• Diabetes mellitus
• Hypertension / cardiovascular disease
• Thyroid disorders
• Recent trauma or surgery
• No known conditions

Giddiness + Lower Limb Numbing Pain in a Diabetic-Hypertensive Patient

Understanding the Symptoms

"Giddiness" - What type?

1. Vertigo - true spinning sensation (vestibular origin)
2. Near-syncope - faintness, pre-fainting
3. Disequilibrium - imbalance of stance/gait
4. Ill-defined lightheadedness / giddiness - often accompanies anxiety, autonomic dysfunction, or postural changes

Top Differential Diagnoses (Most Likely First)

1. Diabetic Peripheral Neuropathy (DPN) - Primary suspect

• Most common cause of noncompressive focal neuropathy
• Causes distal symmetric polyneuropathy - the classic "stocking and glove" distribution - symmetric numbness, burning, or stabbing pain in lower extremities
• The "dying back" axonopathy means symptoms start distally (feet/toes) and ascend
• Autonomic neuropathy from DM also impairs vasomotor reflexes, directly causing the giddiness via orthostatic hypotension
• Tintinalli's Emergency Medicine

2. Orthostatic Hypotension (DM + HTN antihypertensives)

• Very high suspicion here - antihypertensive medications are a well-known cause of postural non-vertiginous dizziness
• Diabetic autonomic neuropathy compounds this by impairing compensatory vasomotor reflexes
• Classic: patient stands up and feels faint/giddy, vision dims, must hold onto something for a few seconds
• Adams & Victor's Principles of Neurology

3. Hypertensive Cerebrovascular Disease / Vertebrobasilar Ischemia

• Chronic HTN is a major risk factor for small vessel disease, lacunar infarcts, and posterior circulation ischemia
• Vertebrobasilar TIAs/ischemia can cause dizziness + contralateral limb sensory symptoms
• Always rule out in an HTN patient - check for other posterior circulation signs (diplopia, dysphagia, ataxia, drop attacks)
• Bradley & Daroff's Neurology in Clinical Practice

4. Lumbar Spinal Stenosis - Neurogenic Claudication (Pseudoclaudication)

• Causes lower limb numbness, weakness, and pain typically affecting the posterior aspect bilaterally
• Symptoms worsen with walking/standing (extension) and are relieved by bending forward/sitting
• Worsened in elderly diabetic-hypertensive patients due to degenerative changes
• Goldman-Cecil Medicine

5. Diabetic Amyotrophy (Lumbosacral Plexopathy)

• Seen in long-standing diabetes - presents with back pain followed by leg weakness and sensory changes
• Deep tendon reflexes are diminished on the affected side
• Tintinalli's Emergency Medicine

Key Clinical Features to Elicit

Investigations to Order

• Lying and standing BP (postural drop >20 mmHg systolic = orthostatic hypotension)
• Blood glucose (hypoglycemia itself causes giddiness + neurological symptoms)
• HbA1c - assess long-term glycemic control
• Urine microalbumin - screens for diabetic microvascular disease

• Nerve conduction studies (NCS) / EMG - confirm peripheral neuropathy type
• MRI Brain - if vertebrobasilar or cerebrovascular ischemia is suspected
• MRI/CT Lumbar spine - if spinal stenosis suspected
• Cranial nerve exam + HINTS test - if true vertigo present (to distinguish peripheral vs. central vertigo)

• CBC (anaemia can cause giddiness)
• Vitamin B12, folate (B12 deficiency causes subacute combined degeneration - demyelination of dorsal + lateral columns, causing sensory neuropathy + gait problems)
• Renal function, lipid profile
• Thyroid function (hypothyroidism causes neuropathy)

Management Principles

Red Flags - Refer/Admit Urgently

• Sudden-onset severe giddiness + unilateral weakness/numbness/facial droop (possible stroke/TIA)
• Loss of consciousness or near-syncope episodes
• Rapidly progressive lower limb weakness or bowel/bladder involvement (possible cord compression or cauda equina)

Clinical Interpretation: HbA1c 10% + BP 150/90 mmHg

What These Numbers Tell You

How HbA1c 10% Explains the Lower Limb Pain/Numbness

• Oxidative stress + neuroinflammation → progressive axonal damage
• Classic distal symmetric polyneuropathy - stocking distribution of numbness, burning, pins-and-needles, worse at night
• Autonomic neuropathy - impairs vasomotor reflexes → orthostatic dizziness/giddiness on standing

How BP 150/90 mmHg Contributes

• Adds hypertensive microvascular disease on top of diabetic neuropathy
• Target in diabetes is <130/80 mmHg (Washington Manual of Medical Therapeutics)
• Antihypertensive medications (especially at suboptimal dose adjustments) can themselves worsen orthostatic hypotension
• Hypertension is also a major independent risk factor for posterior circulation ischemia - must remain on the differential

