Diabetic neuropathy

General:​​[39]American Diabetes Association Professional Practice Committee. Introduction and methodology: standards of care in diabetes-2025. Diabetes Care. 2025 Jan 1;48(1 suppl 1):S1-5. https://diabetesjournals.org/care/article/48/Supplement_1/S1/157562/Introduction-and-Methodology-Standards-of-Care-in http://www.ncbi.nlm.nih.gov/pubmed/39651982?tool=bestpractice.com

• Monitoring of blood glucose, blood pressure, and serum lipids, and monitoring for 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 monitoring for these, even if the patient does not report any symptoms.

Diabetic peripheral neuropathy (DPN):[1]Pop-Busui R, Boulton AJ, Feldman EL, et al. Diabetic neuropathy: a position statement by the American Diabetes Association. Diabetes Care. 2017 Jan;40(1):136-54. https://diabetesjournals.org/care/article/40/1/136/37160/Diabetic-Neuropathy-A-Position-Statement-by-the http://www.ncbi.nlm.nih.gov/pubmed/27999003?tool=bestpractice.com ​​[39]American Diabetes Association Professional Practice Committee. Introduction and methodology: standards of care in diabetes-2025. Diabetes Care. 2025 Jan 1;48(1 suppl 1):S1-5. https://diabetesjournals.org/care/article/48/Supplement_1/S1/157562/Introduction-and-Methodology-Standards-of-Care-in http://www.ncbi.nlm.nih.gov/pubmed/39651982?tool=bestpractice.com ​​

• 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, dysesthesias (unpleasant abnormal sensations of burning and tingling associated with peripheral nerve lesions), and numbness.

• Screening for signs should use simple clinical tests, but it is important to note that these tests will only adequately 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-fiber deficits.

• Electrophysiologic testing is rarely needed, except in situations where the clinical features are atypical (motor deficits greater than sensory deficits; marked asymmetry of the neurologic 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:​​[39]American Diabetes Association Professional Practice Committee. Introduction and methodology: standards of care in diabetes-2025. Diabetes Care. 2025 Jan 1;48(1 suppl 1):S1-5. https://diabetesjournals.org/care/article/48/Supplement_1/S1/157562/Introduction-and-Methodology-Standards-of-Care-in http://www.ncbi.nlm.nih.gov/pubmed/39651982?tool=bestpractice.com

• 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, diarrhea, fecal incontinence, gastroparesis, erectile dysfunction, sudomotor dysfunction with increased or decreased sweating, neurogenic bladder, and unawareness of hypoglycemia.

• Special testing is rarely needed and may not affect management or outcomes. However, the ADA 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:​​[39]American Diabetes Association Professional Practice Committee. Introduction and methodology: standards of care in diabetes-2025. Diabetes Care. 2025 Jan 1;48(1 suppl 1):S1-5. https://diabetesjournals.org/care/article/48/Supplement_1/S1/157562/Introduction-and-Methodology-Standards-of-Care-in http://www.ncbi.nlm.nih.gov/pubmed/39651982?tool=bestpractice.com

• Tight and stable glycemic 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 as for type 1 diabetes, some studies have demonstrated a modest slowing of progression without reversal of neuronal loss. However, all of these studies were undertaken in patients with advanced disease or using end points that are not recommended for clinical trials of DPN.

• Additionally, optimal blood pressure, weight management and serum lipid control is recommended to both reduce the risk of and slow the progression of DN in people with type 1 and type 2 diabetes.​

• Medications for the relief of painful DPN and autonomic neuropathy are recommended because they may reduce pain, and improve quality of life.

• Treatment needs to be monitored regularly in relation to symptoms, adherence, and side effects. The frequency of follow-up will depend on the treatment given and condition.

Foot care:​​[39]American Diabetes Association Professional Practice Committee. Introduction and methodology: standards of care in diabetes-2025. Diabetes Care. 2025 Jan 1;48(1 suppl 1):S1-5. https://diabetesjournals.org/care/article/48/Supplement_1/S1/157562/Introduction-and-Methodology-Standards-of-Care-in http://www.ncbi.nlm.nih.gov/pubmed/39651982?tool=bestpractice.com

• Visual foot exam 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 should be facilitated and referral for special footwear made as indicated.

• The use of specialized therapeutic footwear is recommended for high-risk patients with diabetes, including those with loss of protective sensation (severe peripheral neuropathy), as well as those with foot deformities, ulcers, callus formation, poor peripheral circulation, or a history of amputation.​

Associated microvascular complications

Diabetic retinopathy:​[39]American Diabetes Association Professional Practice Committee. Introduction and methodology: standards of care in diabetes-2025. Diabetes Care. 2025 Jan 1;48(1 suppl 1):S1-5. https://diabetesjournals.org/care/article/48/Supplement_1/S1/157562/Introduction-and-Methodology-Standards-of-Care-in http://www.ncbi.nlm.nih.gov/pubmed/39651982?tool=bestpractice.com

• Patients with type 1 diabetes should have an eye exam within 5 years of onset, with follow-up every 1-2 years if no retinopathy is detected and glycemia is well controlled.

• Patients with type 2 diabetes should have an initial eye exam at time of diagnosis of diabetes, with follow-up every 1-2 years if no retinopathy is detected and glycemia is well controlled.

​Diabetic nephropathy:​[39]American Diabetes Association Professional Practice Committee. Introduction and methodology: standards of care in diabetes-2025. Diabetes Care. 2025 Jan 1;48(1 suppl 1):S1-5. https://diabetesjournals.org/care/article/48/Supplement_1/S1/157562/Introduction-and-Methodology-Standards-of-Care-in http://www.ncbi.nlm.nih.gov/pubmed/39651982?tool=bestpractice.com

• 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.