Diabetic Neurophaty

12/13/2018 https://emedicine.medscape.
com/article/1170337-print

emedicine.medscape.com
Diabetic Neuropathy
Updated: Mar 07, 2018
Author: Dianna Quan, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP
Overview
Practice Essentials
Diabetic neuropathy is the most common complication of diabetes mellitus (DM), affecting as many as 50% of patients with
type 1 and type 2 DM. Diabetic peripheral neuropathy involves the presence of symptoms or signs of peripheral nerve
dysfunction in people with diabetes after other possible causes have been excluded.[1]
Signs and symptoms
In type 1 DM, distal polyneuropathy typically becomes symptomatic after many years of chronic prolonged hyperglycemia,
whereas in type 2, it may be apparent after only a few years of known poor glycemic control or even at diagnosis. Symptoms
include the following:
Sensory – Negative or positive, diffuse or focal; usually insidious in onset and showing a stockingandglove
distribution in the distal extremities
Motor – Distal, proximal, or more focal weakness, sometimes occurring along with sensory neuropathy (sensorimotor
neuropathy)
Autonomic – Neuropathy that may involve the cardiovascular, gastrointestinal, and genitourinary systems and the
sweat glands
Physical examination should include the following assessments:
Peripheral neuropathy testing – Gross light touch and pinprick sensation; vibratory sense; deep tendon reflexes;
strength testing and muscle atrophy; dorsal pedal and posterior tibial pulses; skin assessment; Tinel testing; cranial
nerve testing
Autonomic neuropathy testing – Objective evaluation of cardiovagal, adrenergic, and sudomotor function in a
specialized autonomic laboratory; may be preceded by bedside screening to assess supine and upright blood
pressure and heart rate, with measurement of sinus arrhythmia ratio
Two classification systems for diabetic neuropathy are the Thomas system and the symmetricalversusasymmetrical
system. The Thomas system (modified) is as follows:
Hyperglycemic neuropathy
Generalized symmetrical polyneuropathies
Sensory neuropathy
Sensorimotor neuropathy
Autonomic neuropathy
Focal and multifocal neuropathies
Superimposed chronic inflammatory demyelinating polyneuropathy
Distal symmetrical sensorimotor polyneuropathy is commonly defined according to the following 3 key criteria:
The patient must have diabetes mellitus consistent with a widely accepted definition
Severity of polyneuropathy should be commensurate with duration and severity of diabetes
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Other causes of sensorimotor polyneuropathy must be excluded
Pure autonomic diabetic neuropathy is rare.
Asymmetrical neuropathies include the following:
Median neuropathy of the wrist (carpal tunnel syndrome)
Other single or multiple limb mononeuropathies
Thoracic radiculoneuropathy
Lumbosacral radiculoplexus neuropathy
Cervical radiculoplexus neuropathy
Diabetic polyneuropathy is commonly staged as follows:
NO No neuropathy
N1a Signs but no symptoms of neuropathy
N2a Symptomatic mild diabetic polyneuropathy; sensory, motor, or autonomic symptoms; patient is able to heelwalk
N2b Severe symptomatic diabetic polyneuropathy; patient is unable to heelwalk)
N3 Disabling diabetic polyneuropathy
See Clinical Presentation for more detail.
Diagnosis
Laboratory tests that may be helpful include the following:
Fasting plasma glucose
Hemoglobin A1c
Complete blood count
Complete metabolic panel (electrolytes and liver function panel)
Vitamin B12 and folate levels
Thyroid function tests
Erythrocyte sedimentation rate
Creactive protein
Serum protein electrophoresis with immunofixation electrophoresis
Antinuclear antibody
AntiSSA and SSB antibodies
Rheumatoid factor
Paraneoplastic antibodies
Rapid plasma reagin
Genetic screens
Hematology screen (for anemia)
Sequential multiple analysis7 (renal function and electrolyte imbalances)/complete metabolic panel (CMP)
Other diagnostic modalities that may be considered are as follows:
Electromyography and nerve conduction velocity testing
Electrophysiologic studies
Magnetic resonance imaging
Computed tomography (including singlephoton emission computed tomography)
Nuclear imaging
Doppler imaging
Microdialysis
Electrocardiography
Nerve and skin biopsy (now rarely recommended for clinical purposes)
See Workup for more detail.
Management
Key components of the management of diabetic neuropathy include the following:
Foot care, including regular followup, patient education, and referral as appropriate
Tight, stable glycemic control (most important for slowing progression of neuropathy)
Pain management (eg, with pregabalin, gabapentin, sodium valproate, dextromethorphan, morphine sulfate,
tramadol, oxycodone, duloxetine, topical capsaicin, transdermal lidocaine)
Treatment of diabetic gastroparesis (eg, with erythromycin, cisapride [not available in the United States],
metoclopramide, polyethylene glycol 3350, tegaserod [currently available only on an emergency basis])
Experimental therapies include aldose reductase inhibitors, alphalipoic acid, actovegin, and spinal cord stimulators.
Treatment of autonomic dysfunction must address the following:
Erectile dysfunction
Orthostatic hypotension
Gustatory sweating
Surgical treatment may be considered as follows:
Aggressive debridement or amputation for recalcitrant foot necrosis or infection
Jejunostomy for intractable gastroparesis
Implantation of a penile prosthesis for ongoing impotence
Bracing, special boots, or, in some cases, surgery for Charcot foot
Pancreatic transplantation for diabetes with endstage renal disease
See Treatment and Medication for more detail.
Background
Neuropathies are characterized by a progressive loss of nerve fiber function. A widely accepted definition of diabetic
peripheral neuropathy is "the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes
after exclusion of other causes."[2, 3]
Neuropathies are the most common complication of diabetes mellitus (DM), affecting up to 50% of patients with type 1 and
type 2 DM. In type 1 diabetes mellitus, distal polyneuropathy typically becomes symptomatic after many years of chronic
prolonged hyperglycemia. Conversely, patients with type 2 diabetes mellitus may present with distal polyneuropathy after
only a few years of known poor glycemic control; sometimes, these patients already have neuropathy at the time of
diagnosis. (See Clinical Presentation.)
Neuropathies severely decrease patients' quality of life (QOL). Furthermore, while the primary symptoms of neuropathy can
be highly unpleasant, the secondary complications (eg, falls, foot ulcers, cardiac arrhythmias, and ileus) are even more
serious and can lead to fractures, amputations, and even death in patients with DM.
Since diabetic neuropathy can manifest with a wide variety of sensory, motor, and autonomic symptoms, a structured list of
symptoms can be used to help screen all diabetic patients for possible neuropathy (see History). Physical examination of
patients with suspected distal sensory motor or focal (ie, entrapment or noncompressive) neuropathies should include
assessments for both peripheral and autonomic neuropathy (see Physical Examination).
Multiple consensus panels recommend the inclusion of electrophysiologic testing in the evaluation of diabetic neuropathy. An
appropriate array of electrodiagnostic tests includes both nerve conduction testing and needle EMG of the most distal
muscles usually affected. (See Workup.)
Management of diabetic neuropathy should begin at the initial diagnosis of diabetes. The primary care physician needs to be
alert for the development of neuropathy—or even its presence at the time of initial diabetes diagnosis—because failure to
diagnose diabetic polyneuropathy can lead to serious consequences, including disability and amputation. In addition, the
primary care physician is responsible for educating patients about the acute and chronic complications of diabetes (see
Patient Education). Patients with diabetic peripheral neuropathy require more frequent followup, with particular attention to
foot inspection to reinforce the need for regular selfcare. (See Treatment Strategies and Management.)
Management of diabetic neuropathy includes 2 approaches: therapies for symptomatic relief and those that may slow the
progression of neuropathy. Of all treatments, tight and stable glycemic control is probably the most important for slowing the
progression of neuropathy. Many medications are available for the treatment of diabetic neuropathic pain, although most of
them are not specifically approved by the United States Food and Drug Administration for this use. Nonpharmacologic
treatment includes rehabilitation, which may comprise physical, occupational, speech, and recreational therapy. (See
Medication.)
Anatomy
A review of the anatomy of the peripheral nervous system can facilitate understanding of the classification of diabetic
peripheral neuropathy. Peripheral neurons can be categorized broadly as motor, sensory, or autonomic.
Motor neurons originate in the central nervous system (CNS) and extend to the anterior horn of the spinal cord. From the
anterior horn, they exit the spinal cord (via ventral roots) and combine with other fibers in the brachial or lumbar plexuses
and innervate their target organs through peripheral nerves.
Sensory neurons originate at the dorsal root ganglia (which lie outside the spinal cord) and follow a similar course with motor
neurons. Sensory neurons are subdivided into categories according to the sensory modality they convey (see the Table
below).
Autonomic neurons consist of sympathetic and parasympathetic types. In the periphery, preganglionic fibers leave the CNS
and synapse on postganglionic neurons in the sympathetic chain or in sympathetic ganglia.
The smaller fibers are affected first in DM. With continued exposure to hyperglycemia, the larger fibers become affected.
Fibers of different size mediate different types of sensation, as shown in the table below.
Table. Subdivisions of Sensory Neurons (Open Table in a new window)
Fiber Type Size Modality Myelination
Aalpha (I) 1320 micrometers Limb proprioception Yes
Abeta (II) 612 micrometers Limb proprioception, vibration, pressure Yes
Adelta (III) 15 micrometers Mechanical sharp pain Yes
C (IV) 0.21.5 micrometers Thermal pain, mechanical burning pain No
Pathophysiology
The factors leading to the development of diabetic neuropathy are not understood completely, and multiple hypotheses have
been advanced.[4, 5, 6, 7, 8, 9, 10, 11, 12, 13] It is generally accepted to be a multifactorial process. Development of
symptoms depends on many factors, such as total hyperglycemic exposure and other risk factors such as elevated lipids,
blood pressure, smoking, increased height, and high exposure to other potentially neurotoxic agents such as ethanol.
Genetic factors may also play a role.[14] Important contributing biochemical mechanisms in the development of the more
common symmetrical forms of diabetic polyneuropathy likely include the polyol pathway, advanced glycation end products,
and oxidative stress.
For more information, see Type 2 Diabetes and TCF7L2.
Polyol pathway
Hyperglycemia causes increased levels of intracellular glucose in nerves, leading to saturation of the normal glycolytic
pathway. Extra glucose is shunted into the polyol pathway and converted to sorbitol and fructose by the enzymes aldose
reductase and sorbitol dehydrogenase.[15] Accumulation of sorbitol and fructose lead to reduced nerve myoinositol,
decreased membrane Na+/K+ ATPase activity, impaired axonal transport, and structural breakdown of nerves, causing
abnormal action potential propagation. This is the rationale for the use of aldose reductase inhibitors to improve nerve
conduction.[16]
Advanced glycation end products
The nonenzymatic reaction of excess glucose with proteins, nucleotides, and lipids results in advanced glycation end
products (AGEs) that may have a role in disrupting neuronal integrity and repair mechanisms through interference with nerve
cell metabolism and axonal transport.[17]
Oxidative stress
The increased production of free radicals in diabetes may be detrimental via several mechanisms that are not fully
understood. These include direct damage to blood vessels leading to nerve ischemia and facilitation of AGE reactions.
Despite the incomplete understanding of these processes, use of the antioxidant alphalipoic acid may hold promise for
improving neuropathic symptoms.[18, 19, 20]
Related contributing factors
Problems that are a consequence of or cocontributors to these disturbed biochemical processes include altered gene
expression with altered cellular phenotypes, changes in cell physiology relating to endoskeletal structure or cellular transport,
reduction in neurotrophins, and nerve ischemia.[21] Clinical trials of the beststudied neurotrophin, human recombinant
nerve growth factor, were disappointing. With future refinements, however, pharmacologic intervention targeting one or more
of these mechanisms may prove successful.
In the case of focal or asymmetrical diabetic neuropathy syndromes, vascular injury or autoimmunity may play more
important roles.[22]
Etiology
Risk factors that are associated with more severe symptoms include the following[23] :
Poor glycemic control
Advanced age
Hypertension
Long duration of DM
Dyslipidemia
Smoking
Heavy alcohol intake
HLADR3/4 phenotype
Tall height
Development of symptoms depends on many factors, such as total hyperglycemic exposure and other risk factors such as
elevated lipids, blood pressure, smoking, increased height, and high exposure to other potentially neurotoxic agents such as
ethanol. Genetic factors may also play a role.[14]
Peripheral neuropathies have been described in patients with primary DM (types 1 and 2) and in those with secondary
diabetes of diverse causes, suggesting a common etiologic mechanism based on chronic hyperglycemia. The contribution of
hyperglycemia has received strong support from the Diabetes Control and Complications Trial (DCCT).[24]
An association between impaired glucose tolerance and peripheral neuropathy has been construed as further evidence of a
dosedependent effect of hyperglycemia on nerves, although this relationship remains an area of some controversy for type
2 diabetes and prediabetes.[25, 26, 27, 28]
A study by Jende et al indicated that in patients with type 1 diabetes, the predominant nerve lesions of distal symmetrical
diabetic neuropathy develop in relation to poor glycemic control and nerve conduction loss, while in type 2 diabetes, these
lesions arise in association with lipid metabolism changes.[109]
A study by Pai et al indicated that in adults with type 2 diabetes, an association exists between variability in fasting plasma
glucose and the risk for painful diabetic peripheral neuropathy. Using the coefficient of variation (CV) for fasting plasma
