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Diabetic neuropathy

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Updated 2024 ADA guidelines for the diagnosis and management of diabetic neuropathy.



Diabetic neuropathy is a type of neuropathy that occurs due to microvascular disease and chronic hyperglycemia in diabetic patients.
Diabetic neuropathy is caused by persistent hyperglycemia, microvascular insufficiency, oxidative and nitrosative stress, defective neurotropism, and autoimmune-mediated nerve destruction in patients with diabetes mellitus.
The incidence of diabetic neuropathy is estimated at 17.8 per 100,000 person-years in the United Kingdom.
Disease course
Nerve damage leads to hyperalgesia, dysesthesia, allodynia, weakness, numbness, hypoalgesia, anomalies in thermal sensation and autonomic function, foot ulcerations, gangrene, and amputations.
Prognosis and risk of recurrence
Diabetic neuropathy is associated with a 1.7-12-fold higher risk of amputation. In addition, autonomic neuropathy is associated with a mortality rate of approximately 25-50% at 5-10 years.


Key sources

The following summarized guidelines for the evaluation and management of diabetic neuropathy are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024), the American Diabetes Association (ADA 2024), the American Academy of Neurology (AAN 2022,2010), the Diabetes Canada (DC 2018), and the European Federation of Neurological Societies (EFNS 2010). ...
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Screening and diagnosis

Indications for screening, adults: as per ADA 2024 guidelines, screen for diabetic peripheral neuropathy starting at diagnosis of T2DM and 5 years after the diagnosis of T1DM, and at least annually thereafter.
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  • Indications for screening (children)

Diagnostic investigations

Clinical assessment: as per ADA 2024 guidelines, elicit a careful history and assess either temperature or pinprick sensation (small fiber function) and vibration sensation using a 128-Hz tuning fork (for large-fiber function) for the assessment of distal symmetric polyneuropathy. Obtain annual 10-g monofilament testing in all patients with diabetes to identify feet at risk for ulceration and amputation.
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  • Psychosocial assessment

Medical management

Glycemic control: as per ADA 2024 guidelines, optimize glucose management to slow the progression of neuropathy in patients with T2DM.

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  • Systemic therapy

  • Topical therapy

  • Management of inadequate response

  • BP and lipid control

Nonpharmacologic interventions

Psychosocial interventions: as per AAN 2022 guidelines, consider offering CBT and exercise in patients preferring nonpharmacologic interventions.

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  • Alternative and complementary medicine

  • Footwear

Therapeutic procedures

Transcutaneous electrical nerve stimulation: as per AAN 2010 guidelines, consider offering electric nerve stimulation in patients with painful diabetic neuropathy.

Patient education

General counseling: as per AAN 2022 guidelines, counsel patients that the goal of pharmacologic therapy for painful diabetic neuropathy therapy is to reduce, and not necessarily eliminate, pain.
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Preventative measures

Primary prevention, glycemic control: as per AAFP 2024 guidelines, ensure intensive glycemic control to reduce the risk of developing diabetic peripheral neuropathy.

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  • Primary prevention (BP and lipid control)