Standards of Care and Clinical Practice
Recommendations: Type 2 Diabetes
Last updated: July 2012
Clinical Practice Recommendations
Recommendations for Neuropathy
- Screen patients with diabetes for distal symmetric polyneuropathy (DPN) and autonomic neuropathy at diabetes diagnosis, and then at least annually.
- Consider treatment to reduce neuropathic pain.
Neuropathy is a common complication of diabetes affecting multiple organ systems, and is a significant cause of morbidity and mortality. Poor blood glucose control and smoking can significantly increase the risk of neuropathy and its complications. There is no specific treatment for the nerve damage associated with diabetic neuropathy. Improving glycemic control may slow progression, but does not reverse nerve loss.
There are two main types of diabetic neuropathy: distal symmetric polyneuropathy and autonomic neuropathy.
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- Distal symmetric polyneuropathy, often referred to as peripheral neuropathy, most commonly affects the feet and legs in people with diabetes, and is the major cause of lower extremity problems, including pain, ulceration, and amputations. See the foot care section for recommendations on DPN screening, management, and referral. For guidance on treatment of neuropathic pain, see the IHS Type 2 Diabetes and Neuropathy Treatment Algorithm listed in the Key Tools and Resources section below.
- Autonomic neuropathy is responsible for various cardiovascular, gastrointestinal, and genitourinary clinical problems that can have significant associated morbidity and increased mortality rates. This form of neuropathy can manifest as: resting tachycardia, exercise intolerance, orthostatic hypotension, constipation, gastroparesis, erectile dysfunction, and sudomotor dysfunction. Screening consists of assessing signs and symptoms of autonomic dysfunction when taking the patient’s history and during physical examination. Treatments are available for symptomatic autonomic neuropathy that may improve quality of life, but these treatments do not alter the disease process. See the Tools and Resources below for sources that contain comprehensive discussions of this topic.
Tools for Clinicians and Educators
Patient Education Materials
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IHS Division of Diabetes Treatment and Prevention. Type 2 Diabetes and Neuropathy Treatment Algorithm [PDF - 142KB]
Argoff CE, Misha-Miroslav B, Belgrade MJ, Bennett GJ, Clark MR, Cole E, et al. Consensus guidelines: assessment, diagnosis, and treatment of diabetic peripheral neuropathic pain.
[PDF] Mayo Clin Proc. 2006 Apr;81 Suppl 4 :S12-25.
Boulton AJ, Vinik AI, Arezzo JC, Bril V, Feldman EL, Freeman R, et al. Diabetic neuropathies: a statement by the American Diabetes Association.
[PDF] Diabetes Care. 2005 Apr;28(4):956-62.
Bril V, England J, Franklin GM, Backonja M, Cohen J, Toro DD. Evidence-based guideline: treatment of painful diabetic neuropathy.
Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2011 May 17;76(20):1758-65.
Freeman R. Not all neuropathy in diabetes is of diabetic etiology: differential diagnosis of diabetic neuropathy.
Curr Diab Rep. 2009;9:423-31.
Vinik AI, Casellini C, Nakave A, Patel C. Chapter 31, Diabetic neuropathies. In: Goldfine ID, Rushakoff RJ, editors. Diabetes and carbohydrate metabolism, [Internet] Diabetes Manager.
Wile DJ, Toth C. Association of metformin, elevated homocysteine, and methylmalonic acid levels and clinically worsened diabetic peripheral neuropathy.
[PDF] Diabetes Care. 2010;33:156-61.