glucose, the investigators found that, after consideration of HbA1c, the odds ratios for the development of painful diabetic
peripheral neuropathy were 4.08 and 5.49 for the third and fourth CV quartiles, respectively, compared with the first quartile.
[108]
A study by Altaf et al indicated that obstructive sleep apnea (OSA) is linked to smallfiber neuropathy in type 2 diabetes, with
poly–adenosine diphosphate ribose polymerase activation being a possible mechanism behind OSA’s association with
diabetic peripheral neuropathy and endothelial dysfunction.[29]
A study by Dabelea et al found that among teenagers and young adults who had been diagnosed with type 1 or type 2
diabetes during childhood or adolescence, the ageadjusted prevalence of peripheral neuropathy was greater in those with
type 2 diabetes than in patients with type 1 diabetes (17.7% vs 8.5%, respectively). After modifications had been made for
established risk factors measured over time, the odds ratio for peripheral neuropathy in patients with type 2 diabetes versus
those with type 1 was 2.52.[30]
Epidemiology
United States statistics
A large American study estimated that 47% of patients with diabetes have some peripheral neuropathy.[31] Neuropathy is
estimated to be present in 7.5% of patients at the time of diabetes diagnosis. More than half of cases are distal symmetric
polyneuropathy. Focal syndromes such as carpal tunnel syndrome (1430%),[32, 33, 34] radiculopathies/plexopathies, and
cranial neuropathies account for the rest. Solid prevalence data for the latter 2 lesscommon syndromes is lacking.
The wide variability in symmetric diabetic polyneuropathy prevalence data is due to lack of consistent criteria for diagnosis,
variable methods of selecting patients for study, and differing assessment techniques. In addition, because many patients
with diabetic polyneuropathy are initially asymptomatic, detection is extremely dependent on careful neurologic examination
by the primary care clinician. The use of additional diagnostic techniques, such as autonomic or quantitative sensory testing,
might result in a higher recorded prevalence.[35, 36]
International statistics
In a cohort of 4400 Belgian patients, Pirart et al found that 7.5% of patients already had neuropathy when diagnosed with
diabetes.[37] After 25 years, the number with neuropathy rose to 45%. In the United Kingdom, the prevalence of diabetic
neuropathy among the hospital clinic population was noted to be around 29%.[38]
Diabetic neuropathy in racial minorities
No definite racial predilection has been demonstrated for diabetic neuropathy. However, members of minority groups (eg,
Hispanics, African Americans) have more secondary complications from diabetic neuropathy, such as lowerextremity
amputations, than whites.[23] They also have more hospitalizations for neuropathic complications.
Sex differences in diabetic neuropathy
DM affects men and women with equal frequency. However, male patients with type 2 diabetes may develop diabetic
polyneuropathy earlier than female patients,[39] and neuropathic pain causes more morbidity in females than in males.
Diabetic neuropathy and advancing age
Diabetic neuropathy can occur at any age but is more common with increasing age and severity and duration of diabetes.
Prognosis
Patients with untreated or inadequately treated diabetes have higher morbidity and complication rates related to neuropathy
than patients with tightly controlled diabetes. Repetitive trauma to affected areas may cause skin breakdown, progressive
ulceration, and infection. Amputations and death may result.
Treating diabetic neuropathy is a difficult task for the physician and patient. Most of the medicines mentioned in the
Medication section do not lead to complete symptom relief. Clinical trials are under way to help find new ways to treat
symptoms and delay disease progression.
Mortality is higher in people with cardiovascular autonomic neuropathy (CAN). The overall mortality rate over periods up to
10 years was 27% in patients with DM and CAN detected, compared with a 5% mortality rate in those without evidence of
CAN. Morbidity results from foot ulceration and lowerextremity amputation. These 2 complications are the most common
causes of hospitalization among people with DM in Western countries. Severe pain, dizziness, diarrhea, and impotence are
common symptoms that decrease the QOL of a patient with DM. In patients with diabetic peripheral neuropathy, the
prognosis is good, but the patient's QOL is reduced.
In a Canadian study of patients with painful diabetic neuropathy being managed in a tertiary care setting, Mai et al found that
at 12month followup, significant improvement in pain and function had been achieved in almost one third of these
individuals. That included pain reduction of 30% or greater in 37.2% of patients, functional improvement (reduction of 1 or
greater on the Pain Interference Scale) in 51.2% of patients, and achievement of both of these measures in 30.2% of
patients. Polypharmacy was found to be essential to symptom management and included the use of analgesic
antidepressants and anticonvulsants.[40]
For more information, go to Diabetic Foot.
for more information, go to Diabetic Foot Infections.
Patient Education
Controlling diet and nutrition are paramount to improving the secondary complications of diabetes, including neuropathy.
Patients with diabetic neuropathy should work with nutritionists or their primary care physicians to develop a realistic diet for
lowering blood glucose and minimizing large fluctuations in blood glucose.
Patients with diabetic neuropathy should be encouraged to remain as active as possible. However, those with significant
sensory loss or autonomic dysfunction should be cautioned about exercising in extreme weather conditions, which may
result in injury. For example, patients with extremity numbness may not be aware of frostbite injuries during prolonged cold
exposure, or those with abnormal sweating may become easily overheated in hot conditions. In most cases, consultation
with the patient's regular physician is reasonable before the initiation of a regular exercise program.
Patients with diabetic neuropathy need to be educated on all aspects of their condition, and they need to know that it is very
much affected by poor glycemic control. Prevention of diabetic neuropathy is potentially best achieved by having near
euglycemic control from the onset of DM. Even in patients with symptoms of diabetic neuropathy, controlling blood glucose
to euglycemic levels reduces pain significantly. When a person has poor control and becomes euglycemic quickly, pain may
be exacerbated (possibly due to an insulin effect), but this pain disappears in a few days. The bottom line for patients is that
medications are imperfect. Many result in no pain relief for certain patients. However, glucose control is something that the
patient can achieve that may reduce pain.
The importance of protection and care of insensitive feet cannot be overemphasized. Patients should be instructed to trim
their toenails with great care and to be fastidious about foot hygiene. Any fungal or bacterial infection mandates prompt
medical attention. The need for wellfitting shoes should be stressed.
Diabetic polyneuropathy is often associated with diabetic retinopathy and nephropathy. Patients with neuropathy should be
counseled to seek appropriate eye care and discuss renal care and followup with their primary care physicians or
endocrinologists.
Patient education should begin in the primary care office. The following outline reviews some common questions and
answers that can serve as a springboard for discussion.
What is diabetic neuropathy?
Diabetic neuropathy is nerve damage caused by diabetes. In the United States, diabetes is one of the most common causes
of nerve damage, also known as peripheral neuropathy. Diabetic neuropathy can affect nerves that supply feeling and
movement in the arms and legs. It can also affect the nerves that regulate unconscious vital functions such as heart rate and
digestion.
How does diabetic neuropathy occur?
Doctors have been studying this problem for many years, but they do not yet understand exactly how diabetes damages
nerves. However, they have observed that good control of blood sugar levels helps prevent diabetic neuropathy and slows
its progression, especially in patients with type 1 diabetes.
What are the symptoms?
Symptoms of diabetic neuropathy may include the following:
Numbness or loss of feeling (usually in the feet and legs first, then the hands)
Pain
Muscle weakness
Low blood pressure and dizziness when rising quickly from sitting or lying down
Rapid or irregular heartbeats
Trouble having an erection
Nausea or vomiting
Difficulty swallowing
Constipation or diarrhea
Pain from diabetic neuropathy may range from minor discomfort or tingling in toes to severe pain. Pain may be sharp or
lightninglike, deep and aching, or burning. Extreme sensitivity to the slightest touch can also occur (allodynia).
A study by D’Amato et al indicated that among diabetesrelated complications and comorbidities, painful diabetic
polyneuropathy is the greatest determinant of depression in patients with diabetes. The study involved 181 patients,
including 25 with painful diabetic polyneuropathy and 46 with the painless form of the condition.[41]
How can I help prevent diabetic neuropathy?
The following steps may help to prevent or slow the worsening of diabetic neuropathy[42] :
Control diabetes; try to keep blood sugar at a normal level
Maintain normal blood pressure
Exercise regularly, according to the healthcare provider's recommendation
Stop smoking
Limit the amount of alcohol intake because excessive alcohol also can cause neuropathy or make it worse
Eat a healthy diet and avoid elevated levels of triglycerides in the blood
Maintain a healthy weight
Keep followup appointments with the healthcare provider
How is diabetic neuropathy treated?
No treatment is currently available to reverse neuropathy. The best approach is to control the diabetes and other risk factors.
Muscle weakness is treated with support, such as braces. Physical therapy and regular exercise may help patients maintain
the muscle strength they have.
Pain medications may help make pain more tolerable. Medications can be used to treat nausea, vomiting, and diarrhea.
Men who have trouble having erections because of neuropathy should talk to their healthcare providers. Medications can
help a man achieve and maintain an erection, or prosthetic devices can be put in the penis.
Preventing injuries such as burns, cuts, or broken bones is especially important, because patients with neuropathy have
more complications from simple injuries and may not heal as quickly as healthy individuals.
How can I take care of myself?
Diabetes patients can take the following selfcare measures:
Work with primary care physicians and endocrinologists to control glucose levels
Examine the skin of feet and lower legs regularly to look for injuries
See a healthcare provider promptly for calluses, sores on the skin, or other potential problems so they can be treated
properly.
Wear goodfitting, comfortable shoes that protect the feet
How long will the problem last?
Once a person has neuropathy, the symptoms will persist indefinitely, but most people with diabetic neuropathy are able to
lead active, fulfilling lives. Keeping blood sugar under good control may stop neuropathy from worsening.
For excellent patient education resources, visit eMedicineHealth's Diabetes Center and Men's Health Center. Also, see
eMedicineHealth's patient education articles, Diabetes Mellitus and Diabetic Foot Care.
Presentation
History
In type 1 diabetes mellitus, distal polyneuropathy typically becomes symptomatic after many years of chronic prolonged
hyperglycemia. Conversely, patients with type 2 diabetes mellitus may present with distal polyneuropathy after only a few
years of known poor glycemic control; sometimes, these patients already have neuropathy at the time of diagnosis.
Since diabetic neuropathy can manifest as a wide variety of sensory, motor, and autonomic symptoms, a structured list of
symptoms can be used to help screen all diabetic patients for possible neuropathy.
Sensory symptoms
Sensory neuropathy usually is insidious in onset and shows a stockingandglove distribution in the distal extremities.
Sensory symptoms may be negative or positive, diffuse or focal. Negative sensory symptoms include feelings of numbness
or deadness, which patients may describe as being akin to wearing gloves or socks. Loss of balance, especially with the
eyes closed, and painless injuries due to loss of sensation are common. Positive symptoms may be described as burning,
prickling pain, tingling, electric shock–like feelings, aching, tightness, or hypersensitivity to touch.
Motor symptoms
Motor problems may include distal, proximal, or more focal weakness. In the upper extremities, distal motor symptoms may
include impaired fine hand coordination and difficulty with tasks such as opening jars or turning keys. Foot slapping and toe
scuffing or frequent tripping may be early symptoms of foot weakness. Symptoms of proximal limb weakness include
difficulty climbing up and down stairs, difficulty getting up from a seated or supine position, falls due to the knees giving way,
and difficulty raising the arms above the shoulders.
In the most common presentation of diabetic neuropathy with symmetrical sensorimotor symptoms, minor weakness of the
toes and feet may be seen; severe weakness is uncommon and should prompt investigation into other causes, such as
chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), or vasculitis. More severe weakness may be observed
in asymmetrical diabetic neuropathy syndromes. Motor neuropathy may occur along with sensory neuropathy (sensorimotor
neuropathy).
Autonomic symptoms
Autonomic neuropathy may involve the cardiovascular, gastrointestinal, and genitourinary systems and the sweat glands.
Patients with generalized autonomic neuropathies may report ataxia, gait instability, or near syncope/syncope. In addition,
autonomic neuropathies have further symptoms that relate to the anatomic site of nerve damage—gastrointestinal,
cardiovascular, bladder, or sudomotor.
Gastrointestinal autonomic neuropathy may produce the following symptoms[43] :
Dysphagia
Abdominal pain
Nausea/vomiting
Malabsorption
Fecal incontinence
Diarrhea
Constipation
Cardiovascular autonomic neuropathy may produce the following symptoms[44] :
Persistent sinus tachycardia
Sinus arrhythmia
Decreased heart variability in response to deep breathing
Near syncope upon changing positions from recumbent to standing
Bladder neuropathy (which must be differentiated from prostate or spine disorders) may produce the following symptoms:
