Primary prevention
Optimisation of glycaemic management is the most effective strategy for preventing DN in people with type 1 diabetes, and to a lesser extent in those with type 2 diabetes.[17][25][60] In both types, management of blood pressure, body weight, and serum lipids is also recommended to reduce the risk of DN and slow its progression.[34] However, evidence regarding the benefit of intensive multifactorial interventions (including haemoglobin A1c [HbA1c], blood pressure, cholesterol, aspirin) on the incidence of DN in screen-detected patients with type 2 diabetes is inconclusive.[13]
Secondary prevention
People with DN are especially vulnerable to painless foot injuries, which can lead to ulceration. Preventing foot ulcers is critical, as subsequent wound infections and gangrene can result in amputation. All patients should be screened for DN at diagnosis of type 2 diabetes or impaired glucose tolerance, and 5 years after diagnosis of type 1 diabetes.[34] Screening should then continue at least annually using simple clinical tests.[34]
Effective prevention begins with patient education on proper foot care.[34] Referral for specialised footwear may be necessary to relieve pressure points and reduce the risk of trauma.[34] The use of specialised therapeutic footwear is recommended for high-risk patients, such as those with loss of protective sensation (i.e., severe neuropathy), foot deformities, ulcers, callus formation, poor peripheral circulation, or a history of amputation.[34] Patients should inspect their feet daily and report any injuries or wounds promptly.[34]
One review of 13 randomised clinical trials assessed the benefits and efficacy of various interventions on the prevention of future diabetic foot ulcers. It found that only foot temperature-guided avoidance therapy was beneficial.[242]
Cardiovascular autonomic testing is recommended before a patient with diabetes begins a moderate- or high-intensity exercise programme. People with known cardiovascular autonomic dysfunction should be counselled on the importance of maintaining adequate hydration when exercising.
Optimal management of glucose, blood pressure and serum lipids is recommended to reduce the risk of DN and slow its progression in both type 1 and type 2 diabetes.[34] Control of modifiable risk factors (including glucose, obesity, blood pressure, and lipids), alongside a healthy lifestyle, may also help to prevent other microvascular complications such as retinopathy and nephropathy.[34]
In addition to established preventive measures, emerging evidence suggests that some therapies may promote nerve regeneration. In type 1 diabetes, omega-3 fatty acid supplementation has shown potential neuroprotective effects, possibly through triglyceride-lowering mechanisms.[243][244] In type 2 diabetes, fenofibrate - a peroxisome proliferator-activated receptor alpha (PPAR-alpha) agonist - has been associated with enhanced corneal nerve regeneration in clinical studies.[245] While further research is needed, these findings suggest a potential role for adjunctive therapies aimed at supporting nerve repair in DN.
Patients with painful DN should be screened for comorbid mood and sleep disorders (e.g., major depressive disorder, obstructive sleep apnoea) as treatment of these may help reduce pain and improve quality of life.[63]
Use of this content is subject to our disclaimer