Peripheral Numbness and Tingling Guidelines

Initial Clinical Assessment

The American College of Physicians recommends determining fiber type involvement by asking specifically about burning pain and tingling (small fiber) versus numbness with loss of balance (large fiber) 1, 2
The American Academy of Neurology suggests assessing distribution pattern: distal symmetric suggests metabolic/toxic causes; patchy or asymmetric suggests mononeuropathy multiplex from vasculitis or leprosy 1
Identify red flags for urgent evaluation: hemibody sensory loss without motor weakness requires stroke evaluation within 48 hours 1
Medication review focusing on metformin (especially ≥2g daily), chemotherapy agents, and statins as common culprits 1

The American Academy of Neurology recommends small fiber testing: pinprick sensation and temperature perception 2, 3
Large fiber testing: vibration perception with 128-Hz tuning fork, 10-g monofilament testing, and ankle reflexes 1, 3
Autonomic signs: check for orthostatic hypotension, resting tachycardia, and skin dryness/cracking 3

Order complete blood count (anemia, infection, malignancy screening) 3
Fasting blood glucose and HbA1c (diabetes is the most common treatable cause) 1, 3
Vitamin B12 level (especially critical if patient takes metformin) 1
Hepatitis C serology if risk factors present (up to 50% of HCV patients develop neuropathy) 1

Optimize glycemic control if diabetic (HbA1c target 6-7%); this is the only proven strategy to prevent or delay diabetic neuropathy progression 1, 3
Vitamin B12 supplementation at 2500 mcg daily if deficient, particularly in metformin users 1
First-line pharmacologic options for symptomatic management: duloxetine, pregabalin, and gabapentin 1, 2, 3, 4
Alternative options if first-line agents fail: tricyclic antidepressants (amitriptyline), topical capsaicin (8% patch or 0.075% cream) 3
Physical activity is recommended for both chemotherapy-induced and diabetic neuropathy 3, 4
Acupuncture may be offered for musculoskeletal-related neuropathic symptoms 4

Do NOT use acetyl-L-carnitine for prevention of chemotherapy-induced peripheral neuropathy (harms outweigh benefits) 5
Avoid opioids (tapentadol, tramadol) for chronic neuropathic pain due to addiction risk 3
Monitor metformin users closely for B12 deficiency, as long-term use causes neuropathy in a stocking-glove distribution 1
Annual foot examinations with 10-g monofilament testing are mandatory once loss of protective sensation is documented to prevent ulceration 2, 3
Start medications at lower doses in older patients and titrate slowly to minimize adverse events 3