Poor urinary stream
Feeling of incomplete bladder emptying
Straining to void
Sudomotor neuropathy may produce the following symptoms:
Heat intolerance
Heavy sweating of head, neck, and trunk with anhidrosis of lower trunk and extremities
Gustatory sweating
Physical Examination
Physical examination of patients with suspected distal sensory, motor, or focal (ie, entrapment or noncompressive)
neuropathic symptoms should include assessments for both peripheral and autonomic neuropathy.[45]
Peripheral neuropathy testing
Testing for peripheral neuropathy begins with assessment of gross light touch and pinprick sensation. The first clinical sign
that usually develops in diabetic symmetrical sensorimotor polyneuropathy is decrease or loss of vibratory and pinprick
sensation over the toes. As disease progresses, the level of decreased sensation may move upward into the legs and then
from the hands into the arms, a pattern often referred to as "stocking and glove" sensory loss. Very severely affected
patients may lose sensation in a "shield" distribution on the chest.
Vibratory sense in the feet is tested with a 128Hz tuning fork placed at the base of the great toenail. Test protective
sensation with 5.07 SemmesWeinstein monofilament, briefly applying the tip perpendicular to the plantar surface of the foot,
using sufficient force (10 g) to buckle the monofilament. Inability to perceive the tuning fork or the monofilament identifies
patients who are at increased risk (ie, 60% in the next 3 years) of developing a foot ulcer.[46] The 2 tests should be
performed at least every year.[47]
Test deep tendon reflexes. With neuropathy, these are commonly hypoactive or absent. Perform strength testing and
examine for distal intrinsic extremity muscle atrophy, since weakness of small foot muscles may develop. Check dorsal pedal
and posterior tibial pulses.
Examine the skin for dryness, tinea pedis, cracks, onychomycoses, acute erythema and tenderness, and fluctuance under
calluses.
Perform Tinel testing. Paresthesias or pain suggests median nerve injury.
Perform cranial nerve testing. Have the patient walk on the heels and toes; heeltoe walking tests not only distal lower
extremity strength but balance, as well.
Perkins et al recommended conducting annual screening for diabetic neuropathy using superficial pain sensation testing,
monofilament testing, or vibration testing by the onoff method. These researchers also validated a scoring system to
document and monitor neuropathy in the clinic.[48] Dyck et al described case report forms for recording symptoms and signs
of neuropathy that might be useful in longitudinal followup of individual patients.[49]
Autonomic neuropathy testing
Testing for autonomic neuropathies is performed objectively in a specialized autonomic laboratory, evaluating cardiovagal,
adrenergic, and sudomotor function. However, the clinician may first perform bedside screening to assess if further, more
specialized testing is necessary.
Blood pressure and heart rate measurements with the patient supine and upright are compared. Blood pressure
measurements in patients with autonomic neuropathy may show orthostatic hypotension with reduced compensatory
tachycardia. Testing for orthostatic hypotension is particularly important in patients with longstanding diabetes mellitus.[50]
The sinus arrhythmia (SA) ratio is measured with the patient breathing 6 times per minute while the heart rate is monitored
with a continuous ECG strip. The longest RR interval during expiration and the shortest RR interval during inspiration are
measured, and the average of the 6 breaths is taken. The SA ratio is RR expiration/RR inspiration. The normal ratio is 1:2.
Classification of Diabetic Neuropathy
Diabetic neuropathies are heterogeneous in type; thus, several classifications of diabetic neuropathy have been created and
recognized.[51, 2, 45] Two classification systems will be presented here: the Thomas system and symmetricalversus
asymmetrical neuropathies.
Thomas system
A classification system by Thomas[52] combines anatomy and pathophysiology. It is presented below with a few
modifications:
Hyperglycemic neuropathy (acute)
Generalized symmetrical polyneuropathies
Sensory neuropathy
Sensorimotor neuropathy (chronic, symmetric)
Autonomic neuropathy (cardiovascular, gastrointestinal, genitourinary, sudomotor)
Focal and multifocal neuropathies: this category includes cranial neuropathy, proximal motor neuropathy
(amyotrophy), thoracic or lumbar radiculopathies, and focal limb neuropathies (entrapment neuropathies)
Superimposed chronic inflammatory demyelinating polyneuropathy (CIDP)
Symmetrical versus asymmetrical neuropathies
Another generally accepted classification of diabetic neuropathies divides them broadly into symmetrical and asymmetrical
neuropathies.
Symmetrical polyneuropathies involve multiple nerves diffusely and symmetrically. Distal symmetrical sensorimotor
polyneuropathy is the most common manifestation of diabetic neuropathy. The syndrome has been defined in many ways,
but 3 key criteria are commonly accepted:
The patient must have diabetes mellitus by one of the widely accepted definitions such as those outlined by the
American Diabetes Association or World Health Organization[53, 54]
The severity of polyneuropathy should be commensurate with the duration and severity of the diabetes
Other causes of sensorimotor polyneuropathy must be excluded
Distal symmetrical sensorimotor polyneuropathy affects sensory, motor, and autonomic functions in varying degrees, with
sensory abnormalities predominating. Chronic symmetrical symptoms affect peripheral nerves in a lengthdependent pattern,
with the longest nerves affected first. Patients commonly present with painful paresthesias and numbness, which begin in
the toes and ascend proximally in a stockinglike distribution over months and years.
When sensory symptoms ascend above the knees, similar symptoms develop in the hands, progressing proximally in a
glovelike distribution. At a very late stage, the anterior aspect of the trunk and vertex of the head may be affected. The loss
of sensation in the feet predisposes to development of foot ulcers and gangrene.[55] In addition, mild weakness of foot
muscles and decreased ankle and knee reflexes occur commonly. With impaired proprioception and vibratory perception,
gait may be affected (sensory ataxia).
Smallfiber neuropathy is a distal symmetrical neuropathy involving predominantly smalldiameter sensory fibers (A delta and
C fibers). It manifests as painful paresthesias that patients perceive as burning, stabbing, crushing, aching, or cramplike,
with increased severity at night. There is loss of pain and temperature sensation with relative sparing of distal reflexes and
proprioception.
Although some degree of autonomic involvement is present in most patients with distal symmetrical diabetic polyneuropathy,
patients may not notice autonomic problems, and pure autonomic diabetic neuropathy is rare. Manifestations of autonomic
neuropathy may include orthostatic hypotension, resting tachycardia, loss of normal sinus arrhythmia ratio, anhidrosis, bowel
or bladder dysfunction, and small pupils sluggishly reactive to light.
In diabetic neuropathic cachexia, the patient experiences a precipitous and profound weight loss followed by severe and
unremitting cutaneous pain, smallfiber neuropathy, and autonomic dysfunction. This condition occurs more often in older
men; impotence is common. Muscle weakness is uncommon. The condition usually improves with prolonged glycemic
control; however, symptoms are often refractory to other pharmacologic treatment. Limited anecdotal improvement is
reported with nonpharmacologic treatments such as sympathectomy, spinal cord blockade, and electrical spinal cord
stimulation. Recovery may be incomplete and prolonged over many months
Asymmetrical neuropathies include single or multiple cranial or somatic mononeuropathies. Syndromes include the following:
Median neuropathy of the wrist (carpal tunnel syndrome)
Other single or multiple limb mononeuropathies
Thoracic radiculoneuropathy
Lumbosacral radiculoplexus neuropathy
Cervical radiculoplexus neuropathy
These syndromes are distinguished from typical distal diabetic polyneuropathy by the following characteristics:
They often have a monophasic course
Some are associated with inflammatory angiitis and ischemia (eg, lumbosacral radiculoplexus neuropathy) and may
appear acutely or subacutely
They have a weaker association with total hyperglycemic exposure than symmetrical polyneuropathies
Cranial mononeuropathy most often involves cranial nerves (CN) III, IV, VI, VII, or II. Disease of CN III, IV, and VI manifests
as acute or subacute periorbital pain or headache followed by diplopia. Muscle weakness is typically in the distribution of a
single nerve, and pupillary light reflexes are usually spared. Complete spontaneous recovery usually occurs within 3 months.
Facial neuropathy manifests as acute or subacute facial weakness (taste is not normally affected) and can be recurrent or
bilateral. Most patients recover spontaneously in 36 months.
Anterior ischemic optic neuropathy manifests as acute visual loss or visualfield defects (usually inferior altitudinal). The optic
disc appears pale and swollen; flameshaped hemorrhages may be present.
For more information, see Macular Edema, Diabetic.
Somatic mononeuropathies include focal neuropathies in the extremities caused by entrapment or compression at common
pressure points or by ischemia and subsequent infarction. Entrapment and compression tend to occur in the same nerves
and at the same sites as in individuals without diabetes. Median nerve entrapment at the wrist (carpal tunnel syndrome) is
more common in patients with diabetes and can be treated in the same manner as in patients without diabetes. Symptoms
are often bilateral. The susceptibility to ulnar nerve entrapment at the elbow or common peroneal nerve entrapment at the
fibular head is not definitely increased among patients with diabetes.
Neuropathy secondary to nerve infarction presents acutely, usually with focal pain associated with weakness and variable
sensory loss in the distribution of the affected nerve. Multiple nerves may be affected (mononeuritis multiplex).
Diabetic thoracic radiculoneuropathy presents as burning, stabbing, boring, beltlike, or deep aching pain that usually begins
unilaterally and may subsequently become bilateral. Skin hypersensitivity and allodynia (pain with normally innocuous touch)
may occur. Numbness follows a dermatomal distribution, most prominent in distal distribution of intercostal nerves. Single or
multiple spinal roots are involved. Contiguous territorial extension of symptoms may occur in a cephalad, caudal, or
contralateral direction. In the trunk, thoracoabdominal neuropathy or radiculopathy may cause chest and/or abdominal pain
in the distribution of thoracic and/or upper lumbar roots. Weakness presents in the distribution of the affected nerve root,
such as bulging of the abdominal wall from abdominal muscle paresis (thoracic root). Patients older than 50 years are
affected most often; it is more common in diabetes mellitus type 2 and is often associated with significant weight loss. There
isoftencoexistingdiabeticdistalsymmetrical polyneuropathy.
Diabetic radiculoplexus neuropathy may occur in the cervical or lumbosacral distributions and is referred to in the literature
by various designations, including diabetic amyotrophy, BrunsGarland syndrome, and diabetic plexopathy. The most
frequent initial symptom is sudden, severe, unilateral pain in the hip/lower back or shoulder/neck. Weakness then develops
days to weeks later. Atrophy of the limb musculature may occur. Allodynia, paresthesias, and sensory loss are common.
Symptoms usually begin unilaterally and may later spread to the opposite side. Reflexes in the affected limb may be
depressed or absent. This condition often occurs in patients older than 50 years with poorly controlled diabetes. It is more
common in men than in women. Significant weight loss occurs in 50% of patients. The course is generally monophasic, with
improvement over many months; however, some residual deficits often remain.
For more information, see Diabetic Lumbosacral Plexopathyhere.
Staging
Different clinical neurologic scales can be used to assess the severity of diabetic polyneuropathy.[51]
A common staging scale of diabetic polyneuropathy is as follows[56] :
NO No neuropathy
N1a Signs but no symptoms of neuropathy
N2a Symptomatic mild diabetic polyneuropathy; sensory, motor, or autonomic symptoms; patient able to heel walk
N2b Severe symptomatic diabetic polyneuropathy (as in N2a, but patient unable to heel walk)
N3 Disabling diabetic polyneuropathy
DDx
Diagnostic Considerations
Establishing the diagnosis of diabetic neuropathy requires careful evaluation, because in 1026% of diabetic patients with
neuropathy, the neuropathy may have another cause.[31, 57, 58, 59, 60]
The differential diagnoses to consider vary with the presentation.
Cranial mononeuropathy includes the following:
Intracranial aneurysms
Bell palsy
Thoracoabdominal neuropathy includes the following:
Herpes zoster
Spinal tumors
Myocardial infarction
Acute cholecystitis
Acute appendicitis
Diverticulitis
Lumbosacral radiculoplexopathy includes the following:
Anterior disk protrusion
Spinal cord tumors
Malignant nerve root infiltrations
Inflammatory neuropathies
Peripheral neuropathy includes the following:
Pernicious anemia
Vitamin B6 intoxication
Alcoholism
Uremia
Chemical toxins
Nerve entrapment and compression of benign etiology
Hepatitis
Idiopathic
Congenital (various hereditary sensory motor neuropathies)
Paraneoplastic syndrome
Syphilis
HIV/AIDS
Medication (eg, chemotherapy, isoniazid)
Spine disease (eg, radiculopathy, stenosis, arteriovenous [AV] fistula)
Cardiovascular autonomic neuropathy (in addition to some listed above) includes the following:
Myocardial infarction
Neuropathic arrhythmias (eg, WolffParkinson–White syndrome, sick sinus syndrome)
Volume depletion
Drugs
Gastrointestinal neuropathy includes the following:
Gastrointestinal malignancy
Peptic ulcer disease
Postsurgical vagotomy
Electrolyte imbalance
Bladder dysfunction includes the following:
Bladder outlet obstruction
Prostate cancer
Spinal cauda equine syndrome
Mononeuropathy includes the following:
Vasculitides
Acromegaly
Coagulopathies
Hypothyroidism
For more information, see Diabetic Lumbosacral Plexopathy.
Differential Diagnoses
Alcohol (Ethanol) Related Neuropathy
Amyloid polyneuropathy
Chronic Inflammatory Demyelinating Polyradiculoneuropathy
Chronic Myelogenous Leukemia (CML)
Neurosarcoidosis
Nutritional Neuropathy
Spinal Cord Tumors
Toxic Neuropathy
Uremic Neuropathy
Vasculitic Neuropathy
Vitamin B12 deficiency
Workup

