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Diabetic neuropathy
Background
Overview
Definition
Diabetic neuropathy is a type of neuropathy that occurs due to microvascular disease and chronic hyperglycemia in diabetic patients.
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Pathophysiology
Diabetic neuropathy is caused by persistent hyperglycemia, microvascular insufficiency, oxidative and nitrosative stress, defective neurotropism, and autoimmune-mediated nerve destruction in patients with diabetes mellitus.
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Epidemiology
The incidence of diabetic neuropathy is estimated at 17.8 per 100,000 person-years in the United Kingdom.
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Disease course
Nerve damage leads to hyperalgesia, dysesthesia, allodynia, weakness, numbness, hypoalgesia, anomalies in thermal sensation and autonomic function, foot ulcerations, gangrene, and amputations.
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Prognosis and risk of recurrence
Diabetic neuropathy is associated with a 1.7-12-fold higher risk of amputation. In addition, autonomic neuropathy is associated with a mortality rate of approximately 25-50% at 5-10 years.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of diabetic neuropathy are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2025), the American Academy of Family Physicians (AAFP 2024), the American Academy of Neurology (AAN 2022,2010), the Diabetes Canada (DC 2018), and the European Federation of Neurological Societies (EFNS 2010).
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Screening and diagnosis
Indications for screening, adults: as per ADA 2025 guidelines, screen for diabetic peripheral neuropathy starting at diagnosis of T2DM and 5 years after the diagnosis of T1DM, and at least annually thereafter.
B
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Indications for screening (children)
Diagnostic investigations
Clinical assessment
As per ADA 2025 guidelines:
Elicit a careful history and assess either temperature or pinprick sensation (small-fiber function) and vibration sensation using a 128-Hz tuning fork (for large-fiber function) for the assessment of distal symmetric polyneuropathy. Obtain annual 10-g monofilament testing in all patients with diabetes to identify feet at risk for ulceration and amputation.
B
Assess for symptoms and signs of autonomic neuropathy (orthostatic dizziness, syncope, resting tachycardia, early satiety, erectile dysfunction, changes in sweating patterns, or dry cracked skin in the extremities) starting at diagnosis and at least annually thereafter in patients with evidence of other microvascular complications, particularly kidney disease and diabetic peripheral neuropathy.
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Psychosocial assessment
Medical management
Glycemic control: as per ADA 2025 guidelines, optimize glucose management to slow the progression of neuropathy in patients with T2DM.
B
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Systemic therapy
Topical therapy
Management of inadequate response
BP and lipid control
Nonpharmacologic interventions
Psychosocial interventions: as per AAN 2022 guidelines, consider offering CBT and exercise in patients preferring nonpharmacologic interventions.
C
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Alternative and complementary medicine
Footwear