5.3 Diabetic neuropathy

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5.3.1 Types

1. Somatic – sensory, motor, cranial (focal neuropathy)
2. Autonomic – gastroparesis, hypoglycemia unawareness, postural hypotension, erectile dysfunction etc.

5.3.2 Screening

• Starting at diagnosis of T2DM, then annually.
• 5 years after the diagnosis of T1DM, then annually.
• Testing sensory neuropathy by 10-g monofilament.
• Assessment of either temperature or pinprick sensation (small fiber function) and vibration sensation using a 128-Hz tuning fork (for large-fiber function).
• Symptoms and signs of cranial and autonomic neuropathy should also be assessed.

5.3.3 Treatment²

• Treatment of painful diabetic peripheral neuropathy
  • Metabolic control: optimum glycemic control.
  • For burning pain: antidepressants e.g. duloxetine, tricyclic antidepressants etc. or anticonvulsants e.g. gabapentin, pregabalin, or topical capsaicin etc. are used.
  • For lancinating pain: anticonvulsants e.g. carbamazepine, phenytoin or valproate are used.
  • For painful cramps: quinine sulfate. Aldose reductase inhibitors may be used.
  • Other contributing factors e.g. alcohol, cord lesions, vitamin deficiency, renal failure etc. should be addressed.
• Treatment of autonomic neuropathy
  • Metabolic control: good metabolic control may halt its progression
  • For gastroparesis: erythromycin, metoclopramide, domperidone
  • For diarrhoea: antibiotics, loperamide
  • For impotence: PDE5 inhibitors
  • For neurogenic bladder: intermittent catheterization, surgery, drug (rarely)
  • For orthostatic hypotension: midodrine, mineralocorticoids, elastic stockings, fluid and salt intake, positional adjustments etc.
  • Supportive measures e.g. physiotherapy