Workup
Approach Considerations
Fasting plasma glucose and hemoglobin A1c are important laboratory screening tests for diabetic neuropathy.
Imaging studies rarely help the physician diagnose or manage diabetic neuropathy. However, in the appropriate clinical
setting, MRI of the cervical, thoracic, and/or lumbar regions may help exclude another cause for symptoms mimicking
diabetic neuropathy.
Multiple consensus panels recommend the inclusion of electrophysiologic testing in the evaluation of diabetic neuropathy. An
appropriate array of electrodiagnostic tests includes both nerve conduction testing and needle EMG of the most distal
muscles usually affected.
In a systematic review of 5 studies of noninvasive screening tools for detecting peripheral neuropathies in pediatric patients
with type 1 diabetes, Hirschfeld and colleagues found that the diagnostic utility of the RydelSeiffer tuning fork and 10g
SemmesWeinstein monofilament was low, while that of biothesiometry and a finer (1g) monofilament was acceptable.
Sensitivities and specificities of these screening tools were as follows:[61, 62]
Tuning fork: 8799% (sensitivity); 119% (specificity)
Coarse monofilament: 16% (sensitivity); 64% (specificity)
Fine monofilament: 73% (sensitivity); 87% (specificity)
Biothesiometer: 6180% (sensitivity); 6476% (specificity)
Hemoglobin A1c and Fasting Plasma Glucose
Hemoglobin A1c and fasting plasma glucose are important laboratory screening tests for diabetic neuropathy. Hemoglobin
A1c measurement is useful to assess the adequacy of recent diabetes control; levels are likely to be elevated in patients with
diabetic neuropathies. In some cases, especially with asymmetrical syndromes, the severity of the elevation does not always
correlate with the severity of the nerve disease.
A 3hour glucose tolerance test may be more sensitive in borderline cases. A urinalysis is also helpful to screen for
nephropathy and proteinuria.
Basic Laboratory Screening Tests
Testing is tailored depending on the clinical presentation. Examples of tests suggested as basic screening tools to exclude
common causes of neuropathy other than diabetes include the following:
Complete blood cell count
Complete metabolic panel (electrolytes and liver function panel)
Vitamin B12 and folate levels
Thyroid function tests
Erythrocyte sedimentation rate
Creactive protein
Serum protein electrophoresis with immunofixation electrophoresis
Antinuclear antibody
AntiSSA and SSB antibodies
Rheumatoid factor
Paraneoplastic antibodies
Rapid plasma reagin
Genetic screens
Hematology screen to check for anemia
Sequential multiple analysis7 (SMA7) to check renal function and electrolyte imbalances/complete metabolic panel
(CMP)
For more information, see Type 2 Diabetes and TCF7L2.
Electromyography and Nerve Conduction Studies
Nerve conduction studies (NCS) and electromyography (EMG) can document the characteristics of the neuropathy (eg,
axonal, demyelinating) and the localization (eg, mononeuropathy versus radiculopathy or distal neuropathy) and, possibly,
the severity and even prognosis for morbidity. Multiple consensus panels recommend the inclusion of electrophysiologic
testing in the evaluation of diabetic neuropathy. These same panels recommend the use of nerve conduction velocity
(NCV)/EMG procedures in clinical research studies. An appropriate array of electrodiagnostic tests includes both nerve
conduction testing and needle EMG of the most distal muscles usually affected.
Conventional nerve conduction velocity studies
Conventional NCV testing includes measurement of the speed of both motor and sensory conduction. The amplitude of the
distal response is also measured. The proximal component of conduction can be investigated with Hreflex (S1 root) or F
wave (motor pathways only) response.
Needle electromyography
Needle EMG is performed in the distal muscles in cases of generalized neuropathy and entrapment, in the proximal limb
muscles in amyotrophy, and in the paraspinal and limb muscles in suspected radiculopathy. The examiner searches for
abnormal spontaneous potentials, voluntary motor unit recruitment, and motor unit configuration. In weak patients, the
recruitment characteristics can often help distinguish a neuropathic from a myopathic process.
Nerve conduction study findings
Findings on nerve conduction studies depend on the pattern of nerve damage. Patients with distal symmetrical sensorimotor
polyneuropathy from predominant axonal loss have reduced or absent sensory nerve action potentials, especially in the legs.
With progression of neuropathy, compound motor action potential amplitudes may also be reduced and abnormalities may
be observed in the hands. These changes reflect lengthdependent degeneration of largediameter myelinated nerve fibers.
Conduction velocities are generally within the normal range or only mildly slowed in distal symmetrical polyneuropathy. If
conduction velocities are less than 70% of the lower limit of normal, or if conduction block is present, the patient may have
superimposed peripheral nerve demyelination in addition to the more typical axonal loss seen in distal symmetrical
polyneuropathy. Generalized demyelinating changes on nerve conduction studies should prompt further evaluation for CIDP.
Focal slowing of conduction velocity at common sites of entrapment may indicate one of the mononeuropathy syndromes
discussed above.
In patients with diabetes, nerve conduction study abnormalities may be found even in the absence of clinical symptoms of
polyneuropathy. In a prospective study by WalterHöliner et al of 38 children and adolescents with type 1 diabetes, clinical
neurologic examination revealed diabetic peripheral neuropathy in 13.2% of the group, compared with 31.6% of patients
when diagnosis was made using nerve conduction velocity testing. Thus, the latter test demonstrated the widespread
existence of subclinical diabetic peripheral neuropathy in the study’s patients.[110]
Electromyographic sampling of distal lower extremity muscles may reveal acute and ongoing denervation in the form of
positive sharp waves and fibrillation potentials (spontaneous discharges). Reinnervation changes such as largeamplitude,
longduration, and polyphasic motor unit potentials reflect chronicity. Abnormalities in paraspinal muscles (eg, spontaneous
discharges) usually reflect disease in spinal nerve roots.
Some studies have proposed that the severity of electrophysiologic abnormalities not only correlates with symptoms but also
predicts the level of morbidity related to DM. Most authors suggest the NCV results to be stable or worsening over time;
however, in 1998, Tkac found that the NCV levels could improve with glycemic control.[63]
Electrophysiologic Studies
Electrophysiologic studies are the most sensitive, reliable, and reproducible measures of nerve function.[64]
Electrophysiologic findings usually correlate with morphologic changes on nerve biopsy. Common early findings are
abnormal nerve conduction studies or reduced variability of heart rate with deep breathing or Valsalva maneuver. Although
electrodiagnostic studies can characterize and quantitate nerve dysfunction, they cannot distinguish diabetic neuropathy
from neuropathy of other causes.
Composite scores, combining clinical, quantitative sensory,[36] and electrophysiologic measures, are often used in natural
history and efficacy studies. Examples include the Neuropathy Impairment Score in the Lower Limbs + 7 and the Michigan
Diabetic Neuropathy score.[45, 65]
MRI and CT
Plexus MRI may be helpful to exclude other problems (eg, tumor) in patients with radiculoplexus neuropathy syndromes. For
patients who cannot have MRI, CT myelography is an alternative to exclude compressive lesions and other pathology in the
spinal canal. In cranial nerve palsies, brain imaging, usually with MRI, is helpful to exclude intracranial aneurysms,
compressive lesions, and infarcts.
Nuclear Imaging
Scintigraphic techniques are used to detect and quantify cardiac autonomic neuropathy (for research purposes). Techniques
include radiolabeled analogs of norepinephrine, 123Imetaiodobenzylguanidine (MIBG), and 11Chydroxyephedrine.
Adrenergic nerve terminals of the heart actively take up these compounds. Combining this technique with singlephoton
emission computed tomography (SPECT) scanning allows detection of decreased innervation of the heart.
Doppler Imaging
Laser Doppler can be used to measure skin perfusion. In this test, skin blood flow is measured by continuous laser Doppler
assessment in response to several stimuli.
Microdialysis
Microdialysis has been used to study nitric oxide release, which participates in vasodilation of the microvasculature. In this
test, probes are inserted into the dermis (with an ISONO Mark II oxide meter, a microsensor that measures nitric oxide
release from single cells).
Electrocardiography
Electrocardiography may reveal prolongation of the QT interval. This is secondary to imbalance between right and left heart
sympathetic innervation. This abnormality is thought to increase risk of arrhythmias. A screening ECG is advisable for
patients with longstanding DM.
Nerve and Skin Biopsy
A nerve biopsy can be obtained, typically of the sural nerve, to confirm and help diagnose the neuropathic stage (ie, mild,
moderate, severe). However, this is an invasive procedure and carries the risk of producing chronic pain, numbness, and
cold insensitivity in the distribution of the sural nerve. Thus, with NCV/EMG and QST available, the sural nerve biopsy is
rarely needed for diagnostic purposes any longer.
A skin biopsy can be obtained for research purposes only. Immunohistochemistry is used to quantify the cutaneous nerves
to provide a morphologic assessment of diabetic neuropathies. This tool is new for clinical research, and it is used as an
endpoint in diabetic neuropathy. The procedure requires only a 3cm skin biopsy and enables a direct study of small nerve
fibers (ie, Cfibers) that produce pain and temperature sensation.
Biopsy rarely is recommended for clinical purposes. Reasons for this move away from biopsies in clinical trials include the
invasive nature of the procedure with its attendant risks, discomfort to the patient, cost, problems with reproducibility due to
sampling error, and availability of other methods to obtain similar information. This study is performed primarily when the
etiology of the neuropathy is in question or in research settings. Several studies have looked at biopsies, mainly of the sural
nerve in humans. These studies were performed in advanced neuropathy; vessels were found to be thickened, and nerves
were found to have undergone severe damage. Indications of nerve regrowth were small and weak.
Future Approaches
The following additional diagnostic approaches for diabetic neuropathy are currently in use or under intense study. Details of
these techniques are beyond the scope of this review.
Skin punch biopsy/intraepidermal nerve fiber density testing[66] and immunohistochemical staining of peripheral
nerves
Quantitative sensory testing
Imaging using MRI and ultrasonography
Treatment
Approach Considerations
Management of diabetic neuropathy should begin at the initial diagnosis of diabetes. The primary care physician needs to be
alert for the development of neuropathy—or even its presence at the time of initial diabetes diagnosis—because failure to
diagnose diabetic polyneuropathy can lead to serious consequences, including disability and amputation.[67, 68, 69, 70]
Consider any patient with clinical evidence of diabetic peripheral neuropathy to be at risk for foot ulceration, and provide
education on foot care.[71] If necessary, refer the patient to a podiatrist. Admit patients for an infected diabetic foot ulcer or
gangrene.
For more information, see Diabetic Foot.
For more information, see Diabetic Foot Infections.
Patients with diabetic peripheral neuropathy require more frequent followup, with particular attention to foot inspection to
reinforce the need for regular selfcare. The provision of regular foot examinations and reinforcement of the educational
message on foot care have been shown in several studies to significantly reduce rates of ulceration and even amputation.
[72]
The primary care physician is responsible for educating patients about the acute and chronic complications of diabetes,[46]
including the psychological impact of sexual dysfunction in both men and women. The importance of involving a neurologist
(preferably with expertise in peripheral neuropathy) in the treatment of patients with diabetic neuropathy cannot be
overemphasized.
Glycemic Control
Of all treatments, tight and stable glycemic control is probably the most important for slowing the progression of neuropathy.
[73] Because rapid swings from hypoglycemia to hyperglycemia have been suggested to induce and aggravate neuropathic
pain, the stability of glycemic control may be as important as the actual level of control in relieving neuropathic pain. The
Diabetes Control and Complications Trial (DCCT) demonstrated that tight blood sugar control in patients with type 1 diabetes
decreased the risk of neuropathy by 60% in 5 years.[24, 74] The effect of tight glycemic control on polyneuropathy in
patients with type 2 diabetes or those with impaired glucose tolerance/impaired fasting glucose is not as clear and requires
further prospective study.[75]
A 2012 Cochrane review indicates that tight glycemic control prevents the development of clinical neuropathy and reduces
nerve conduction and vibration threshold abnormalities in patients with either type 1 or type 2 diabetes. However, tight
