Management of Diabetic Peripheral Neuropathy

Glycemic Control and Neuropathic Pain

Achieving good glycemic control may modestly slow the progression of diabetic peripheral neuropathy in type 2 diabetes, but it will not reverse existing nerve damage or eliminate established neuropathic pain, according to the American Diabetes Association 1, 2
Glycemic control effectively prevents diabetic peripheral neuropathy in type 1 diabetes but only modestly slows progression in type 2 diabetes—it does not reverse neuronal loss that has already occurred 3, 1
No compelling evidence exists supporting glycemic control or lifestyle management as effective therapies for established neuropathic pain in diabetes, leaving only pharmaceutical interventions as treatment options 1, 2

Intensive blood pressure management decreased cardiac autonomic neuropathy risk by 25% in the ACCORD trial and is now recognized as important for preventing neuropathy progression, especially in type 2 diabetes, as recommended by the American College of Cardiology 1, 2
Hypertension is an independent risk factor for diabetic peripheral neuropathy development with an odds ratio of 1.58 1
Positive effects of physical activity, weight loss, and bariatric surgery have been reported in individuals with diabetic peripheral neuropathy, though conventional lipid-lowering therapy does not appear effective in treating or preventing neuropathy 1, 2

The American Academy of Neurology recommends gabapentinoids, serotonin-norepinephrine reuptake inhibitors, sodium channel blockers, and tricyclic antidepressants as first-line treatments for neuropathic pain in diabetic peripheral neuropathy 1, 2
Initial pain treatment should also focus on concurrent treatment of sleep and mood disorders, as these occur with increased frequency in individuals with diabetic peripheral neuropathy 1, 2
Over two-thirds of patients with painful diabetic neuropathy have anxiety and/or depression, which must be addressed for optimal outcomes, according to the American Psychiatric Association 6

Up to 50% of diabetic peripheral neuropathy may be asymptomatic, and if not recognized with preventive foot care implemented, patients are at risk for injuries, diabetic foot ulcers, and amputations 3
Opioids should generally be avoided for management of chronic neuropathic pain due to the risk of addiction, as recommended by the Centers for Disease Control and Prevention 2