Position statement on diabetic neuropathy urges early recognition, appropriate management

The American Diabetes Association offered advice on prevention, screening, and treatment of diabetic peripheral neuropathies and cardiovascular autonomic neuropathies.

A position statement from the American Diabetes Association offered advice on preventing or delaying the development of diabetic peripheral neuropathies (DSPN) and cardiovascular autonomic neuropathies (CAN), among many other recommendations.

The position statement appeared in the January 2017 Diabetes Care.

Most common among diabetic neuropathies is chronic DSPN, which comprises about 75% of the diabetic neuropathies. The position statement defined it for clinical practice as the presence of symptoms and signs of peripheral nerve dysfunction in people with diabetes after the exclusion of other causes.

Prevention of diabetic neuropathies should focus on glucose control and lifestyle modifications, the statement said, including optimizing glucose control as early as possible to prevent or delay the development of DSPN in all patients with diabetes and CAN in people with type 1 diabetes. Clinicians should also consider a multifactorial approach targeting glycemia among other risk factors to prevent CAN in people with type 2 diabetes.

The position statement also said:

  • Tight glucose control targeting near-normal glycemia in patients with type 1 diabetes dramatically reduces the incidence of DSPN and is recommended for DSPN in type 1 diabetes;
  • Intensive glucose control alone is modestly effective in preventing DSPN in patients with type 2 diabetes with more advanced disease and multiple risk factors and comorbidities. Patient-centered goals should be targeted; and
  • Lifestyle interventions are recommended for preventing DSPN in patients with prediabetes/metabolic syndrome and type 2 diabetes.

Patients with type 1 diabetes for five or more years and all patients with type 2 diabetes should be assessed annually for DSPN using medical history and simple clinical tests. Up to half of patients may experience symptoms, whereas the rest are asymptomatic, the statement reads. Patients may not report symptoms by themselves but may do so after a physician asks, the statement said. Assessment should include a careful history and either temperature or pinprick sensation (small-fiber function), as well as vibration sensation using a 128-Hz tuning fork (large-fiber function). All patients should have an annual 10-g monofilament testing to assess for feet at risk for ulceration and amputation.

For pain management in patients with DSPN:

  • Physicians should consider either pregabalin or duloxetine as the initial approach in the symptomatic treatment for neuropathic pain in diabetes;
  • Gabapentin may also be used as an effective initial approach, taking into account patients' socioeconomic status, comorbidities, and potential drug interactions;
  • Tricyclic antidepressants are also effective for neuropathic pain in diabetes but should be used with caution given the higher risk of serious side effects. They are approved by the U.S. Food and Drug Administration; and
  • Opioids, including tapentadol or tramadol, are not recommended as first- or second-line agents for treating the pain associated with DSPN due to the high risks of addiction and other complications.

CAN prevalence increases substantially with diabetes duration, the statement noted, offering these recommendations:

  • Symptoms and signs of autonomic neuropathy should be assessed in patients with microvascular and neuropathic complications;
  • In the presence of symptoms or signs of CAN, tests excluding other comorbidities or drug effects or interactions that could mimic CAN should be performed; and
  • Physicians should consider assessing symptoms and signs of CAN in patients with hypoglycemia unawareness.