glucose control also increases the risk of severe hypoglycemic episodes, and this should be considered when assessing its
risk/benefit ratio.[76]
Diabetic Neuropathic Pain Management
Many medications are available for the treatment of diabetic neuropathic pain. Oral agents include antidepressants and
anticonvulsant drugs. According to the 2011 guideline issued by the American Academy of Neurology (AAN), American
Academy of Physical Medicine and Rehabilitation (AANEM) and the American Academy of Physical Medicine and
Rehabilitation (AAPMR) guideline for the treatment of painful diabetic neuropathy (PDN), pregabalin is recommended for
treatment of diabetic neuropathic pain. The drug has been proven effective and can improve quality of life. However,
physicians should determine if the drug is clinically appropriate for their patients on a casebycase basis. Gabapentin and
sodium valproate should also be considered for diabetic neuropathy pain management.
According to a Cochrane review evaluating gabapentin for chronic neuropathic pain and fibromyalgia, gabapentin leads to
significant pain relief in patients with chronic neuropathic pain when compared with a placebo. Although patients frequently
experience adverse side effects, these are usually tolerable, and serious side effects were not increased when compared
with side effects associated with the placebo.[77]
According to the 2011 AAN/AANEM/AAPMR guideline, dextromethorphan, morphine sulfate, tramadol, and oxycodone
should be considered for PDN treatment. No one opioid is recommended over another.
Topical therapy with capsaicin or transdermal lidocaine may be useful in some patients, especially those with more localized
pain or those in whom interactions with existing oral medications is a concern. The 2011 AAN/AANEM/AAPMR guideline
recommends that both of these agents be considered in for treatment of PDN. In clinical trials, capsaicin has been effective
in reducing pain in PDN, but many patients cannot tolerate the side effects, such as burning pain on contact with warm/hot
water or in hot weather. Any of these medications may be associated with adverse effects, and patients should be counseled
about possible problems before initiating treatment.[78, 58] Patients should be assessed every 6 weeks so that adverse
effects can be monitored if possible. Decrease or increase drug dose if indicated.
For many of these medications, use for neuropathic pain is offlabel; they were approved by the Food and Drug
Administration for other indications. Many are in the news for questionable side effects (eg, increased blood pressure and
edema from salt retention with fludrocortisones). Nevertheless, multiple clinical studies show benefit for the use of these
medications in the treatment of neuropathic pain. Use of these medications is well within the standard of care in most
medical communities. A number of medications are currently undergoing evaluation in clinical trials. Some are licensed for
use in other countries.
In a review of 6 trials (2220 patients) on duloxetine's effects on painful diabetic peripheral neuropathy (3 trials) and
fibromyalgia (3 trials), Lunn et al concluded that 60 mg of duloxetine daily can relieve the pain of peripheral neuropathy in the
shortterm, calculating a 1.65 risk ratio for a 50% pain reduction at 12 weeks.[79] Adverse events were common and dose
dependent, according to the authors, but serious ones were rare. The 2011 AAN/AANEM/AAPMR guideline recommends
considering the antidepressants amitriptyline, venlafaxine, and duloxetine for the treatment of PDN, although data are
insufficient to recommend one of these agents over the others.
There was no difference identified between gabapentin and tricyclic antidepressants in the achievement of pain relief of
diabetic neuropathy or postherpetic neuralgia in a study by Chou et al. The authors performed a metaanalysis of headto
head trials comparing the results of gabapentin and tricyclic antidepressants for pain relief in diabetic neuropathy.[80] .
Pregabalin has similar efficacy as gabapentin for most part.
Pain Control in Pregnancy
During pregnancy, prescribing medicine for pain control is difficult. The best hope for pain control in rare cases of young
women with severe neuropathy is to control their blood glucose diligently and try to control pain with acetaminophen. At the
end of the third trimester, the physician can prescribe amitriptyline, gabapentin, and other medications as indicated if the
benefit clearly outweighs the risk to the fetus. Physical therapy may be effective in pregnant patients by increasing their
circulation.
To see complete information on Diabetes Mellitus and Pregnancy, please visit our main article.
Diabetic Gastroparesis
Erythromycin and metoclopramide are used to treat diabetic gastroparesis. Additionally, MiraLax (polyethylene glycol 3350)
is gaining increasing popularity as the firstline agent for severe constipation and lower motor unit bowel.[43]
A newer agent, tegaserod (Zelnorm), may be helpful in patients with chronic ileus. In early 2010, however, tegaserod
marketing was suspended because of a metaanalysis showing an excess number of serious cardiovascular adverse events,
including angina, myocardial infarction, and stroke, in those taking tegaserod compared with placebo. Tegaserod is currently
available only on an emergency basis. For more information, see the FDA Postmarket Drug Safety Information for Patients
and Providers.
Dietary Supplements
Vitamin supplementation is being studied to see if that can have an impact. One study of zinc sulfide showed improvement in
glycemic control in 60 patients.[81] Certain B vitamins are often prescribed in an attempt to reduce paresthesias.
Experimental Therapies
Aldose reductase inhibitors
Aldose reductase inhibitors block the ratelimiting enzyme in the polyol pathway that is activated in hyperglycemic states.
Numerous studies of aldose reductase inhibitors (eg, alrestatin, sorbinil, tolrestat, epralrestat) have been published in the
past 30 years, but many of the earlier trials had problems related to poor study design (eg, enrolling patients with advanced
neuropathy who were unlikely to benefit from treatment).
These medications are not currently available in the United States.[82, 83] Epralrestat is currently marketed only in Japan.
Epalrestat reduces intracellular sorbitol accumulation, which has been implicated in the pathogenesis of lateonset
complications of diabetes mellitus. Epalrestat 150 mg/day for 12 weeks improved motor and sensory nerve conduction
velocity and vibration threshold compared with baseline and placebo in patients with diabetic neuropathy. Subjective
symptoms, including pain, numbness, hyperesthesia, coldness in the extremities, muscular weakness, dizziness, and
orthostatic fainting, were also improved.[84, 85]
Alphalipoic acid
In a multicenter placebocontrolled trial of the antioxidant alphalipoic acid, Ziegler and colleagues reported shortterm
symptomatic relief of neuropathy symptoms in patients with type 2 diabetes and symptomatic neuropathy.[18] Other studies
of this drug are ongoing.
Actovegin
A deproteinized derivative of calf blood, actovegin contains inorganic substances (eg, electrolytes, trace elements) and
organic components (eg, amino acids, oligopeptides, nucleosides, glycosphingolipids). Actovegin also contains inositol
phosphooligosaccharides (IPOs), which are thought to elicit central and peripheral insulin effects. Ziegler et al found that
treatment with actovegin improved neuropathic symptoms, vibration perception threshold, sensory function, and quality of life
in 567 patients with type 2 diabetes mellitus and diabetic polyneuropathy. In this multicenter, randomized, doubleblind trial,
sequential intravenous (2000 mg/d) and oral (1800 mg/d) actovegin treatment was given over 160 days.[78]
Spinal cord stimulators and other therapies
Pain medicine specialists have been experimenting with spinal cord stimulator implants in severely painful cases.[86] One
such study of 10 patients showed that median background and peak pain scores at the end of the study were, respectively,
77 and 81 with the stimulator off and 23 and 20 with the stimulator on. Exercise tolerance significantly improved at 3 months
(n = 7, median increase 85%) and at 6 months. Further study is necessary.[87] Alternative and complementary therapies for
pain (eg, acupuncture) are under investigation.[88, 21]
Treatment of Autonomic Dysfunction
Erectile dysfunction
Although several modalities are available, erectile dysfunction from diabetic neuropathy is a very difficult condition to treat.
All other causes of impotence must be excluded. Once the diagnosis has been confirmed, the oral agent sildenafil Viagra)
and related phosphodiesterase type 5 (PDE5) inhibitors can be used (if not contraindicated in the patient). Older methods
such as vacuum devices or intracavernosal papaverine injections may be tried. Referral to a urologist is suggested.
Symptomatic orthostatic hypotension can be troubling in patients with diabetic neuropathy. Increasing the dietary fluid and
salt intake, along with use of compression stockings, may help. If these modalities do not improve symptoms, then
medication may help.[50]
Gustatory sweating
Glycopyrrolate is an antimuscarinic compound that can be used for the treatment for diabetic gustatory sweating. When
applied topically to the affected area, it results in a marked reduction in sweating while eating a meal.
Surgical Treatment
Surgery is indicated in patients with infected foot ulcers when the infection cannot be controlled medically. Aggressive
debridement or amputation may be necessary if signs of necrosis or infection do not improve with IV antibiotics.[89, 90]
Jejunostomy may be performed in patients with intractable gastroparesis (ie, severe nausea and vomiting, severe weight
loss). This will allow patients to be fed enterally, bypassing the paralytic stomach.
When impotence is a continual problem, the patient may pursue the option of a penile prosthesis.
The feet of patients with DM often become insensate and are highly susceptible not only to ulcers but also to the Charcot
foot (ie, a foot that loses its structure secondary to trauma and acute arthropathy) from frequent and multiple traumas.
Charcot foot, which occurs not only in diabetic peripheral neuropathy but in other types of severe neuropathy as well, can be
treated with bracing or special boots. In some cases, surgery is used to correct the deformity.[91, 92]
For more information, see Perioperative Management of the Diabetic Patient.
For more information, see Diabetic Foot.
For more information, see Diabetic Foot Infections.
Pancreatic Transplantation
Pancreatic transplantation in patients with diabetes and endstage renal disease can stabilize neuropathy and in some
instances improve motor, sensory, and autonomic function for as long as 48 months after uremia plateaus.[72]
Rehabilitation
Physical therapy
Physical therapy may be a useful adjunct to other therapy, especially when muscular pain and weakness are a manifestation
of the patient's neuropathy. The physical therapist can instruct the patient in a general exercise program to maintain his or
her mobility and strength. An aquatic therapist can also be helpful.
The patient also should be educated on independent pain management and relaxation strategies to assist with pain control.
Transcutaneous electrical nerve stimulation (TENS) may be a recommended modality for patients with neuropathic pain, and
the physical therapist can be helpful in teaching and monitoring the patient in its use. In a 1999 case report, Somers and
Somers found that application of TENS to the skin of the lumbar region was an effective treatment for the pain of diabetic
neuropathy, but no controlled studies have confirmed this finding.[93] The 2011 AAN/AANEM/AAPMR guideline supports
TENS as probably effective as a treatment for PDN.[94]
In cases of foot ulcers, physical therapy may be indicated for wound care. Treatments may consist of whirlpool, Unna boots
(if necessary, although not commonly used), and debridement. For patients with autonomic neuropathy, balance training and
fall prevention education is paramount.
Brace assessment and orthotic or prosthetic training are useful when appropriate, and walkingaid assessment and
implementation may be necessary.
Occupational therapy
Occupational therapy may be necessary in cases where there is severe loss of functional status. When only the lower limbs
are involved, patients may need home modifications and equipment. When the upper limbs are involved, patients may need
more extensive functional restoration and adaptive equipment. When secondary complications require amputation of a limb,
even more intensive functional retraining is required.
Speech therapy
Involvement of a speech therapist rarely is indicated, but professionals from this discipline can help with patients affected by
gastroparesis or dysphagia.
Recreational therapy
A recreational therapist may help the patient with performance of community activities. Many patients with chronic disease,
especially elderly patients, become isolated and are at risk for comorbid conditions such as depression.
Complications of Disease
Peripheral neuropathy can lead to foot ulcers and leg amputations. When a foot ulcer shows signs of infection (eg, thick
yellow drainage, erythema around the wound, fever, necrotic tissue), the patient often fares much better by being admitted to
a hospital, having the extent of infection assessed (eg, with MRI), and receiving IV antibiotics and foot debridement (if
necessary).
