Diabetic Neuropathy

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PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

See also: Diabetes, Foot Care and Foot Ulcers written for patients

There is a separate article on Diabetic Foot. Diabetes may cause polyneuropathy, mononeuropathy, amyotrophy and autonomic neuropathy.

Diabetic neuropathy is a common complication of both type 1 diabetes and type 2 diabetes. Neuropathy plays a major role in the development of foot ulcers, which cause an enormous effect on quality of life for the patient (especially if amputation becomes necessary) and is also responsible for a very large health and social services expenditure.

Optimal control of all metabolic factors and regular organised surveillance of all people with diabetes is essential to reduce the risk of both development and progression of diabetic neuropathy and therefore reduce the risk of disability for the patient.

Motor, sensory and autonomic fibres may all be affected by diabetic neuropathy.

Neuropathies related to diabetes can affect 60-70% of people with diabetes.[1] Neuropathy associated with type 2 diabetes may be present at the time of diagnosing diabetes. Neuropathy associated with type 1 diabetes usually develops more than 10 years after the diagnosis of diabetes. Diabetes is the most common cause of peripheral neuropathy in the world.[2] 

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Risk factors

  • Smoking.
  • Age over 40 years.
  • History of periods of poor glycaemic control.
  • Prevalence increases with increased duration of diabetes.
  • People with signs of neuropathy are likely also to have evidence of diabetic nephropathy and diabetic retinopathy.
  • Hypertension.
  • Ischaemic heart disease.

This depends on the type of neuropathy involved. 50% of people with diabetic polyneuropathy may have no symptoms and are only diagnosed by careful, regular and thorough clinical examination.[4] 

Peripheral sensorimotor (chronic peripheral neuropathy)

  • Sensory nerves are affected more than motor.
  • Touch, pain and temperature sensation and proprioception in lower limbs in a glove and stocking distribution.
  • Loss of ankle jerks and, later, knee jerks.
  • Hands are only affected in severe long-standing neuropathy.
  • Equal prevalence in types 1 and 2.

Acute diffuse painful (acute peripheral neuritis)

  • Often abrupt onset and not related to duration of diabetes.
  • Can resolve completely.
  • Burning foot pain, often worse at night.
  • Associated with poor glycaemic control but sometimes initially follows establishing good glycaemic control.
  • Examination may be normal apart from hyperaesthesia.

Autonomic neuropathy

  • Risk factors include hypertension and dyslipidaemia. It is more common in females.
  • May present with:
    • Cardiac autonomic neuropathy, which has been linked to:[5] 
      • Resting tachycardia, postural hypotension, orthostatic bradycardia and orthostatic tachycardia.
      • Exercise intolerance.
      • Decreased hypoxia-induced respiratory drive.
      • Loss of baroreceptor sensitivity, increased intra-operative or peri-operative cardiovascular lability.
      • Increased incidence of asymptomatic myocardial ischaemia, myocardial infarction, decreased rate of survival after myocardial infarction.
      • Congestive heart failure.
    • Genitourinary:
      • Impotence, retrograde ejaculation, urinary hesitancy, overflow incontinence.
      • At least 25% of men with diabetes have problems with sexual function.
      • There is often no association with glycaemic control, duration or severity of diabetes.
      • Risk factors for erectile dysfunction include increasing age, alcohol, initial glycaemic control, intermittent claudication and retinopathy.
    • Gastrointestinal:
      • Nausea and vomiting.
      • Abdominal distension.
      • Dysphagia.
      • Diarrhoea.
    • Gustatory sweating, anhidrosis.
  • Tends to be associated with peripheral neuropathy.
  • People with both types 1 and 2 are affected.
  • High mortality rate (50% within three years) mainly due to chronic kidney disease but often no obvious cause.
  • Tight glycaemic control reduces the risk.

Mononeuropathy

  • External pressure or entrapment - eg, carpal tunnel syndrome.
  • Isolated neuropathies of either the cranial or peripheral nerves. Mononeuropathies of cranial nerves III, IV and VI, intercostal nerves and femoral nerves are common.
  • Occasionally more than one nerve is involved (mononeuritis multiplex).

Proximal motor (diabetic amyotrophy)

  • Main motor manifestation.
  • Severe pain and paraesthesiae in the upper legs, with weakness and muscle wasting of the thigh and pelvic girdle muscles.
  • May be asymmetrical and there may be extensor plantars.
  • Mainly affects middle-aged and elderly patients.
  • Usually associated with a period of very poor glycaemic control, sometimes with dramatic weight loss.
  • Pain and weakness gradually reduce once good glycaemic control has returned.
  • Full assessment of diabetes and blood pressure control. Assessment of other possible causes - eg, TFTs, B12.
  • May require nerve conduction studies and electromyography.
  • Regular surveillance for signs of neuropathy to allow early intervention.
  • Tight glycaemic control.
  • Prevention of foot trauma.

