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Management of type 2 diabetes: A handbook for general practice
Last revised: 17 Sep 2020
Grade: A, level 1
Grade: B, level 2
Diabetic neuropathies increase with age, duration of diabetes and level of control of diabetes. They are heterogeneous, with diverse clinical manifestations, and may be focal or diffuse.
Symptoms include pain and paraesthesia, and if the autonomic nervous system is involved, gastrointestinal, bladder and sexual problems may arise. These increase the patient’s burden of self-care and overall management. Foot ulceration and amputation are important and costly sequelae of diabetic neuropathy2 (refer to the section ‘Microvascular complications: Foot care’).
Manifestations of diabetes-related peripheral neuropathy include:
Autonomic neuropathy may result in:
Before any treatment is instigated, exclusion of non-diabetic causes of neuropathy is suggested. This includes assessment for vitamin B12 deficiency, hypothyroidism and renal disease, and a review of neurotoxic drugs, including excessive alcohol consumption.
The clinical focus is on prevention via optimising glycaemic management and early recognition, facilitated by good history and routine sensory testing.
People with type 2 diabetes should be checked for diabetic peripheral neuropathy at diagnosis, and at least annually thereafter.1
Tests to assess for diabetic peripheral neuropathy are shown in Box 1. Combinations of more than one test have >87% sensitivity in detecting diabetic peripheral neuropathy. Loss of 10 g monofilament perception and reduced vibration perception predict foot ulcers.3
Several neuropathy scoring systems (diabetic neuropathy symptom score, neuropathy impairment score and Michigan neuropathy screening instrument) may be used with examination to confirm diagnosis and assess severity.4–6
Motor neuropathy sometimes occurs, with muscle wasting, weakness and abnormalities of gait. This can contribute to foot problems by altering the biomechanics of the ankle and foot.
Cardiovascular autonomic neuropathy should be suspected with resting tachycardia (>100 beats per minute) or orthostatic reduction in blood pressure (a fall in systolic blood pressure >20 mmHg on standing without an appropriate heart rate response). This applies to patients not currently on antihypertensive agents that may cause variations in blood pressure responsiveness, such as β-blockers. It is associated with increased cardiac event rates.
Management of diabetes-related neuropathy mainly involves professional assessment and foot care to prevent diabetes-associated foot disease. The appearance of peripheral neuropathy should prompt review of glycaemic control and consideration of intensified management to prevent progression.2
The pain of peripheral neuropathy can be difficult to manage, although there is evidence that several agents can improve symptom control and quality of life.
For information about the Foot Forward program to prevent amputation, contact Diabetes Australia.
Type 2 diabetes: Goals for optimum management (PDF 0.04 MB)
Australian type 2 diabetes management algorithm (PDF 0.04 MB)
Management of type 2 diabetes: A handbook for general practice - Clinical summary (PDF 0.24 MB)
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