Autonomic neuropathy is associated with dizziness and falling with resultant injuries, nausea and vomiting, severe diarrhea,
and dehydration, all of which can lead to hyperosmolar nonketotic diabetic coma or diabetic ketoacidosis and death.
Cardiovascular autonomic neuropathy can cause death.
Consultations
Most diabetic patients benefit from consultation with an endocrinologist at periodic intervals, and those with more brittle
diabetes may benefit from regular endocrinology consultations to assist in diabetes management.
Patients with diabetes who develop neuropathy should see a neurologist early in the course of neuropathy. Patients with
neuropathy symptoms or signs that seem out of proportion to the severity of diabetes should be evaluated by a neurologist
to help exclude other underlying causes of neuropathy.
Physical medicine and rehabilitation physicians provide a functionalbased comprehensive evaluation and treatment
program for patients with diabetic neuropathy. Ulcer management may warrant consultation with a specialist at a wound
clinic or perhaps a vascular surgeon. A cardiologist should monitor patients who have electrocardiographic abnormalities
and/or suggestion of cardiac autonomic neuropathy. A gastroenterologist can monitor patients with intractable GI problems,
such as gastroparesis and diarrhea.
Consultation with the appropriate specialist is also advisable if there are questions about the diagnosis of a particular form of
neuropathy, or if the patient does not tolerate firstline medications.
LongTerm Monitoring
Patients with diabetic neuropathy should have regular monitoring by a primary care physician. Patients should be monitored
every 4 weeks to 3 months to try to assess whether therapy is working to decrease pain or nausea or vomiting and also to
taper off medications for painful peripheral neuropathy. Objective measures of function and improvement should be taken at
every visit. Examine the patient's feet and assess with monofilament and tuning fork on every visit when the patient comes in
for DM care. Monitoring patients closely for glycemic control is essential.[65]
Confocal microscopy of the cornea lends itself to longitudinally assessing progression of neuropathy. Furthermore,
improvements in risk factors such as glycated hemoglobin (HbA1c) levels may be associated with morphological repair of
nerve fibers.[95]
Medication
Medication Summary
For the treatment of diabetic neuropathy, acute cases may be able to be managed with standard analgesics, but other
agents will likely be necessary for chronic pain. Occasionally, muscle relaxants may be of benefit in the first 2 weeks of
therapy.
Each type of pain or a combination of pain types should be treated. Reevaluation of the painful neuropathy should be
performed every 6 weeks.[96] Every effort should be made to taper and eventually to stop therapies. Therapies may need to
be reinstated at later dates if symptoms flare up.
The pharmacologic agents listed below are commonly used for the symptomatic treatment of diabetic neuropathy. Most are
not specifically approved by the United States Food and Drug Administration for this use, however.[18, 80, 82, 83, 67, 25,
20, 97, 98, 99]
Nonsteroidal AntiInflammatory Drugs (NSAIDs)
Class Summary
In patients with acute painful neuropathy, simple analgesics such as nonsteroidal antiinflammatory drugs [NSAIDs] and
acetaminophen may provide pain control.[96] They also may be used as firstline therapy in painful peripheral neuropathy.
With chronic painful neuropathy, simple analgesics are typically not effective. More often, chronic neuropathic pain requires
treatment with offlabel medications.
Ibuprofen (Advil, Motrin IB)
NSAIDs may help decrease inflammation caused by diabetic neuropathy. They also decrease pain.
Naproxen (Naprosyn)
For relief of mildtomoderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which
results in a decrease of prostaglandin synthesis.
Analgesic, Topical
Class Summary
Identifying the type of pain can direct the course of therapy. Dysesthetic pain can be relieved with capsaicin cream (Dolorac,
Capsin, Zostrix) applied qid. Capsaicin cream may cause pain during the initial few applications; patients need to be made
aware of this potential effect. Additionally, few patients comply with the frequent dosing, and the cream is messy on socks
and shoes. Several recent studies have advocated topical administration of lidocaine as treatment of postherpetic neuralgia.
Lidocaine gel (5%) in placebocontrolled study showed significant relief in 23 patients studied. Lidocaine tape also decreases
severity of pain.
Capsaicin cream (Zostrix)
Natural chemical derived from plants of Solanaceae family. By depleting and preventing reaccumulation of substance P in
peripheral sensory neurons, may render skin and joints insensitive to pain. Substance P thought to be chemomediator of
pain transmission from periphery to CNS.
Anticonvulsant
Class Summary
Gabapentin (Neurontin) has been reported to work excellently in the treatment of dysesthetic pain.[97] Carbamazepine
(Tegretol, Carbatrol, Epitol) has been used mainly for partial seizures and can be used in peripheral neuropathy as a third
line agent if all other agents fail to reduce or improve symptoms of diabetic neuropathy. Carbamazepine is a potentially
effective treatment for chronic neuropathic pain.[100] However, the studies evaluating carbamazepine for chronic
neuropathic pain must be interpreted with caution.
Pregabalin (Lyrica) is approved for the treatment of pain due to generalized diabetic peripheral neuropathy and may be
considered as a firstline agent in diabetic peripheral neuropathic pain.[101]
In October 2017, the FDA approved Lyrica CR (pregabalin extendedrelease tablets) for the treatment of diabetic peripheral
neuropathy, as well as postherpetic neuralgia. The agency based its approval of the drug, which is taken once daily, on the
success of a randomized, placebocontrolled trial involving patients with postherpetic neuralgia, with pain intensity improving
by at least 50% in 73.6% of those patients treated with Lyrica CR and in 54.6% of patients in the placebo group.[102]
According to the 2011 American Academy of Neurology (AAN)/American Association of Neuromuscular and
Electrodiagnostic Medicine (AANEM)/American Academy of Physical Medicine and Rehabilitation (AAPMR) guideline,
lamotrigine (Lamictal) should probably not be recommended for diabetic neuropathy treatment due to relative inefficacy in
pain control when compared with placebo.[103]
Gabapentin (Neurontin)
Excellent in treating pain described as dysesthetic, such as burning or pins and needles. Gabapentin should be used after all
other firstline measures have been used without relief. This drug is a secondgeneration anticonvulsant. Gabapentin
increases brain GABA levels, binds to the alpha2delta subunit of voltagegated calcium channels, and inhibits branched
chain amino acid transferase.
Carbamazepine (Tegretol, Carbatrol, Epitol)
AED used mainly in partial seizures. Can be used in peripheral neuropathy as a thirdline agent if all other agents fail to
reduce or improve symptoms of diabetic neuropathy.
Firstgeneration anticonvulsant. Slows the recovery rate of voltagegated Na channels, minor Ca2+ channel antagonist
effect, and is related chemically to tricyclic antidepressants.
Pregabalin (Lyrica, Lyrica CR)
FDA approved for the treatment of pain due to generalized diabetic peripheral neuropathy. The FDA has also approved the
oncedaily treatment Lyrica CR (pregabalin extendedrelease tablets) for the pain of diabetic peripheral neuropathy.
Pregabalin is excellent in treating pain described as dysesthetic, such as burning or pins and needles. It may be considered
as a firstline agent in diabetic peripheral neuropathic pain. This drug is also a secondgeneration anticonvulsant. Pregabalin
binds to the alpha2delta subunit of voltagegated calcium channels and inhibits branched chain amino acid transferase.
This reduces inappropriate calcium influx into a hypersensitized cell.
Phenytoin (Dilantin)
May stabilize neuronal membranes and treat neuralgia by increasing efflux or decreasing influx of sodium ions across cell
membranes in motor cortex during generation of nerve impulses. When serum level in or near therapeutic range, adjust dose
in 30 to 50mg increments. Smalldose increments may cause greater than expected increases in serum concentration (ie,
MichaelisMenten drug kinetics). Steadystate serum levels may take up to 3 wk to occur because halflife is concentration
dependent.
Antidepressant, Tricyclic
Class Summary
For paresthetic pain, tricyclic antidepressants such as imipramine (Tofranil), nortriptyline (Pamelor, Aventyl), and amitriptyline
(Elavil) have been shown to be useful as analgesics for paresthetic pain.[99]
Amitriptyline (Elavil)
By inhibiting reuptake of serotonin and/or norepinephrine by presynaptic neuronal membrane, may increase synaptic
concentration in CNS. Useful as analgesic for certain types of chronic and neuropathic pain.
Imipramine (Tofranil)
This is the original TCA used for depression. These agents have been suggested to act by inhibiting reuptake of
norepinephrine at synapses in central descending pain modulating pathways located in the brainstem and spinal cord.
Nortriptyline (Pamelor, Aventyl HCl)
Has demonstrated effectiveness in treatment of chronic pain; by inhibiting reuptake of serotonin and/or norepinephrine by
presynaptic neuronal membrane, may increase synaptic concentration in CNS; pharmacodynamic effects such as
desensitization of adenyl cyclase and downregulation of betaadrenergic receptors and serotonin receptors also appear to
be involved in mechanisms of action.
Antidepressant, Selective Serotonin/norepinephrine Reuptake Inhibitor
(ssnri)
Class Summary
Duloxetine (Cymbalta) was the first medication to be approved specifically for the treatment of diabetic neuropathy.
Venlafaxine (Effexor) has been recommended by the AAN/AANEM/AAPMR guidelines for consideration in diabetic
neuropathy pain management.[104]
Duloxetine (Cymbalta)
Indicated for diabetic peripheral neuropathic pain. Potent inhibitor of neuronal serotonin and norepinephrine reuptake.
Antidepressant, Serotonin Reuptake Inhibitor
Class Summary
Paroxetine (Paxil) can be used as secondline or thirdline treatment of painful diabetic neuropathy and is helpful in patients
who are already depressed. Citalopram (Celexa) can be used as a second or thirdline therapy in neuropathy resulting from
paresthesia.[99]
Citalopram (Celexa)
One of the newest antidepressants can be used as a second or thirdline therapy in neuropathy resulting from paresthesia.
Paroxetine (Paxil)
SSRI that can be used in secondline or thirdline treatment of painful diabetic neuropathy; good for patients who already are
depressed.
Antiarrhythmic Agent, Class Ib
Lidocaine anesthetic (Lidoderm)
Several recent studies have advocated topical administration of lidocaine as treatment of postherpetic neuralgia. Lidocaine
gel (5%) in placebocontrolled study showed significant relief in 23 patients studied. Lidocaine tape also decreases severity
of pain.
Prokinetic Agents
Class Summary
Medications for diabetic gastroparesis are erythromycin (EMycin, Erythrocin, EryTab, E.E.S.), cisapride (Propulsid), and
metoclopramide (Reglan, Maxolon, Clopra). However, in 2009 the FDA issued a black box warning that longterm use of
metoclopramide has been linked to the development of tardive dyskinesia.[105]
Erythromycin (EryTab)
Macrolide antibiotic that duplicates the action of motilin, which is responsible for the migrating motor complex activity. Binds
to and activates motilin receptors. IV administration of this drug enhances the emptying rate of both liquids and solids. Effect
can be seen with PO erythromycin. Substitution of the entericcoated form may be tolerated better by the patient.
Metoclopramide (Reglan)
Dopamine antagonist that stimulates acetylcholine release in the myenteric plexus. Acts centrally on chemoreceptor triggers
in the floor of the fourth ventricle, which provides important antiemetic activity; side effects and tachyphylaxis are problems.
Antidepressant, Tetracyclic
Desipramine (Norpramin)
These agents have been suggested to act by inhibiting reuptake of noradrenaline at synapses in central descending pain
modulating pathways located in the brainstem and spinal cord.
Synthetic Adrenocortical Steroids
Class Summary
Florinef is used in severely symptomatic orthostatic hypotension. Use if salt tablets and pressure stockings fail to alleviate
hypotension.
Fludrocortisone acetate (Florinef)
Used to increase standing blood pressure. Acts to increase sodium retention and expand plasma volume.
Cholinergic Agent
Bethanechol hydrochloride
Used for selective stimulation of the bladder to produce contraction to initiate micturition and empty the bladder. Found to be
most useful in patients who have bladder hypocontractility, provided they have functional and coordinated sphincters. Rarely
used due to difficulty in timing effect and because of gastrointestinal stimulation.
Laxative, Bowel Evacuant
Polyethylene glycol (PEG) solution (MiraLax, GlycoLax)
For treatment of occasional constipation. In theory, less risk of dehydration or electrolyte imbalance with isotonic
polyethylene glycol compared with hypertonic sugar solutions. Laxative effect generated because polyethylene glycol is not
absorbed and continues to hold water by osmotic action through small bowel and colon, resulting in mechanical cleansing.
Questions & Answers
Overview
What are the signs and symptoms of diabetic neuropathy?
What should the physical exam of diabetic neuropathy include?
