Treatment for Diabetic Neuropathy in Non-Compliant Patients

Assessment and Diagnosis

The American Diabetes Association recommends screening all patients with type 2 diabetes for diabetic peripheral neuropathy (DPN) at diagnosis and those with type 1 diabetes 5 years after diagnosis, with annual evaluations thereafter 2, 3
Assessment should include small-fiber function tests, such as pinprick and temperature sensation tests, and large-fiber function tests, such as vibration sensation using a 128-Hz tuning fork, to evaluate the severity of neuropathy 3, 1
Protective sensation should be evaluated using 10-g monofilament testing to identify feet at risk for ulceration, with up to 50% of DPN cases being asymptomatic but still increasing the risk for foot ulceration and amputation 2, 3

The American College of Clinical Pharmacology recommends first-line medications, including pregabalin, starting at lower doses and titrating up, and duloxetine, 60 mg once daily, for the treatment of DPN 1
Alternative options, such as gabapentin, 300-1,200 mg three times daily, and tricyclic antidepressants, such as amitriptyline and nortriptyline, may be considered if first-line treatments are ineffective or poorly tolerated 4, 1

Regular follow-up appointments, scheduled more frequently, can help monitor progress and reinforce adherence to treatment plans, with a focus on symptom relief and clear communication using simple language and visual aids 5, 1

The American Diabetes Association recommends setting realistic, achievable glycemic targets rather than ideal ones, and monitoring for medication side effects that may affect glycemic control, such as duloxetine, which may worsen glycemic control in some patients 2, 3, 1

The American Podiatric Medical Association recommends providing clear, simplified foot care instructions focused on daily inspection, using visual aids and demonstration techniques, and emphasizing the direct connection between foot care and avoiding amputation 3, 2, 1

The American College of Clinical Pharmacology recommends avoiding opioids for chronic neuropathic pain due to the risk of addiction and potential for worsening non-compliance, and monitoring for adverse effects, starting with lower doses and titrating slowly, especially in older patients 1
Other causes of neuropathy, such as alcohol toxicity, vitamin B12 deficiency, hypothyroidism, and autonomic neuropathy, should be considered and screened for, especially in non-compliant patients who may have multiple risk factors 2, 6, 3, 5