Introduction

Neuropathy is one of the most common complications of diabetes. There are different types of diabetic neuropathy. Distal symmetric polyneuropathy (DSPN) and diabetic autonomic neuropathy such as cardiovascular autonomic neuropathy (CAN) are the most studied. DSPN is the most common, accounting for 75% of diabetic neuropathy. Prevention of diabetic neuropathy is very important because there are no treatments that correct the underlining nerve damage.

Prevention

Lifestyle modifications and blood glucose control are important for the prevention of diabetic neuropathy.

Glucose Control Recommendations

• Optimize glucose control as early as possible to prevent or delay neuropathy in patients with diabetes.

• A multifactorial approach to targeting blood glucose is recommended in order to prevent neuropathy in patients with type 2 diabetes.

Lifestyle Modifications

• Patients with type 2 diabetes should prioritize lifestyle modifications such as eating a balanced diet, achieving a healthy weight and exercising regularly to prevent neuropathy.

• There is no consensus on diet regimens and types of exercise, however, it is well established that these interventions are beneficial.

Treatment

General Recommendations

• Maintain tight glucose control, targeting near normal glucose levels in patients with type 1 diabetes to reduce the incidence of neuropathy.

• Intensive glucose control alone is modestly effective for preventing neuropathy in patients with advanced type 2 diabetes, other related conditions, and multiple risk factors. Other patient specific conditions should also be managed.

• Lifestyle interventions are recommended to prevent neuropathy in patients with type 2 diabetes or pre-diabetic/metabolic syndrome.

Pain Management Recommendations

• Pregabalin (Lyrica) or duloxetine (Cymbalta) should be considered for the initial treatment of neuropathic pain in people with diabetes.

• Gabapentin may also be used initially to treat neuropathic pain.

• Tricyclic antidepressants are effective for diabetic neuropathic pain, however, tricyclic antidepressants are not FDA approved for treating neuropathy and they may have a higher risk of serious side effects.

• Opioids, including tapentadol or tramadol (Ultra), are not recommended as first or second line agents because they have a high risk of addiction and other complications.

There is no compelling evidence that blood glucose control or lifestyle modifications are  effective for treating neuropathic pain in diabetes and pre-diabetes. Pregabalin has been studied the most and it has been shown to be 30%-50% effective for the improvement of pain and works more rapidly than gabapentin. 

Duloxetine is a selective norepinephrine and serotonin reuptake inhibitor and has shown efficacy in randomized trials. Is side effects may be more severe in older patients. 

Opioids relieve diabetic neuropathy pain when compared to placebo. However, due to the high risk of addiction, abuse, sedation and other complications, opioids are not recommended for treating neuropathy until other treatments have failed.

Conclusion

Diabetic neuropathy is a diagnosis of exclusion. Although up to 50% of diabetic peripheral neuropathies may be asymptomatic it is important to recognize the importance of regular foot care and screening strategies in order to prevent ulcers and amputations. Patients and health care providers should be proactive in directing treatment and screening for the management of diabetic neuropathy.

References 

Diabetic Neuropathy: A Position Statement by the American Diabetes Association. Diabetes Care 2017;40:136–154