Primary prevention
Control of hyperglycemia has been demonstrated to be the most effective strategy in preventing DN in type 1 and to a lesser extent type 2 diabetes.[9][30][63] 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.[39]
The effect of intensive multifactorial treatment (including hemoglobin A1c [HbA1c], blood pressure, cholesterol, aspirin) on the incidence of DN in people screened for type 2 diabetes is unclear.[17]
The table that follows summarizes recommendations for primary prevention of diabetic neuropathy taken from the American Diabetes Association (ADA) standards of care in diabetes.[39]
Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Adult with type 1 or type 2 diabetes
All
Intervention
Optimize glycemic control
Optimize glucose management using an insulin-containing regimen (for type 1 diabetes) and lifestyle modifications with or without pharmacotherapy (for type 2 diabetes); there is evidence to suggest that this will prevent or delay the development of neuropathy in people with type 1 diabetes, and slow the progression of neuropathy in people with type 2 diabetes.
It is necessary to balance this potential benefit against the potential risks, including hypoglycemia.
Goal
Individualized glycemic goal and reduced risk of diabetic neuropathy
For many nonpregnant adults, an HbA1c goal of <7% (<53 mmol/mol) without significant hypoglycemia is appropriate.
Using healthcare professional judgment, and taking into consideration the preference of the person with diabetes, it may be acceptable and even beneficial to aim for an HbA1c goal lower than 7% (53 mmol/mol), if it can be achieved safely without significant hypoglycemia or other adverse effects of treatment.
Less stringent glycemic goals may be appropriate for individuals with limited life expectancy or where the harms of treatment are greater than the benefits.
Glycemic targets are individualized according to a number of factors, including:
Risks of hypoglycemia and adverse effects of drugs
Disease duration
Life expectancy
Important comorbidities
Established vascular complications
Individual needs and preferences
Resources and support system
Reassess glycemic goals based on the individualized criteria above.
With overweight or obesity
Intervention
Weight management
Optimize weight using lifestyle interventions with or without pharmacotherapy in line with guidelines on the management of overweight and obesity in the general population.
Obesity is consistently associated with neuropathy in cross-sectional and longitudinal studies. Effects of treatments of obesity on neuropathy outcomes are less well studied.
See Obesity in adults.
Goal
Weight loss; reduced risk and slowed progression of diabetic neuropathy
With elevated blood pressure (BP) (systolic BP 120-129 mmHg and diastolic BP <80 mmHg)
Intervention
Optimize BP (with nonpharmacologic interventions)
Optimize BP control to reduce the risk or slow the progression of diabetic neuropathy.
For those with elevated BP, the following nonpharmacologic interventions may be reasonable to consider:
Weight loss when indicated
A Dietary Approaches to Stop Hypertension (DASH)-style eating pattern, including reducing sodium and increasing potassium intake
Moderation of alcohol intake
Smoking cessation
Increased physical activity
Goal
Reduced BP, reduced cardiovascular risk, and reduced risk of diabetic neuropathy
With hypertension (systolic BP ≥130 mmHg or diastolic BP ≥80 mmHg)
Intervention
Optimize BP (with nonpharmacologic and pharmacologic interventions)
Optimize BP control using lifestyle modifications to reduce the risk or slow the progression of diabetic neuropathy.
Nonpharmacologic interventions:
This includes:
Weight loss when indicated
A Dietary Approaches to Stop Hypertension (DASH)-style eating pattern, including reducing sodium and increasing potassium intake
Moderation of alcohol intake
Smoking cessation
Increased physical activity
Pharmacologic interventions (antihypertensive drugs):
The recommended initial choice of agent depends on:
Whether or not albuminuria is present
The severity of hypertension
It is recommended that clinicians start:
A single antihypertensive agent for patients with initial BP ≥130/80 mmHg <150/90 mmHg
Two antihypertensive agents for those with initial BP ≥150/90 mmHg
Multiple-drug therapy is generally required to achieve BP targets. However, note that certain combinations of antihypertensives are not recommended (e.g., an ACE inhibitor plus an angiotensin-II receptor antagonist), and specific contraindications may apply.
Goal
Reduced BP, reduced cardiovascular risk, and reduced risk of diabetic neuropathy
It is recommended that the BP target is individualized through a shared decision making process that addresses cardiovascular risk, potential adverse effects of antihypertensive drugs, and individual preferences.
The on-treatment target BP goal is <130/80 mmHg, if it can be safely attained, for those with and without chronic kidney disease.
With dyslipidemia
Intervention
Intensify lifestyle interventions and optimize glycemic control; consider lipid-lowering pharmacotherapy
In people with type 2 diabetes, dyslipidemia is a key factor in the development of diabetic neuropathy. The association is less clear in people with type 1 diabetes. The optimal intervention to prevent neuropathy in people with diabetes and dyslipidemia is uncertain. Lifestyle interventions (physical activity, weight loss) and metabolic surgery may be beneficial, but use of conventional lipid-lowering pharmacotherapy (e.g., statins, fenofibrates) has not been shown to be effective in preventing or slowing progression of diabetic neuropathy.
Goal
Improved lipid profile, reduced cardiovascular risk, and reduced risk of diabetic neuropathy
Secondary prevention
People with DN are particularly at risk of painless foot injuries. Preventing foot ulceration is important, as subsequent wound infection and gangrene can lead to 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.[39] Screening should be conducted at least annually thereafter, using simple clinical tests.[39]
Proper care of the foot and prevention of ulceration begins with educating the patient on proper foot care.[39] Referral for specialized footwear may be indicated to relieve pressure points and reduce risk of foot trauma.[39] The use of specialized therapeutic footwear is recommended for high-risk patients with diabetes, 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.[39] Patients also need to check their feet daily and report any injuries or wounds at an early stage.[39]
One review of 13 randomized 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.[273]
Cardiovascular autonomic testing is recommended before a patient with diabetes begins a moderate- or high-intensity exercise program. People with known cardiovascular autonomic dysfunction should be advised about the need for appropriate hydration when exercising.
Optimal glucose, blood pressure 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.[39] Control of modifiable risk factors (glucose, obesity, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).[39]
Patients with painful DN should be assessed for presence of comorbid mood and sleep disorders (e.g., major depressive disorder, obstructive sleep apnea).[66]
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