From the Guidelines
Diabetic neuropathy presents with a diverse clinical picture that varies based on the type and severity of nerve damage, with the most common form being distal symmetric polyneuropathy, which typically begins with sensory symptoms in the toes and feet that progress proximally in a "stocking-glove" distribution, as noted in the 2023 standards of care in diabetes 1.
Clinical Presentation
The clinical presentation of diabetic neuropathy can be divided into several categories, including:
- Distal symmetric polyneuropathy: characterized by sensory symptoms such as numbness, tingling, burning pain, or electric shock-like sensations in the toes and feet, which can progress proximally in a "stocking-glove" distribution 1.
- Autonomic neuropathy: manifests as orthostatic hypotension, gastroparesis, constipation or diarrhea, urinary retention, erectile dysfunction, and anhidrosis 1.
- Mononeuropathies: affecting cranial nerves (especially III, IV, VI, and VII) or focal nerves (median, ulnar, peroneal) can cause acute focal deficits 1.
- Diabetic amyotrophy: presents with severe pain and weakness in proximal muscles, particularly in the thighs 1.
Importance of Early Recognition
Early recognition of these symptoms is crucial as they indicate poor glycemic control and increased risk for complications like foot ulcers and amputations, as highlighted in the 2023 standards of care in diabetes 1.
Assessment and Screening
All people with diabetes should be assessed for diabetic peripheral neuropathy starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes and at least annually thereafter, using a careful history and assessment of either temperature or pinprick sensation and vibration sensation using a 128-Hz tuning fork, as recommended in the 2023 standards of care in diabetes 1. Additionally, annual 10-g monofilament testing should be performed to identify feet at risk for ulceration and amputation 1.
Treatment and Management
While specific treatment to reverse the underlying nerve damage is currently not available, glycemic control can effectively prevent diabetic peripheral neuropathy and cardiac autonomic neuropathy in type 1 diabetes, and may modestly slow their progression in type 2 diabetes, as noted in the 2023 standards of care in diabetes 1. Therapeutic strategies, including pharmacologic and nonpharmacologic treatments, can potentially reduce pain and improve quality of life, with options such as pregabalin or duloxetine recommended as initial pharmacologic treatments for neuropathic pain in diabetes, as suggested in the 2018 standards of medical care in diabetes 1.
From the Research
Clinical Presentation of Diabetic Neuropathy
The clinical presentation of diabetic neuropathy (DN) can vary, but it is often characterized by:
- Progressive distal symmetric polyneuropathy, which is the most common form of DN 2
- Autonomic neuropathy, radiculo-plexopathies, and mononeuropathies 2
- Distal sensory or motor function loss, often presenting in a glove and stocking-like distribution 2, 3
- Neuropathic pain, which can be disabling and devastating, affecting 30-40% of patients with DN 2, 4
- Symptoms such as pain, paraesthesia, and sensory loss, which can significantly impact a patient's quality of life 5, 4
Types of Diabetic Neuropathy
There are several types of diabetic neuropathy, including:
- Sensorimotor neuropathy, marked by pain, paraesthesia, and sensory loss 5
- Autonomic neuropathy, which can contribute to myocardial infarction, malignant arrhythmia, and sudden death 5
- Cardiovascular, gastrointestinal, and genitourinary autonomic neuropathies, which can cause various complications such as gastroparesis and sexual dysfunction 5
Diagnosis and Management
Diagnosing DN can be challenging, particularly in patients with early and mild neuropathy, and there is currently no single established diagnostic gold standard 2