycin

30. A 45-year-old patient is newly diagnosed with type 2 diabetes. When should screening for peripheral neuropathy be initiated?

At diagnosis of diabetes
10 years after diagnosis
Only if symptoms develop
5 years after diagnosis

31. Regarding the use of capsaicin cream for painful diabetic neuropathy, what limits its acceptability and generalizability in clinical practice?

Lack of efficacy in clinical trials
Drug interactions with diabetes medications
Systemic absorption causing hypotension
Short-term pain associated with effective treatment

32. A patient with type 2 diabetes on metformin presents with new peripheral neuropathy symptoms. Which investigation is particularly important given the medication history?

Serum calcium
Serum B12
Serum ferritin
Serum magnesium

33. Diabetes is the leading cause of neuropathy in which geographic region?

North America
South America
Asia
Europe

34. A patient with diabetes and diabetic bladder dysfunction needs treatment for painful neuropathy. Which medication is contraindicated in this patient?

Pregabalin
Gabapentin
Duloxetine
Amitriptyline

35. Which of the following is the most common form of diabetic neuropathy?

Diabetic radiculoplexus neuropathy
Cranial neuropathy
Distal symmetric polyneuropathy (DSPN)
Cardiac autonomic neuropathy

36. What defines postural hypotension in the diagnosis of cardiac autonomic neuropathy?

A fall of greater than 10 mmHg systolic on standing
Any decrease in blood pressure when standing
A fall of greater than 30 mmHg diastolic on standing
A fall of greater than 20 mmHg systolic without an appropriate increase in heart rate

37. A patient with type 2 diabetes presents with unilateral facial weakness. Which cranial nerves are most commonly affected in diabetic cranial neuropathies?

Cranial nerves III, IV, VI, and VII
Cranial nerves I, II, V, and VIII
Cranial nerves II, V, VII, and X
Cranial nerves IX, X, XI, and XII

38. What resting heart rate is considered a feature of cardiac autonomic neuropathy (resting tachycardia)?

>90 beats/min
≥100 beats/min
>80 beats/min
≥110 beats/min

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