Update on the Management of Diabetic Neuropathy

Abstract

IN BRIEF Distal symmetric polyneuropathy (DSPN) and diabetic autonomic neuropathies, particularly cardiovascular autonomic neuropathy (CAN), are prevalent diabetes complications with high morbidity, mortality, and amputation risks. The diagnosis of DSPN is principally a clinical one based on the presence of typical symptoms combined with symmetrical, distal-to-proximal stocking-glove sensory loss. CAN is an independent risk factor for cardiovascular mortality, arrhythmia, silent ischemia, major cardiovascular events, and myocardial dysfunction. Screening for CAN in high-risk patients is recommended. Symptoms of gastroparesis are nonspecific and do not correspond with its severity. Diagnosis of gastroparesis should exclude other factors well documented to affect gastric emptying such as hyperglycemia, hypoglycemia, and certain medications. There is a lack of treatment options targeting the neuropathic disease state. Managing neuropathic pain also remains a challenge. Given the high risk of addiction, abuse, psychosocial issues, and mortality, opioids are not recommended as first-, second-, or third-line agents for treating painful DSPN.

FIGURE 1.

Algorithm for management of patients with pain due to DSPN. *Pregabalin is FDA-approved for painful DSPN, whereas gabapentin is not. Pharmacokinetic profile, spectrum of AEs and drug interactions, comorbidities, and costs should be considered in selecting the agent of choice. **Duloxetine is FDA-approved for painful DSPN, whereas venlafaxine is not. Pharmacokinetic profile, spectrum of AEs, drug interactions, comorbidities, and costs should be considered in selecting the agent of choice. #None is FDA-approved for painful DSPN. Spectrum of AEs, drug interactions, and comorbidities should be considered in selecting these agents. Reprinted with permission from ref. 1.