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Diabetic Neuropathy: a Position Statement by the American

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Diabetic Neuropathy: a Position Statement by the American 136 Diabetes Care Volume 40, January 2017 Diabetic Neuropathy: A Position Rodica Pop-Busui,1 Andrew J.M. Boulton,2 Eva L. Feldman,3 Vera Bril,4 Roy Freeman,5 Statement by the American Rayaz A. Malik,6 Jay M. Sosenko,7 and Dan Ziegler8 Diabetes Association Diabetes Care 2017;40:136–154 | DOI: 10.2337/dc16-2042 Diabetic neuropathies are the most prevalent chronic complications of diabetes. This heterogeneous group of conditions affects different parts of the nervous system and presents with diverse clinical manifestations. The early recognition and appropriate man- agement of neuropathy in the patient with diabetes is important for a number of reasons: 1. Diabetic neuropathy is a diagnosis of exclusion. Nondiabetic neuropathies may be present in patients with diabetes and may be treatable by specific measures. 2. A number of treatment options exist for symptomatic diabetic neuropathy. 3. Up to 50% of diabetic peripheral neuropathies may be asymptomatic. If not recognized and if preventive foot care is not implemented, patients are at risk for injuries to their insensate feet. 4. Recognition and treatment of autonomic neuropathy may improve symptoms, POSITION STATEMENT reduce sequelae, and improve quality of life. Among the various forms of diabetic neuropathy, distal symmetric polyneurop- athy (DSPN) and diabetic autonomic neuropathies, particularly cardiovascular au- tonomic neuropathy (CAN), are by far the most studied (1–4). There are several 1 atypical forms of diabetic neuropathy as well (1–4). Patients with prediabetes may Division of Metabolism, Endocrinology & Diabe- – tes, Department of Internal Medicine, University also develop neuropathies that are similar to diabetic neuropathies (5 10). Table 1 of Michigan, Ann Arbor, MI provides a comprehensive classification scheme for the diabetic neuropathies. 2University of Manchester and the Royal Infirmary, Due to a lack of treatments that target the underlying nerve damage, prevention Manchester, U.K. is the key component of diabetes care. Screening for symptoms and signs of diabetic 3Department of Neurology, University of Michigan, neuropathy is also critical in clinical practice, as it may detect the earliest stages of Ann Arbor, MI 4Department of Neurology, University of Toronto, neuropathy, enabling early intervention. Although screening for rarer atypical forms Toronto, Ontario, Canada of diabetic neuropathy may be warranted, DSPN and autonomic neuropathy are the 5Department of Neurology, Harvard Medical most common forms encountered in practice. The strongest available evidence School, Boston, MA regarding treatment pertains to these forms. 6Department of Medicine, Weill Cornell Medicine- Qatar, Doha, Qatar and New York, NY This Position Statement is based on several recent technical reviews, to which the reader 7 – Division of Endocrinology, University of Miami is referred for detailed discussion and relevant references to the literature (3,4,11 16). Miller School of Medicine, Miami, FL 8German Diabetes Center Dusseldorf,¨ Leibniz PREVENTION Center for Diabetes Research at Heinrich Heine Prevention of diabetic neuropathies focuses on glucose control and lifestyle modifica- University, and Department of Endocrinology and Diabetology, Medical Faculty, Heinrich tions. Available evidence pertains only to DSPN and CAN, and most of the large trials Heine University, Dusseldorf,¨ Germany that have evaluated the effect of glucose control on the risk of complications have Corresponding author: Rodica Pop-Busui, rpbusui@ included DSPN and CAN as secondary outcomes or as post hoc analyses rather than as umich.edu. primary outcomes. In addition, in some of these trials, the outcome measures used to This position statement was reviewed and ap- evaluate neuropathy may have limited ability to detect a benefit, if present. proved by the American Diabetes Association Professional Practice Committee in September 2016 and ratified by the American Diabetes As- Recommendations sociation Board of Directors in October 2016. c Optimize glucose control as early as possible to prevent or delay the devel- R.P.