What is the modified Thomas classification system for diabetic neuropathy?
How is distal symmetrical sensorimotor polyneuropathy defined?
How common is pure autonomic diabetic neuropathy?
What are asymmetrical diabetic neuropathies?
How is diabetic polyneuropathy staged?
Which lab tests may be helpful in the diagnosis of diabetic neuropathy?
Which imaging modalities may be considered for the diagnosis of diabetic neuropathy?
What are the key components of diabetic neuropathy management?
Which autonomic dysfunctions must be managed in patients with diabetic neuropathy?
What are the surgical options for diabetic neuropathy?
How is diabetic neuropathy defined?
What is the frequency of diabetic neuropathy?
What are secondary complications of diabetic neuropathy?
What are the manifestations of diabetic neuropathy?
What is the role of electrophysiologic testing in the evaluation of diabetic neuropathy?
How is diabetic neuropathy managed?
What are the treatment options for diabetic neuropathy?
How are peripheral neurons categorized in diabetic neuropathy?
What is the anatomy of motor neurons in diabetic neuropathy?
What is the anatomy of sensory neurons in diabetic neuropathy?
What is the anatomy of autonomic neurons in diabetic neuropathy?
What are the subdivision of sensory neurons in diabetic neuropathy?
What are the risk factors for the development of diabetic neuropathy?
What is the role of hyperglycemia in the pathophysiology of diabetic neuropathy?
What is the role of advanced glycation end products (AGEs) in the pathophysiology of diabetic neuropathy?
What is the role of oxidative stress in the pathophysiology of diabetic neuropathy?
What are contributing factors to the development of focal or asymmetrical diabetic neuropathy syndromes?
What are the risk factors associated with severe symptoms of diabetic neuropathy?
How do symptoms of diabetic neuropathy develop?
What is the most common etiologic mechanism of diabetic neuropathy?
What is the association between impaired glucose tolerance and diabetic peripheral neuropathy?
What are the roles of poor glycemic control, nerve conduction loss, and lipid metabolism changes in the etiology of diabetic
peripheral neuropathy?
What is the association between variability in fasting plasma glucose and diabetic peripheral neuropathy?
What is the role of obstructive sleep apnea (OSA) in the etiology of diabetic neuropathy?
What is the odds ratio for peripheral neuropathy in patients with type 2 diabetes versus those with type 1?
What is the prevalence of diabetic neuropathy in the US?
Why is there variability in US prevalence data for diabetic neuropathy?
What is the global prevalence of diabetic neuropathy?
What are the racial predilections for diabetic neuropathy?
How does the prevalence of diabetic neuropathy vary by sex?
How does the prevalence of diabetic neuropathy vary by age?
What is the prognosis of untreated diabetic neuropathy?
What are the limitations of diabetic neuropathy treatments?
What is the mortality rate for diabetic neuropathy?
How does tertiary care affect the outcomes of diabetic neuropathy?
What is the role of diet and nutrition in the management of diabetic neuropathy?
What activity modifications are needed for patients with diabetic neuropathy?
What information about diabetic neuropathy should patients be given?
What foot protection and care instructions should patients with diabetic neuropathy receive?
What are the ophthalmologic and renal conditions associated with diabetic neuropathy?
Where should patient education for diabetic neuropathy be given?
How does diabetic neuropathy occur?
What are the symptoms of diabetic neuropathy?
How is the pain of diabetic neuropathy characterized?
How is diabetic neuropathy prevented?
How is diabetic neuropathy treated?
What are the selfcare measures for diabetic neuropathy?
What is the duration of diabetic neuropathy symptoms?
Presentation
What should be the focus of history for diabetic neuropathy?
What are the sensory symptoms of diabetic neuropathy?
What are the motor symptoms of diabetic neuropathy?
What is the most common presentation of diabetic neuropathy?
What are the autonomic symptoms of diabetic neuropathy?
What are the GI symptoms of diabetic neuropathy?
What are the cardiovascular symptoms of diabetic neuropathy?
What are the symptoms of bladder neuropathy in patients with diabetes?
What are the sudomotor symptoms of diabetic neuropathy?
What is included in the physical exam of patients with diabetic neuropathy?
What is the role of pinprick testing in the assessment of diabetic neuropathy?
How is vibratory sense in the feet assessed in diabetic neuropathy?
How are deep tendon reflexes assessed in diabetic neuropathy?
What is the focus of skin exam in diabetic neuropathy?
What does a finding of paresthesias suggest in the assessment of diabetic neuropathy?
How is cranial nerve testing performed in patients with diabetic neuropathy?
What should be included in an annual screening for diabetic neuropathy?
When is specialized autonomic testing indicated in the assessment of diabetic neuropathy?
How is blood pressure measured in the assessment of diabetic neuropathy?
What are the classification systems for diabetic neuropathy?
What is the Thomas system for classification of diabetic neuropathy?
What are the broad classifications used for diabetic neuropathy?
What are the criteria used to define distal symmetrical sensorimotor diabetic polyneuropathy?
What is chronic symmetrical diabetic neuropathy?
What is the progression of symptoms for chronic symmetrical diabetic neuropathy?
What is smallfiber diabetic neuropathy?
What are some manifestations of autonomic diabetic neuropathy?
What is diabetic neuropathic cachexia?
What are the subtypes of asymmetrical diabetic neuropathy?
How are asymmetrical diabetic differentiated from distal diabetic neuropathy?
What is cranial diabetic mononeuropathy?
What are manifestations of facial diabetic neuropathy?
What are manifestations of anterior ischemic optic diabetic neuropathy?
What are somatic diabetic mononeuropathies?
What are the signs and symptoms of diabetic thoracic radiculoneuropathy?
Where in the body does diabetic radiculoplexus neuropathy occur?
What are the symptoms of diabetic radiculoplexus neuropathy?
How is the severity of diabetic neuropathy assessed?
How is diabetic neuropathy staged?
DDX
What is required to establish the diagnosis of diabetic neuropathy?
What are the differential diagnoses for cranial diabetic mononeuropathy?
What are the differential diagnoses for thoracoabdominal diabetic neuropathy?
What are the differential diagnoses for diabetic lumbosacral radiculoplexopathy?
What are the differential diagnoses for peripheral diabetic neuropathy?
What are the differential diagnoses for cardiovascular autonomic neuropathy?
What are the differential diagnoses for GI diabetic neuropathy?
What are the differential diagnoses for bladder dysfunction in diabetic neuropathy?
What are the differential diagnoses for diabetic mononeuropathy?
What are the differential diagnoses for Diabetic Neuropathy?
Workup
Which lab tests are used to screen for diabetic neuropathy?
What is the role of imaging studies in the diagnosis of diabetic neuropathy?
What is the role of electrophysiologic testing in the diagnosis of diabetic neuropathy?
What is the accuracy of screening tools used for diabetic neuropathy?
What is the role of hemoglobin A1c measurement and fasting plasma glucose testing in the diagnosis of diabetic
neuropathy?
Which tests are used to exclude common causes of neuropathy other than diabetes?
What is the role of nerve conduction studies (NCS) and electromyography (EMG) in the diagnosis of diabetic neuropathy?
What is the role of nerve conduction velocity (NCV) studies in the diagnosis of diabetic neuropathy?
What is the role of needle electromyography (EMG) in the diagnosis of diabetic neuropathy?
Which nerve conduction study findings are characteristic of diabetic neuropathy?
Which findings on electromyographic samplings are characteristic of diabetic neuropathy?
How are electrophysiologic studies used for the diagnosis of diabetic neuropathy?
What is the role of MRI and CT scanning in the diagnosis of diabetic neuropathy?
What is the role of nuclear imaging in the diagnosis of diabetic neuropathy?
What is the role of Doppler imaging in the diagnosis of diabetic neuropathy?
What is the role of microdialysis in the diagnosis of diabetic neuropathy?
What is the role of electrocardiography in the diagnosis of diabetic neuropathy?
What is the role of nerve biopsy in the diagnosis of diabetic neuropathy?
What is the role of skin biopsy in the diagnosis of diabetic neuropathy?
Why are biopsies rarely recommended for the diagnosis of diabetic neuropathy?
Which diagnostic approaches for diabetic neuropathy are investigational?
Treatment
When should the management of diabetic neuropathy begin?
What complications are at increased risk with diabetic peripheral neuropathy?
What is included in the followup of patients with peripheral diabetic neuropathy?
What is the role of a primary care physicians in the treatment of diabetic neuropathy?
What is the role of glycemic control in the treatment of diabetic neuropathy?
Which medications are used in the treatment of diabetic neuropathic pain?
What is the role of gabapentin in the treatment of diabetic neuropathy?
What are the AAN/AANEM/AAPMR treatment guidelines for painful diabetic neuropathy (PDN)?
What are the AAN/AANEM/AAPMR guidelines for topical treatment used for painful diabetic neuropathy (PDN)?
What are the advantages and disadvantages of administering offlabel medications to treat diabetic neuropathic?
What is the role of duloxetine in the treatment of diabetic neuropathy?
What are the differences in efficacy between gabapentin and tricyclic antidepressants for the treatment of diabetic
neuropathic pain?
Which medications are used to control diabetic neuropathic pain during pregnancy?
Which medications are used to treat gastroparesis in diabetic neuropathy?
What is the role of dietary supplements in the treatment of diabetic neuropathy?
What is the role of aldose reductase inhibitors in the treatment of diabetic neuropathy?
What is the role of alphalipoic acid in the treatment of diabetic neuropathy?
What is the role of actovegin in the treatment of diabetic neuropathy?
What is the role of spinal cord stimulator implants in the treatment of diabetic neuropathy?
How is erectile dysfunction due to diabetic neuropathy treated?
How is symptomatic orthostatic hypotension due to diabetic neuropathy treated?
How is gustatory sweating in diabetic neuropathy treated?
When is surgery indicated in the treatment of diabetic neuropathy?
What is the role of jejunostomy in the treatment of diabetic neuropathy?
When is penile prosthesis indicated in the treatment of diabetic neuropathy?
How are feet complications of diabetic neuropathy treated?
What are the benefits of pancreatic transplantation for treatment of diabetic neuropathy?
What is the role of physical therapy in the treatment of diabetic neuropathy?
What is the role of transcutaneous electrical nerve stimulation (TENS) in the treatment of diabetic neuropathy?
When is physical therapy indicated in the treatment of foot ulcers due to diabetic neuropathy?
What are some therapies used to improve balance in patients with diabetic neuropathy?
When is occupational therapy indicated in the treatment of diabetic neuropathy?
When is speech therapy indicated in the treatment of diabetic neuropathy?
What is the role of recreational therapy in the treatment of diabetic neuropathy?
What are possible complications of peripheral diabetic neuropathy?
What are possible complications of autonomic diabetic neuropathy?
What is the role of an endocrinologist in the management of diabetic neuropathy?
When is a neurology consultation indicated in the management of diabetic neuropathy?
What are the benefits of physical medicine and rehabilitation in the management of diabetic neuropathy?
When are specialist consultations needed in the management of diabetic neuropathy?
What is included in the longterm monitoring of diabetic neuropathy?
Medications
Which medications are used in the treatment of diabetic neuropathy?
Which medications in the drug class Nonsteroidal AntiInflammatory Drugs (NSAIDs) are used in the treatment of Diabetic
Neuropathy?
Which medications in the drug class Analgesic, Topical are used in the treatment of Diabetic Neuropathy?
Which medications in the drug class Anticonvulsant are used in the treatment of Diabetic Neuropathy?
Which medications in the drug class Antidepressant, Tricyclic are used in the treatment of Diabetic Neuropathy?
Which medications in the drug class Antidepressant, Selective Serotonin/norepinephrine Reuptake Inhibitor (ssnri) are used
in the treatment of Diabetic Neuropathy?
Which medications in the drug class Antidepressant, Serotonin Reuptake Inhibitor are used in the treatment of Diabetic
Neuropathy?
Which medications in the drug class Antiarrhythmic Agent, Class Ib are used in the treatment of Diabetic Neuropathy?
Which medications in the drug class Prokinetic Agents are used in the treatment of Diabetic Neuropathy?
Which medications in the drug class Antidepressant, Tetracyclic are used in the treatment of Diabetic Neuropathy?
Which medications in the drug class Synthetic Adrenocortical Steroids are used in the treatment of Diabetic Neuropathy?
Which medications in the drug class Cholinergic Agent are used in the treatment of Diabetic Neuropathy?
Which medications in the drug class Laxative, Bowel Evacuant are used in the treatment of Diabetic Neuropathy?

