Neuropathy screening and treatment

Recommendations

* All patients should be screened for distal symmetric polyneuropathy (DPN) at diagnosis and at least annually thereafter, using simple clinical tests. (A)
* Electrophysiological testing is rarely ever needed, except in situations where the clinical features are atypical. (E)
* Once the diagnosis of DPN is established, special foot care is appropriate for insensate feet to decrease the risk of amputation. (B)
* Simple inspection of insensate feet should be performed at 3- to 6-month intervals. An abnormality should trigger referral for special footwear, preventive specialist, or podiatric care. (B)
* Screening for autonomic neuropathy should be instituted at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes. Special electrophysiological testing for autonomic neuropathy is rarely needed and may not affect management and outcomes. (E)
* Education of patients about self-care of the feet and referral for special shoes/inserts are vital components of patient management. (B)
* A wide variety of medications is recommended for the relief of specific symptoms related to autonomic neuropathy and are recommended, as they improve the quality of life of the patient. (E)

The diabetic neuropathies are heterogeneous with diverse clinical manifestations. They may be focal or diffuse. Most common among the neuropathies are chronic sensorimotor DPN and autonomic neuropathy. Although DPN is a diagnosis of exclusion, complex investigations to exclude other conditions are rarely needed. 

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The early recognition and appropriate management of neuropathy in the patient with diabetes is important for a number of reasons:
1) nondiabetic neuropathies may be present in patients with diabetes and may be treatable;
2) a number of treatment options exist for symptomatic diabetic neuropathy;
3) up to 50% of DPN may be asymptomatic and patients are at risk of insensate injury to their feet;
4) autonomic neuropathy may involve every system in the body; and
5) cardiovascular autonomic neuropathy causes substantial morbidity and mortality. Specific treatment for the underlying nerve damage is currently not available, other than improved glycemic control, which may slow progression but rarely reverses neuronal loss. Effective symptomatic treatments are available for the manifestations of DPN and autonomic neuropathy.

Diagnosis of neuropathy

Patients with diabetes should be screened annually for DPN using tests such as pinprick sensation, temperature and vibration perception (using a 128-Hz tuning fork), 10-g monofilament pressure sensation at the dorsal surface of both great toes, just proximal to the nail bed, and ankle reflexes. Combinations of more than one test have >87% sensitivity in detecting DPN. Loss of 10-g monofilament perception and reduced vibration perception predict foot ulcers. A minimum of one clinical test should be carried out annually, and the use of two tests will increase diagnostic ability.

Focal and multifocal neuropathy assessment requires clinical examination in the area related to the neurological symptoms.

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AMERICAN DIABETES ASSOCIATION
DIABETES CARE, VOLUME 27, SUPPLEMENT 1, JANUARY 2004

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May 27, 10 • Diabetes mellitus