Diabetic Neuropathy Guidelines Updated

Endocrinologists and neurologists recently worked with the American Diabetes Association to create a new position statement regarding the prevention, treatment, and management of diabetic neuropathy.

"Our goal was to update the document so that it not only had the most up-to-date evidence, but also was easy to understand and relevant for primary care physicians," said statement lead author Rodica Pop-Busui, MD, PhD, professor of internal medicine at Michigan Medicine Division of Metabolism, Endocrinology and Diabetes. "We wanted it to be accessible to whoever takes care of diabetes patients, not just specialists."

It is estimated that up to 70% of patients with diabetes develop diabetic neuropathy, which is characterized by pain and numbness experienced in the legs and feet.

The new statement includes recommendations that outline prevention measures. Preventing diabetic neuropathy is important, since little is known about reversing the nerve damage. The researchers devised management and treatment strategies for multiple types of diabetic neuropathies.

The last ADA statement on diabetic neuropathy was created in 2005, and now provides an extensive amount of information.

"We wanted to unify all of the various forms of diabetic neuropathy in a more objective and easy-to-follow recommendation method," Dr Pop-Busui, MD said. "Many physicians have used different classifications for neuropathies. We came to a consensus to classify them in a more logical pattern, or format, for clinical care."

In the statement, the researchers created a classification system that describes the 3 main types: diffuse neuropathy, mononeuropathy, and radiculopathy or polyradiculopathy.

Diffuse neuropathy can then be described as peripheral or autonomic, and includes distal symmetric polyneuropathy (DSPN) and cardiovascular autonomic neuropathy (CAN), according to the statement. Mononeuropathy describes when 1 single nerve or a small group of nerves is damaged, and radiculopathy occurs when the root of a nerve is pinched.

The investigators then devised prevention tactics to improve care. In patients with type 1 diabetes, blood glucose levels should be controlled to prevent DSPN and CAN. Patients with type 2 diabetes should control blood glucose levels to prevent DSPN, and target glycemia to prevent CAN, according to the statement.

"We asked ourselves: What are the critical steps that have to be followed to diagnose diabetic neuropathy efficiently without ordering unnecessary evaluations for the patient, which can be expensive and may involve long wait times?" Dr Pop-Busui said. "We agreed on an algorithm that can be used in the clinical care setting so physicians have an easier understanding of when to perform a center evaluation or when they should refer the patient to a neurologist."

According to the new statement, all patients should be screened for DSPN upon diagnosis of type 2 diabetes, and 5 years after diagnosis of type 1 diabetes, followed by annual screenings. Patients should be screened through temperature, pinprick sensation, or vibration sensation tests.

The authors also advised that patients with diabetes should undergo 10-gram monofilament testing to assess if there is a risk for ulceration or amputation of the feet.

Only if atypical symptoms are displayed or if diagnosis is unclear should a patient receive electrophysiological testing or be referred to a neurologist, according to the statement.

Physicians should consider prescribing pregabalin or duloxetine to patients who are experiencing symptoms of diabetic neuropathy. Socioeconomic status, comorbidities, and drug interactions should be considered if gabapentin is prescribed, according to the authors.

Tricyclic antidepressants have shown promise as a treatment, but have a higher side effect profile and have not received FDA approval. The authors caution that opioids should not be prescribed for patients with DSPN due to the risk of misuse and complications.

"Treatment of neuropathy pain is specifically relevant because, unfortunately, there has been much overprescribing of narcotics for neuropathic pain," Dr Pop-Busui said. "We now provide clear evidence to fellow physicians that other agents are available and are more effective in treating diabetic neuropathy. We also demonstrate that there are ways to stay away from prescribing opioids and avoiding the epidemic of addiction and serious health consequences associated with opioid use in patients with diabetes."

The overall goal of updating the statement was to give a broader view of diabetic neuropathy and improve care.

"We hope these guidelines bring together primary care physicians, endocrinology specialists and neurologists to expand the care provided to diabetic patients,” Dr Pop-Busui concluded.