Contributor Information and Disclosures
Author
Dianna Quan, MD Professor of Neurology, Director of Electromyography Laboratory, University of Colorado School of
Medicine

Dianna Quan, MD is a member of the following medical societies: American Academy of Neurology, American Association of
Neuromuscular and Electrodiagnostic Medicine, American Neurological Association

Disclosure: Nothing to disclose.
Coauthor(s)
Helen C Lin, MD Assistant Professor of Neurology, Medical College of Wisconsin

Helen C Lin, MD is a member of the following medical societies: American Academy of Neurology, American Association of
Neuromuscular and Electrodiagnostic Medicine

Chief Editor
Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology,
Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern
Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical
Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Acknowledgements
Neil A Busis, MD Chief, Division of Neurology, Department of Medicine, Head, Clinical Neurophysiology Laboratory,
University of Pittsburgh Medical CenterShadyside
Neil A Busis, MD is a member of the following medical societies: American Academy of Neurology and American Association
of Neuromuscular and Electrodiagnostic Medicine
Milind J Kothari, DO Professor and ViceChair, Department of Neurology, Pennsylvania State University College of Medicine;
Consulting Staff, Department of Neurology, Penn State Milton S Hershey Medical Center
Milind J Kothari, DO is a member of the following medical societies: American Academy of Neurology, American Association
of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy;
EditorinChief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
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Diabetic Neurophaty

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Diabetic Neurophaty

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12/13/2018 https://emedicine.medscape.

Fiber Type Size Modality Myelination

Aalpha (I) 1320 micrometers Limb proprioception Yes

Abeta (II) 612 micrometers Limb proprioception, vibration, pressure Yes

Adelta (III) 15 micrometers Mechanical sharp pain Yes

C (IV) 0.21.5 micrometers Thermal pain, mechanical burning pain No

Você também pode gostar

Diabetic Neurophaty

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Diabetic Neurophaty

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12/13/2018 https://emedicine.medscape.

Fiber Type Size Modality Myelination

A­alpha (I) 13­20 micrometers Limb proprioception Yes

A­beta (II) 6­12 micrometers Limb proprioception, vibration, pressure Yes

A­delta (III) 1­5 micrometers Mechanical sharp pain Yes

C (IV) 0.2­1.5 micrometers Thermal pain, mechanical burning pain No

Você também pode gostar

Aalpha (I) 1320 micrometers Limb proprioception Yes

Abeta (II) 612 micrometers Limb proprioception, vibration, pressure Yes

Adelta (III) 15 micrometers Mechanical sharp pain Yes

C (IV) 0.21.5 micrometers Thermal pain, mechanical burning pain No