From the ACP Diabetes Care Guide

Persons with diabetes are at increased risk for macrovascular disease; microvascular disease, including retinopathy and nephropathy; peripheral and autonomic neuropathies; and lower extremity disease.

• Diabetic retinopathy is the leading cause of noncongenital blindness among adults.
• Diabetes is the most common cause of endstage kidney disease in the United States, especially among Native American, Hispanic, and African American persons. One quarter to one third of patients with type 1 or type 2 diabetes develop some degree of nephropathy.
• Diabetes doubles the risk for cardiovascular disease in men and triples it in women (data from the Multiple Risk Factor Intervention Trial [MRFIT]).
• Patients with diabetes are several-fold more likely to have peripheral arterial disease than patients without diabetes.
• Peripheral arterial disease and foot ulcers in patients with diabetes account for two thirds of all nontraumatic amputations performed in the United States.

Screening for and prevention of these complications are fundamental to the care of patients with diabetes and are important components of quality of care initiatives for diabetes.

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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Diabetic neuropathy has many manifestations because injury occurs to sensory, motor, and autonomic nerves. The most common presentation is the loss of sensation in a “stocking-glove” distribution, associated with paresthesias or painful dysesthesia. Loss of sensation in the lower extremities is also a major factor in the development of foot ulcerations.

Less commonly, acute mononeuropathies may involve either cranial or peripheral nerves, and sometimes even entire spinal nerve roots (radiculopathy). The latter may have perplexing clinical presentations that mimic the pain associated with acute myocardial infarction, acute cholelithiasis, or nephrolithiasis.

Autonomic neuropathy presents as erectile dysfunction in men, and orthostatic hypotension, gastroparesis, diabetic diarrhea, and atonic bladder.

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Question
In adults with diabetes, how effective are treatments for painful diabetic neuropathy?

Conclusion
Tricyclic antidepressants, traditional anticonvulsants, newer-generation anticonvulsants, opioids, duloxetine, and capsaicin cream are effective short-term treatments for painful diabetic neuropathy in adults, although side effects may result in discontinuation of treatment.

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Question
In patients with type 2 diabetes, does pioglitazone reduce cardiovascular events, other adverse events, and mortality or improve health-related quality of life?

Conclusions
Based on 1 randomized trial, pioglitazone does not reduce risk for mortality or cardiovascular events in patients with type 2 diabetes. Some evidence exists that pioglitazone increases risk for such adverse events as weight gain, decrease in hemoglobin level, and edema.

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Question
In patients with chronic noncancer pain (CNCP), are opioids more effective than placebo or other analgesics for relieving pain and improving functional outcomes?

Conclusions
In patients with chronic noncancer pain, weak and strong opioids are more effective than placebo for relieving pain and improving functional outcomes, although they are less effective than other analgesics for improving functional outcomes. Strong opioids are more effective than other analgesics for relieving pain.

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Question
In patients with type 2 diabetes and microalbuminuria, is a targeted intensive multifactorial intervention more effective than conventional treatment?

Conclusion
In patients with type 2 diabetes and microalbuminuria, a targeted, long-term, intensified, multifactorial intervention using behavioral modification and polypharmacologic therapy was more effective than conventional treatment for reducing cardiovascular and microvascular events.

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Question
How accurate are sensory symptoms for predicting polyneuropathy detected by clinical neurologic examination in patients with type 2 diabetes mellitus?

Conclusion
Neuropathic sensory symptoms did not accurately detect polyneuropathy in patients with type 2 diabetes mellitus.

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