Diabetic neuropathy

General:[34]

Monitoring of blood glucose, blood pressure, serum lipids, and other complications is part of the general management of diabetes in all patients.
DN may mask common comorbid conditions including chest pain, angina, and claudication. It is therefore important to consider routinely screening for these, even if the patient does not report any symptoms.

Diabetic peripheral neuropathy (DPN):[1][34]

All patients should be assessed for DPN starting at diagnosis of type 2 diabetes, and 5 years after the diagnosis of type 1 diabetes, and at least annually thereafter.
The most common symptoms include pain, dysaesthesias (unpleasant abnormal sensations of burning and tingling associated with peripheral nerve lesions), and numbness.
Screening for signs of DPN should use simple clinical tests, but it is important to note that these tests will only reliably detect moderate to severe neuropathy. Assessment for DPN should start distally on both sides and move proximally until a threshold is detected. In the setting of typical neuropathic symptoms, it is important to identify underlying small-fibre deficits.
Electrophysiological testing is rarely needed, except in situations where the clinical features are atypical (e.g., motor deficits greater than sensory deficits; marked asymmetry of the neurological deficits; initial symptoms in the upper extremities; rapid progression).
Patients with severe or atypical neuropathy should be screened for other causes such as toxins (e.g., alcohol), vitamin B12 deficiency (especially in those taking metformin for prolonged periods), hypothyroidism, renal disease, malignancies, infections (e.g., HIV), chronic inflammatory demyelinating neuropathy, inherited neuropathies, and vasculitis.

Diabetic autonomic neuropathy:[34]

People who have had type 1 diabetes for ≥5 years and all individuals with type 2 diabetes should be assessed annually for autonomic neuropathy.
Major clinical signs/symptoms of diabetic autonomic neuropathy include resting tachycardia, orthostatic hypotension, constipation, diarrhoea, faecal incontinence, gastroparesis, erectile dysfunction, sudomotor dysfunction (with increased or decreased sweating), neurogenic bladder, and unawareness of hypoglycaemia.
Special testing is rarely needed and may not affect management or outcomes. However, the American Diabetes Association recommends that further testing can be considered if symptoms are present. Testing will depend on the end organ involved, but might include cardiovascular autonomic testing, sweat testing, urodynamic studies, gastric emptying, or endoscopy/colonoscopy.

Prevention and treatment of neuropathies:[34]

Tight and stable glycaemic control, started as early as possible, has been shown to be effective at preventing the development of DPN and autonomic neuropathy in patients with type 1 diabetes.
While the evidence is not as strong for type 2 diabetes, some studies have demonstrated a modest slowing of disease progression but no reversal of neuronal loss. However, these studies were undertaken in patients with advanced disease or using end points that are not recommended for clinical trials of DPN.
Optimal management of blood pressure, weight, and serum lipids is recommended to reduce the risk of DN and slow its progression in people with both type 1 and type 2 diabetes.
Drugs aimed at relieving pain associated with DPN and autonomic neuropathy are advised, as they can reduce pain improve sleep, and improve quality of life.
Treatment needs to be monitored regularly with regard to symptoms, adherence, and side effects. The frequency of follow-up will depend on the specific therapy and the patient’s condition.

Foot care:[34]

Visual foot examination should be performed at each visit for patients with sensory loss or a history of ulceration or amputation.
All patients should be educated about self-care of the feet. Enhanced foot care education programmes should be provided as needed, and referrals for specialised footwear should be made as appropriate.
The use of specialised therapeutic footwear is recommended for high-risk patients with diabetes, including those with loss of protective sensation (severe peripheral neuropathy), foot deformities, ulcers, callus formation, poor peripheral circulation, or a history of amputation.

Diabetic retinopathy:[34]

Patients with type 1 diabetes should have an eye examination within 5 years of onset, with follow-up every 1-2 years if no retinopathy is detected and glycaemia is well controlled.
Patients with type 2 diabetes should have an initial eye examination at time of diagnosis of diabetes, with follow-up every 1-2 years if no retinopathy is detected and glycaemia is well controlled.

Diabetic nephropathy:[34]

Patients with type 1 diabetes should be screened for kidney disease 5 years after diagnosis, with follow-up occurring at least annually.
Patients with type 2 diabetes should be screened for kidney disease at the time of diagnosis, with follow-up occurring at least annually.

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Monitoring