Pinprick and temperature sensation may be used to evaluate small-fiber function, while proprioception, 10-g monofilament testing, ankle reflexes, and vibration perception using a 128-Hz tuning fork may be used to assess large-fiber function. Annual 10-g monofilament testing should be conducted in all patients at risk for foot ulceration and amputation.1 “Electrophysiological testing or referral to a neurologist is rarely needed for screening, except in situations where the clinical features are atypical, the diagnosis is unclear, or a different etiology is suspected,” the guidelines suggest.
In pain treatment, pharmaceutical interventions are the only measures supported by compelling evidence, while glycemic control and lifestyle management are not. Dr Pantalone thinks this point should have been included. “Their hard recommendations, as in routine clinical practice, the false belief of many clinicians that better glycemic control in patients with existing neuropathic pain will help to improve pain control, leads to inappropriate delays in the initiation of pharmacologic therapy and thus delays in improving patient discomfort,” he said.
Recommendations for the management of symptomatic neuropathic pain include pregabalin or duloxetine and possibly gabapentin as an initial treatment approach. Tricyclic antidepressants may also be effective, although they are not approved by the US Food and Drug Administration (FDA) for this indication and carry the risk of serious adverse effects. Opioids should generally not be used as first- or second-line pain treatment strategies in these cases due to the risk of addiction and other adverse effects.1
Diabetic Autonomic Neuropathies
The prevalence of CAN increases with diabetes duration, affecting at least 30% of patients with type 1 diabetes after 20 years and up to 60% of patients with type 2 diabetes after 15 years.11,12 CAN is a risk factor for mortality and several types of cardiovascular dysfunction.
The researchers recommended that patients with microvascular and neuropathic pain be evaluated for signs and symptoms of CAN. If detected, tests should be performed to rule out other conditions that could mimic CAN. Since hypoglycemia unawareness may be linked with CAN, clinicians may consider screening patients accordingly.13 “CAN treatment is generally focused on alleviating symptoms and should be targeted to the specific clinical manifestation,” they stated.
“The position statement also reminds clinicians that there are other forms of diabetic neuropathy,” Dr Pantalone added. The recommendations touch on detection and treatment of less common types, including gastrointestinal and urogenital neuropathies, as well as atypical forms such as mononeuropathies and treatment-induced neuropathy.
The researchers offered suggestions to improve the design of future clinical trials in this area, which have yet to produce promising results pertaining to therapies for diabetic neuropathy.
Next steps should include “continued efforts to find effective and safe disease-modifying agents to reverse this complication and improve patients’ quality of life and daily function,” said Dr Pop-Busui. “We hope these guidelines bring together primary care physicians, endocrinology specialists, and neurologists to expand the care provided to diabetic patients.”
- Pop-Busui R, Boulton AJM, Feldman EL, et al. Diabetic neuropathy: a position statement by the American Diabetes Association. Diabetes Care. 2017;40:136-154. doi:10.2337/dc16-2042
- Diabetes Control and Complications Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin dependent diabetes mellitus. N Engl J Med. 1993;329(14):977-986.
- Martin CL, Albers JW, Pop-Busui R; DCCT/ EDIC Research Group. Neuropathy and related findings in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications study. Diabetes Care. 2014;37(1):31-38. doi:10.2337/dc13-2114
- Callaghan BC, Cheng HT, Stables CL, Smith AL, Feldman EL. Diabetic neuropathy: clinical manifestations and current treatments. Lancet Neurol. 2012;11(6):521-534. doi:10.1016/S1474-4422(12)70065-0
- Ismail-Beigi F, Craven T, Banerji MA, et al.; ACCORD trial group. Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial. Lancet. 2010;376(9739):419-430. doi:10.1016/S0140-6736(10)60576-4
- Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003;348(5):383-393. doi:10.1056/NEJMoa021778
- Singleton JR, Marcus RL, Jackson JE, K Lessard M, Graham TE, Smith AG. Exercise increases cutaneous nerve density in diabetic patients without neuropathy. Ann Clin Transl Neurol. 2014;1(10):844-849. doi:10.1002/acn3.125
- Albers JW, Pop-Busui R. Diabetic neuropathy: mechanisms, emerging treatments, and subtypes. Curr Neurol Neurosci Rep. 2014;14:473. doi:10.1007/s11910-014-0473-5
- Dyck PJ, Albers JW, Andersen H, et al; for the Toronto Expert Panel on Diabetic Neuropathy. Diabetic polyneuropathies: update on research definition, diagnostic criteria and estimation of severity. Diabetes Metab Res Rev. 2011;27:620-628. doi:10.1002/dmrr.1226
- Brown SJ, Handsaker JC, Bowling FL, Boulton AJ, Reeves ND. Diabetic peripheral neuropathy compromises balance during daily activities. Diabetes Care. 2015;38(6):1116-1122. doi:10.2337/dc14-1982
- Spallone V, Ziegler D, Freeman R, et al; Toronto Consensus Panel on Diabetic Neuropathy. Cardiovascular autonomic neuropathy in diabetes: clinical impact, assessment, diagnosis, and management. Diabetes Metab Res Rev. 2011;27(7):639-653. doi:10.1002/dmrr.1239
- Ang L, Jaiswal M, Martin C, Pop-Busui R. Glucose control and diabetic neuropathy: lessons from recent large clinical trials. Curr Diab Rep. 2014;14(9):528. doi:10.1007/s11892-014-0528-7
- Ziegler D, Keller J, Maier C, Pannek J; German Diabetes Association. Diabetic neuropathy. Exp Clin Endocrinol Diabetes. 2014;122(7):406-415. doi:10.1055/s-0034-1366435