A 56-year-old man with a history of type 2 diabetes comes to the clinic for review. He complains of
bilateral burning pain and weakness in both thighs, worse on the left than the right, which is
unbearable.
He takes metformin and a sulphonylurea to maximal doses for his diabetic control, and has a history
of hypertension.
On examination his BP is 148/79 mmHg, pulse is 70 and regular, BMI is 31. There is bilateral loss of
sensation in his feet. He has proximal muscle wasting of both lower limbs.
Investigations show:
Haemoglobin 135 g/L (135-177)
White cell count 8.3 ×10 /L (4-11)
Platelets 201 ×10 /L (150-400)
Sodium 142 mmol/L (135-146)
Potassium 4.7 mmol/L (3.5-5)
Creatinine 132 µmol/L (79-118)
HbA 84 mmol/mol (<36)
9.8% (<5.5)
Which of the following is the most appropriate way to manage the pain and muscle wasting in his
thighs?
Add pioglitazone
Amitriptyline
Duloxetine
Physiotherapy
Transition to insulin Correct
This man’s symptoms are consistent with diabetic amyotrophy, which mainly affects middle aged
patients with diabetes and is associated with a period of poor glycaemic control. It may also be
associated with marked weight loss. Symptoms slowly improve with improved glycaemic control.
Given his HbA is markedly elevated at 84 mmol/mol (9.8%), insulin is the most appropriate next
step.
Whilst duloxetine is first line therapy and amitriptyline second line therapy for peripheral diabetic
neuropathy, it is improved glycaemic control which has most effect on diabetic amyotrophy, so these
are not correct options.
Whilst pioglitazone would improve his diabetic control, his HbA is probably too elevated at 84
mmol/mol (9.8%) to enable him to reach target on triple oral therapy, therefore it is not the correct
option.
Whilst physiotherapy may help regain muscle strength, it is improved glycaemic control which is the
most important initial therapeutic intervention.