Management of painful neuropathy

May require a great deal of support for the depressing and disabling nature of the condition.

General measures

  • Bed foot cradles for problems at night.
  • Simple analgesia taken in advance of diurnal symptoms.
  • Contact dressings.

Drug treatments recommended by the National Institute for Health and Care Excellence (NICE)[6]

  • Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain.
  • If the initial treatment is not effective or is not tolerated, offer one of the remaining three drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated.
  • Consider tramadol only if acute rescue therapy is needed.
  • Consider capsaicin cream for people with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments.
  • Opioids other than tramadol should be avoided unless part of shared-care arrangements after specialist assessment.
  • Patients on drug treatment should be reviewed early when starting treatment for dosage titration, or when changing dose to monitor for adverse effects and tolerability.
  • Regular reviews (NICE does not specify a time interval) should also be arranged to check progress, adverse effects, mood, quality of sleep and any problems with daily activities.

When to refer
Consider referral to a pain clinic and/or condition-specific service at any stage (including initial presentation) if:

  • Pain is severe.
  • Pain significantly limits activity.
  • The underlying condition has deteriorated.

Management of autonomic neuropathy[7]

See the separate article on Autonomic Neuropathy. In all patients, optimise control of diabetes.

  • Cardiovascular effects - various cardio-active drugs are being used to reverse the effects on the cardiovascular system, including angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, diuretics and digoxin.
  • Erectile dysfunction: see the separate article on Erectile Dysfunction.
  • Gastroparesis:
    • Investigation using radiological or radioisotope methods may help in the diagnosis.
    • Investigation of cardiovascular autonomic neuropathy may help in the diagnosis.
    • Metoclopramide and domperidone are worth a trial.
  • Diabetic nocturnal diarrhoea:
    • Investigation must exclude other causes of intestinal upset.
    • May be helped by high doses of codeine, loperamide or diphenoxylate, or by erythromycin or tetracycline.
  • Gustatory sweating:
    • Explanation and counselling are often required.
    • Topical or oral anticholinergic agents (eg, poldine methylsulfate) may be effective.
  • Postural hypotension:
    • May respond to fludrocortisone.
  • Autonomic neuropathy is associated with a high mortality rate, mainly due to its association with chronic kidney disease, cardiopathy and hypotension.
  • Diabetic peripheral neuropathy is a major cause of morbidity and increased mortality and increases the risk of burns, injuries and foot ulceration.[9] 
  • People with diabetes are more likely to undergo lower limb amputation.
  • Tight glycaemic control has been clearly shown to reduce the risk of neuropathy.
  • Smoking avoidance or cessation.

Further reading & references

  1. Charnogursky G, Lee H, Lopez N; Diabetic neuropathy. Handb Clin Neurol. 2014;120:773-85. doi: 10.1016/B978-0-7020-4087-0.00051-6.
  2. Said G; Diabetic neuropathy. Handb Clin Neurol. 2013;115:579-89. doi: 10.1016/B978-0-444-52902-2.00033-3.
  3. Guidelines on the management of neuropathic pain; Clinical Resource Efficiency Support Team (February 2008).
  4. Shakher J, Stevens MJ; Update on the management of diabetic polyneuropathies. Diabetes Metab Syndr Obes. 2011;4:289-305. doi: 10.2147/DMSO.S11324. Epub 2011 Jul 21.
  5. Vinik AI, Erbas T; Diabetic autonomic neuropathy. Handb Clin Neurol. 2013;117:279-94. doi: 10.1016/B978-0-444-53491-0.00022-5.
  6. Neuropathic pain – pharmacological management: The pharmacological management of neuropathic pain in adults in non-specialist settings; NICE Clinical Guideline (November 2013)
  7. Vinik AI, Ziegler D; Diabetic cardiovascular autonomic neuropathy. Circulation. 2007 Jan 23;115(3):387-97.
  8. Management of diabetes; Scottish Intercollegiate Guidelines Network - SIGN (March 2010)
  9. Tesfaye S, Selvarajah D; Advances in the epidemiology, pathogenesis and management of diabetic peripheral neuropathy. Diabetes Metab Res Rev. 2012 Feb;28 Suppl 1:8-14. doi: 10.1002/dmrr.2239.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Colin Tidy
Current Version:
Peer Reviewer:
Dr John Cox
Document ID:
2054 (v24)
Last Checked:
21/05/2014
Next Review:
20/05/2019

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