Diabetic Neuropathy Treatment Recommendations for Primary Care Providers

New guidelines regarding the prevention, treatment, and management of diabetic neuropathy have been released in a position statement published in Diabetes Care.

A group of endocrinologists and neurologists, led by investigators at Michigan Medicine, partnered with the American Diabetes Association (ADA) to craft the statement, which provides physicians with more information and guidelines for the condition.

The paper stresses the importance of preventing diabetic neuropathy, since treatments to reverse the underlying nerve damage are lacking.

Although the ADA released a statement on diabetic neuropathy in 2005, the new update better reflects the current landscape of care, according to the authors.

“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 lead author Rodica Pop-Busui, MD, PhD. “We wanted it to be accessible to whoever takes care of diabetes patients, not just specialists.

Currently, many physicians will use different classifications for neuropathies. To address this, the authors sought to unify the different forms of diabetic neuropathy into a more “objective and easy-to-follow recommendation method.”

The investigators came to a consensus to classify them in a more logical format for clinical care.

“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 wait times? 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,” Pop-Busui said.

The classification system for diabetic neuropathies was divided into 3 main types: diffuse neuropathy, mononeuropathy, and radiculopathy or polyradiculopathy.

Diffuse neuropathy was further broken into 2 categories: peripheral and autonomic. Peripheral affects the hand and feet, whereas autonomic affects internal organs. Examples include distal symmetric polyneuropathy (DSPN) and cardiovascular autonomic neuropathy (CAN).

Mononeuropathy occurs when a single nerve or isolated nerve group is damaged, according to the guidelines. Radiculopathy occurs when the root of a nerve is pinched.

Recommendations for overall diabetic neuropathy prevention are as follows:

• For patients with type 1 diabetes, try to control glucose as soon as possible to prevent or delay the development of DSPN and CAN.
• For patients with type 2 diabetes, work to effectively control glucose to prevent or slow DSPN progression.
• A multifactorial approach with targeting glycemia and other risk factors for CAN prevention should be considered for patients with type 2 diabetes.

Recommendations for screening, diagnosis, management, and treatment for the specific forms are also included in the position paper. For DSPN, the investigators recommend:

• All patients should be screened for DSPN as soon as they are diagnosed with type 2 diabetes, and 5 years after a type 1 diabetes diagnosis, followed by annual screenings.
• Consider screening for patients with prediabetes who have symptoms of peripheral neuropathy.
• Assessments should include a careful history check in addition to a either a temperature or pink-prick sensation or a vibration sensation. Furthermore, all patients should have an annual 10-gram monofilament testing to determine whether their feet are at risk for ulceration of amputation.
• Referring a patient to a neurologist for electrophysiological testing is rarely needed for screening, unless symptoms are atypical, such as motor greater than sensory neuropathy, rapid onset, or asymmetrical presentation. Additionally, patients can be referred if the diagnosis is unclear or a different etiology is suspected.

In regards to DSPN pain management—–a common compliant of individuals with diabetic neuropathy—–the investigators recommend the following:

• Either pregabalin or duloxetine should be considered as the initial approach.
• Gabapentin may also be considered an effective initial approach, but the patient’s socioeconomic status, comorbidities, and potential drug interactions must be taken into account.
• Tricyclic antidepressants are effective as well, but are not FDA-approved. They should be used with caution because of their higher risk of serious adverse events.
• Opioids are not recommended as first- or second-line treatments for pain associated with DSPN, due to the high risk of addiction and other complications.

“Treatment of neuropathy pain is specifically relevant because, unfortunately, there has been much overprescribing of narcotics for neuropathic pain,” Pop-Busui said. “We no provide clear evidence to fellow physicians that other agents are available and are more effective in treatment 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 National Institute of Diabetes and Digestive and Kidney Diseases estimates that 60% to 70% of individuals with diabetes develop some form of diabetic neuropathy.

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