Diabetic Neuropathy Management
Initial Diagnostic Evaluation
- The American Diabetes Association recommends screening all type 2 diabetes patients at diagnosis and type 1 diabetes patients 5 years after diagnosis, then annually thereafter, for diabetic peripheral neuropathy using simple bedside tests such as 10-g monofilament, 128-Hz tuning fork for vibration, and pinprick/temperature sensation 1, 3
- Assess small-fiber function using pinprick and temperature sensation tests, and large-fiber function using 128-Hz tuning fork for vibration perception, 10-g monofilament testing, and ankle reflexes 1
- Up to 50% of diabetic peripheral neuropathy cases are asymptomatic but still carry ulceration risk 1, 3
Disease-Modifying Treatment
- Tight glycemic control effectively prevents and delays diabetic peripheral neuropathy and cardiac autonomic neuropathy in type 1 diabetes, but does not reverse established neuronal loss 1, 3
- The American Diabetes Association recommends targeting HbA1c of 6-7% to prevent neuropathy progression 2
Symptomatic Pain Management
- The American Diabetes Association recommends pregabalin, duloxetine, and gabapentin as first-line pharmacological options for symptomatic pain management in diabetic peripheral neuropathy 2
- Avoid opioids for chronic neuropathic pain due to addiction risk and lack of long-term safety data 6
Autonomic Neuropathy Assessment
- Screen for cardiac autonomic neuropathy (CAN) symptoms, including resting tachycardia and orthostatic hypotension, and perform cardiovascular autonomic testing with heart rate variability during deep breathing 1, 3
- CAN is associated with mortality independently of other cardiovascular risk factors 1, 3
Foot Care and Ulcer Prevention
- Perform comprehensive foot examination annually in all diabetes patients to identify ulcer and amputation risk, and examine feet at every visit for patients with insensate feet, foot deformities, or prior ulcers 4
- Refer patients with loss of protective sensation, structural abnormalities, history of ulcers/amputation, or who smoke to foot care specialists for ongoing preventive care 4