commonest manifestation of diabetic neuropathy - prevalence ranges from 20 to 50 per cent - varies depending on the diagnostic criteria used and the populations studied
senorimotor neuropathy can lead to loss of protective sensation and altered foot biomechanics - this increases risk of developing foot ulcers
all individuals with diabetes should receive an annual foot examination that should include evaluation of neurological status, vascular status, foot structure and skin integrity
patients with identified problems should be offered regular chiropody
patients should be educated about the importance of foot monitoring on a daily basis, looking for dry skin, abrasions, fissures, calluses or early skin ulcers
feet should be kept clean and dry
prevent drying and cracking of the skin via the use of emollients or lotions
regular and proper nail care
regular debridement of calluses reduces localised pressure and the risk of foot ulceration (2)
wear appropriate footwear
painful diabetic neuropathy
maintain good glycaemic control - optimal diabetic control is beneficial for the management of painful neuropathy in patients with type 1 diabetes
if mild to moderate pain then paracetamol or a non-steroidal anti-inflammatory drug may bring symptomatic relief
gabapentin
this is licensed for the treatment of neuropathic pain
an effective alternative to a tricyclic antidepressant
can be started at 300mg the first day, 300mg twice daily the second day, 300mg three times daily the third day, increasing in steps of 300mg daily to the maximum dose of 1.8g daily (usually in three divided doses) for which it is licensed in the UK (2)
main adverse effects include somnolence, dizzziness, headache, diarrhoea and confusion.
alternative therapeutic agents:
phenytoin and carbamazepine (both unlicensed usage) may be effective in the management of stabbing or shooting pain. However side effects are common. Carbamazepine 200-800mg per day in divided doses has been used in the management of this condition
capsaicin cream - this is licensed for the treatment of diabetic neuropathy
should be applied four times a day, but can cause a transient worsening of symptoms during the first one or two weeks of treatment, and can take up to six weeks for its full analgesic effect to develop (2)
pregabalin - there is evidence that pregabalin demonstrated early and sustained improvement in pain and a beneficial effect on sleep in patients with diabetic neuropathy (4). Pregabalin was well tolerated at all doses (4)
some opoid analgesics (e.g. tramadol) may have a role when other treatments have failed
NICE suggest that (3):
for people with painful diabetic neuropathy, offer oral duloxetine as first-line treatment. If duloxetine is contraindicated, offer oral amitriptyline*
for duloxetine: start at 60 mg per day (a lower starting dose may be appropriate for some people), with upward titration to an effective dose or the person's maximum tolerated dose of no higher than 120 mg per day
for amitriptyline*:
start at 10 mg per day, with gradual upward titration to an effective dose or the person's maximum tolerated dose of no higher than 75 mg per day (higher doses could be considered in consultation with a specialist pain service)
* in these recommendations, drug names are marked with an asterisk if they do not have UK marketing authorisation for the indication in question at the time of publication (March 2010). Informed consent should be obtained and documented
for people with painful diabetic neuropathy: if first-line treatment was with duloxetine, switch to amitriptyline* or pregabalin, or combine with pregabalin if first-line treatment was with amitriptyline*, switch to or combine with pregabalin
autonomic neuropathy
diabetic diarrhoea
can develop as a result of bacterial overgrowth which can be treated with antibiotics such as erythromycin or tetracycline (unlicensed use) (2). Otherwise codeine phosphate is generally the most effective drug. Note that other pathological causes of prolonged diarrhoea need to be excluded
gastroparesis
an antiemetic which promotes gastric transit (e.g. domperidone or metoclopramide) may be useful
NICE suggest (5):
a clinician should consider the diagnosis of gastroparesis in an adult with erratic blood glucose control or unexplained gastric bloating or vomiting, taking into consideration possible alternative diagnoses
consider a trial of metoclopramide, domperidone or erythromycin for an adult with gastroparesis
if gastroparesis is suspected, consider referral to specialist services if:
differential diagnosis is in doubt, or
persistent or severe vomiting occurs
neuropathic postural hypotension
the use of the mineralocorticoid fludrocortisone 100 to 400 mcg daily (unlicensed use) may be beneficial. This treatment option results in an increase in plasma volume (uncomfortable oedema may be an adverse effect)
gustatory sweating - various systemic therapies have been used with varying degrees of success, mainly anticholinergic agents, but their side-effects, such as dry mouth, constipation, worsening of gastroparesis and confusion, limit their use (2)
neuropathic oedema - treatment options include the use of ephedrine hydrochloride (unlicensed use)
Notes:
a systematic review concerning pharmacological options for diabetic neuropathy concluded (6)
anticonvulsants and antidepressants are still the most commonly used options to manage diabetic neuropathy.
oral tricyclic antidepressants and traditional anticonvulsants are better for short term pain relief than newer generation anticonvulsants
evidence of the long term effects of oral antidepressants and anticonvulsants is lacking
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