General practice management of type 2 diabetes


Neuropathy
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Clinical context


Pain and paraesthesia are common peripheral neuropathic symptoms, and if the autonomic nervous system is involved, gastrointestinal, bladder and sexual problems arise.

Diabetic neuropathic complications increase the patient’s burden of self care and overall management.

The clinical focus is on prevention via good glycaemic control, and early recognition facilitated by good history and routine sensory testing. New modalities are arriving to assist in the management of diabetic neuropathies.

Before any treatment is instigated, exclusion of non-diabetic causes of neuropathy is suggested. This includes assessment for vitamin B12 deficiency, hypothyroidism, renal disease and a review of neurotoxic drugs including excessive alcohol consumption.

Autonomic neuropathy

Autonomic neuropathy may result in:

  • orthostatic hypotension with >20 mmHg drop
  • impaired and unpredictable gastric emptying (gastroparesis), which can cause a person’s blood glucose levels to be erratic and difficult to control. Pro-kinetic agents such as metoclopramide, domperidone or erythromycin may improve symptoms
  • diarrhoea
  • delayed/incomplete bladder emptying
  • erectile dysfunction and retrograde ejaculation in males
  • reduced vaginal lubrication with arousal in women
  • loss of cardiac pain, ‘silent’ ischaemia or myocardial infarction
  • sudden, unexpected cardiorespiratory arrest, especially under anaesthetic or treatment with respiratory-depressant medications
  • difficulty recognising hypoglycaemia (hypoglycaemic unawareness)
  • unexplained ankle oedema.

Cardiovascular autonomic neuropathy should be suspected by resting tachycardia (>100 bpm) or orthostatic reduction in BP (a fall in SBP >20 mmHg on standing without an appropriate heart rate response). This applies to patients not currently on antihypertensive agents that may cause variations in BP responsiveness such as β-blockers. It is associated with increased cardiac event rates.
 

Diabetic peripheral neuropathy

 

Recommendations

Reference

Grade*

All patients should be screened for distal symmetric polyneuropathy starting at diagnosis of type 2 diabetes and at least annually thereafter, using simple clinical tests

19
American Diabetes Association, 2015

B

Antidepressants, including tricyclics, duloxetine and venlafaxine should be considered for the treatment of patients with painful diabetic peripheral neuropathy

65
SIGN, 2014

A

Anticonvulsants, including pregabalin and gabapentin, should be considered for the treatment of patients with painful diabetic peripheral neuropathy

65
SIGN, 2014

A

*Refer to Summary, explanation and source of recommendations for an explanation of the level of evidence and grade of evidence

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.


In practice


Early recognition and appropriate management is important. People with type 2 diabetes should have an annual check for diabetic peripheral neuropathy.The appearance of peripheral neuropathy should prompt review and consideration of improved glycaemic control.

The Diabetes Neuropathy Score may be used to confirm diagnosis and assess severity (refer to Table 9).160,161

Table 9. Diabetic neuropathy symptom score162
 

 

1.

Are you experiencing unsteadiness in walking (need for visual control, increase in the dark, walk like a drunk man, lack of contact with floor)?

 

2.

Do you have a burning, aching pain or tenderness at your legs or feet (occurring at rest or at night, not related to exercise, excluding intermittent claudication)?

 

3.

Do you have prickling sensations on your legs and feet (occurring at rest or at night, distal>proximal, stocking glove distribution)?

 

4.

Do you have places of numbness on your legs or feet (distal>proximal, stocking glove distribution)?

Score:

  • 1 point if a symptom occurred several times a week during the past two weeks
  • No points if this does not occur

0 points, polyneuropathy absent; 1–4 points, polyneuropathy present

©Jan-Willem G (JWG) Meijer, MD PhD, Revant Rehabilitation Centers, Breda, The Netherlands, jw.meijer@revant.nl

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.

Tricyclic medications should be used as a first-line treatment, although side effects are relatively uncommon.

Gabapentin provides pain relief of a high level in approximately one-third of people who take this medication for painful neuropathic pain. Side effects are common (66%).163 Pregabalin at daily oral doses of 300–600 mg provides high levels of benefit for a minority of patients experiencing neuropathic pain including painful diabetic neuropathy.164

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.

Combinations of more than one test have >87% sensitivity in detecting diabetic peripheral neuropathy (refer to Box 7). Loss of 10 g monofilament perception and reduced vibration perception predict foot ulcers.165
 


Box 7. Tests to assess for peripheral neuropathy

  • Pinprick sensation
  • Vibration perception (using a 128-hz tuning fork
  • 10 g monofilament pressure
  • sensation at the distal plantar aspect of both great toes and metatarsal joints
  • Assessment of ankle reflexes.

Diabetes Australian and RACGP logo's
 
  1. National Health and Medical Research Council. National evidence-based guideline: Prevention, identification and management of foot complications in diabetes. Canberra: NHMRC, 2011.
  2. Yang Z, Chen R, Zhang Y, et al. Scoring systems to screen for diabetic peripheral neuropathy (Protocol). Cochrane Database Syst Rev 2014(4):CD010974.
  3. Meijer JW, Smit AJ, Sonderen EV, Groothoff JW, Eisma WH, Links TP. Symptom scoring systems to diagnose distal polyneuropathy in diabetes: The Diabetic Neuropathy Symptom score. Diabet Med 2002;19(11):962–65.
  4. Moore RA, Wiffen PJ, Derry S, McQuay HJ. Gabapentin for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev 2011;CD007938.
  5. Moore RA, Straube S, Wiffen PJ, Derry S, McQuay HJ. Pregabalin for acute and chronic pain in adults. Cochrane Database Syst Rev 2009;(3):CD007076.
  6. Boulton AJ, Vinik AI, Arezzo JC, et al. Diabetic neuropathies: A statement by the American Diabetes Association. Diabetes Care 2005;28(4):956–62.