-B. and A.J.M.B. served as co-chairs of the opment of distal symmetric polyneuropathy and cardiovascular autonomic writing committee. neuropathy in people with type 1 diabetes. A © 2017 by the American Diabetes Association. c Optimize glucose control to prevent or slow the progression of distal symmet- Readers may use this article as long as the work ric polyneuropathy in people with type 2 diabetes. B is properly cited, the use is educational and not c Consider a multifactorial approach targeting glycemia among other risk factors to for profit, and the work is not altered. More infor- prevent cardiovascular autonomic neuropathy in people with type 2 diabetes. C mation is available at http://www.diabetesjournals .org/content/license. care.diabetesjournals.org Pop-Busui and Associates 137 fi Table 1—Classification for diabetic neuropathies Similar to the ndings in DSPN, the Diabetic neuropathies most robust evidence for CAN preven- A. Diffuse neuropathy tion was reported in type 1 diabetes. DSPN Intensive glucose control designed to c Primarily small-fiber neuropathy achieve near-normal glycemia reduced c Primarily large-fiber neuropathy the risk of incident CAN during the Di- c Mixed small- and large-fiber neuropathy (most common) abetes Control and Complications Trial Autonomic (DCCT) by 45% and by 31% in its follow-up Cardiovascular c Reduced HRV study, the Epidemiology of Diabetes In- c Resting tachycardia terventions and Complications (EDIC) c Orthostatic hypotension study (27). The highly reproducible and c Sudden death (malignant arrhythmia) sensitive testing protocol, the robust Gastrointestinal definitions used for CAN, and the large c Diabetic gastroparesis (gastropathy) sample size in DCCT/EDIC enhance the c Diabetic enteropathy (diarrhea) validity of the results and support the c Colonic hypomotility (constipation) Urogenital rationale for implementing and main- c Diabetic cystopathy (neurogenic bladder) taining tight glucose control as early as c Erectile dysfunction possible in the course of type 1 diabetes. c Female sexual dysfunction In contrast, glycemic control in type 2 Sudomotor dysfunction diabetes has not consistently lowered c Distal hypohydrosis/anhidrosis, the risk of CAN (25). However, a multi- c Gustatory sweating Hypoglycemia unawareness factorial intervention, including a life- Abnormal pupillary function style component, targeting glucose and B. Mononeuropathy (mononeuritis multiplex) (atypical forms) cardiovascular disease risk factors re- Isolated cranial or peripheral nerve (e.g., CN III, ulnar, median, femoral, peroneal) duced the risk of CAN by 60% in people Mononeuritis multiplex (if confluent may resemble polyneuropathy) with type 2 diabetes (28). C. Radiculopathy or polyradiculopathy (atypical forms) Radiculoplexus neuropathy (a.k.a. lumbosacral polyradiculopathy, proximal motor Lifestyle Modifications amyotrophy) Thoracic radiculopathy The best models to date regarding pa- Nondiabetic neuropathies common in diabetes rameters for an evidence-based, inten- Pressure palsies sive lifestyle intervention come from the Chronic inflammatory demyelinating polyneuropathy Diabetes Prevention Program (DPP) Radiculoplexus neuropathy (29), the Steno-2 Study (28), the Italian Acute painful small-fiber neuropathies (treatment-induced) supervised treadmill study (30), and the University of Utah type 2 diabetes study (31). The latter study recently reported nerve fiber regeneration in patients with Glucose Control people with type 2 diabetes develop type 2 diabetes engaged in an exercise Enhanced glucose control in people with DSPN despite adequate glucose control program compared with loss of nerve fi- type 1 diabetes dramatically reduces the (20,25). The presence of multiple comor- bers in those who only followed standard incidence of DSPN (78% relative risk re- bidities, polypharmacy, hypoglycemia, of care. Overall, such an approach focuses – duction) (17 19). In contrast, enhanced and weight gain might have attenuated on either exercise alone (supervised aer- glucose control in people with type 2 di- the effects of glucose control in these obic and/or resistance training) (30,31) or abetes reduces the risk of developing trials and contributed to inconsistent combined dietary modification and exer- – DSPN modestly (5% 9% relative risk re- findings (25). Specific glucose-lowering cise. There is no consensus regarding di- duction) (20,21). In a small trial of Japa- strategies may also contribute to the dis- etary regimens, and although the DPP nese patients with early type 2 diabetes, crepancy. For example, participants, par- used a low-calorie, low-fat diet, others intensive insulin treatment was associ- ticularly men, in the Bypass Angioplasty have championed a Mediterranean diet ated with improvement in selected Revascularization Investigation in Type 2 that is moderately lower in carbohydrate DSPN measures (22), and the Action to Diabetes (BARI 2D) study treated with in- (45%) and higher in fat (35%–40%), with Control Cardiovascular Risk in Diabetes sulin sensitizers had a lower incidence of less than 10% of saturated fat. (ACCORD) trial reported a modest but DSPN over 4 years than those treated Although the DPP (32) and the Impaired significant DSPN risk reduction with with insulin/sulfonylurea (26). This out- Glucose Tolerance Neuropathy (IGTN) the glycemia intervention in individuals come may be a result of less weight gain study (33) reported benefits of lifestyle with type
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