Priority Action Plan

1. Tighten Glycemic Control - URGENT

• HbA1c 10% needs to come down to <7-7.5%
• Review current diabetes regimen - consider intensification (add basal insulin if on OHAs, optimise doses)
• If already on insulin, review dosing and compliance
• Refer to endocrinologist / diabetes specialist

2. BP Management - Optimize

• Target: <130/80 mmHg in a diabetic patient
• First-line in diabetic HTN: ACE inhibitor or ARB (also nephroprotective - checks for microalbuminuria)
• If already on an antihypertensive - check if it is causing orthostatic drops (check lying/standing BP)
• Avoid overtreatment causing hypotension (which worsens giddiness)

3. Symptomatic Neuropathy Pain Treatment

Note: NSAIDs are relatively contraindicated in this patient - risk of renal impairment and cardiovascular effects in a diabetic-hypertensive

4. Screen for End-Organ Damage (Given both DM + HTN uncontrolled)

5. Foot Care Counselling - Mandatory

• Unnoticed trauma → ulcers → infection → amputation
• Instruct: daily foot inspection, protective footwear, no bare-foot walking, immediate review of any wound

Bottom Line

1. Bring HbA1c down - this is the most impactful intervention
2. Control BP to <130/80 with an ACEi/ARB
3. Symptomatic relief with pregabalin or duloxetine while the underlying cause is addressed

Complete Treatment Plan

PILLAR 1 - Glycemic Control (Most Urgent)

Target: HbA1c < 7% (individualize to <7.5% if elderly/hypoglycemia-prone)

Step-up antidiabetic therapy:

At HbA1c 10%, most guidelines recommend starting or intensifying insulin alongside oral agents. The DCCT/EDIC trial showed intensive control reduces neuropathy by 60%. - Harrison's Principles of Internal Medicine 22e

Important: Metformin reduces intestinal absorption of Vitamin B12 - check B12 levels and supplement if deficient, as B12 deficiency independently worsens neuropathy. - Harrison's

PILLAR 2 - Blood Pressure Control

Target: < 130/80 mmHg (in diabetic patients)

Drug of choice:

ACEi/ARB is recommended as first-line for all patients with diabetes and hypertension and is renoprotective even in normoalbuminuric patients. - Washington Manual of Medical Therapeutics

⚠️ Caution: Do NOT over-treat BP aggressively in a patient with autonomic neuropathy - this will worsen orthostatic hypotension and worsen the giddiness. Titrate slowly and always recheck lying/standing BP.

PILLAR 3 - Treat the Neuropathy (Symptomatic)

For lower limb numbing pain:

Symptomatic treatment using gabapentinoids (pregabalin, gabapentin), SNRIs (duloxetine, venlafaxine), tricyclics, and capsaicin patch have efficacy for painful DPSN. Opioids are not first-line due to addiction risk. - Harrison's Principles of Internal Medicine 22e

NSAIDs are contraindicated in this patient - risk of renal impairment and cardiovascular harm in DM + HTN.

For the giddiness (orthostatic hypotension from autonomic neuropathy):

• Rise slowly from sitting/lying - dangle legs before standing
• Increase dietary salt and fluid intake (unless contraindicated by severe HTN)
• Compression stockings on lower limbs
• Elevate head of bed by 10-20 degrees
• Avoid prolonged standing, hot showers, large meals

• Midodrine (alpha-1 agonist, FDA-approved for orthostatic hypotension) - 2.5-5 mg TDS
• Droxidopa - also FDA-approved for neurogenic orthostatic hypotension
• Fludrocortisone (mineralocorticoid) - increases plasma volume - use cautiously in HTN
• Harrison's Principles of Internal Medicine 22e

PILLAR 4 - Lifestyle Modifications

PILLAR 5 - Monitoring & Follow-up

PILLAR 6 - Additional Cardiovascular Protection

• Statin therapy (Atorvastatin 20-40 mg) - reduce LDL; high CV risk regardless of baseline lipids
• Low-dose Aspirin - consider if 10-year CV risk >10% or existing CVD (discuss risks vs benefits)
• The SGLT2 inhibitor also independently reduces CV mortality and heart failure hospitalizations

Summary Card

PROBLEM             TREATMENT
─────────────────────────────────────────────────────
HbA1c 10%         → Intensify regimen: Metformin + SGLT2i ± Insulin
BP 150/90          → ACEi/ARB (Ramipril/Losartan) + Amlodipine if needed
Limb neuropathy    → Pregabalin 75 mg BD or Duloxetine 60 mg OD
Giddiness (OH)     → Slow posture changes + Midodrine if needed; review BP meds
Foot risk          → Daily foot care, podiatry referral
CV risk            → Statin + SGLT2i + BP/glucose control
B12 (if on MF)     → Check and supplement