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Diabetic Peripheral Neuropathy: Diagnosis and Treatment

Peripheral neuropathy is the most common microvascular complication of diabetes and a major risk factor for foot ulceration. We review symptoms, diagnostic tests and evidence-based therapy.

Published9 min read

Diabetic peripheral neuropathy (DPN) affects roughly half of patients with long-standing diabetes and is the dominant risk factor for diabetic foot ulceration.

Common patterns

  • Distal symmetric polyneuropathy (most common, stocking-glove pattern)
  • Autonomic neuropathy (gastroparesis, orthostatic hypotension)
  • Mononeuropathy (median, ulnar, peroneal)
  • Diabetic amyotrophy (proximal, often type 2 diabetes)

Bedside diagnosis

  1. 10 g Semmes-Weinstein monofilament at ten plantar sites
  2. 128 Hz tuning fork at the hallux
  3. Pinprick sensation
  4. Achilles reflex
  5. Inspection for foot deformity

First-line drug therapy

ADA/AAN evidence supports pregabalin, duloxetine, gabapentin and amitriptyline as first-line agents. Start low, titrate slowly, monitor side-effects.

References

  1. Pop-Busui R, et al. Diabetic Neuropathy: ADA Position Statement. Diabetes Care. 2017;40(1):136–154. https://doi.org/10.2337/dc16-2042
  2. Price R, et al. Painful diabetic polyneuropathy practice guideline. Neurology. 2022;98(1):31–43. https://doi.org/10.1212/WNL.0000000000013038
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