Diabetic Peripheral Neuropathy Diagnosis and Management

Primary Diagnostic Considerations

The American Diabetes Association recommends that diabetic neuropathy is a diagnosis of exclusion, and other causes must be systematically ruled out, including vitamin B12 deficiency, hypothyroidism, renal disease, alcohol toxicity, neurotoxic medications, chronic inflammatory demyelinating neuropathy, malignancies, infections, inherited neuropathies, and vasculitis 1
Up to 50% of diabetic peripheral neuropathy may be asymptomatic, so absence of pain does not exclude this diagnosis, according to the American Diabetes Association 1, 3
The involvement of large fibers causes numbness and loss of protective sensation, which is a major risk factor for diabetic foot ulceration, as stated by the American Diabetes Association 1
Small-fiber involvement produces pain, dysesthesias, burning, and tingling sensations, according to the American Diabetes Association 1

A comprehensive neurological assessment, including small-fiber function testing and large-fiber function testing, is recommended by the American Diabetes Association to diagnose diabetic peripheral neuropathy 1, 5
The American Diabetes Association suggests ordering laboratory tests, such as glucose and HbA1c, vitamin B12 level, thyroid function tests, and renal function, to identify treatable causes of neuropathy 1, 4

The American Diabetes Association recommends optimizing glucose control to prevent or delay neuropathy development in type 1 diabetes and slow progression in type 2 diabetes 1, 3
Pregabalin or duloxetine are FDA-approved and recommended as initial pharmacologic treatments for neuropathic pain in diabetes by the American Diabetes Association 3, 5
The American Diabetes Association suggests performing comprehensive foot evaluations at least annually to identify risk factors for ulcers and amputations 3, 5