Diabetic sensorimotor polyneuropathy remains inadequately diagnosed and treated, according to international experts who have developed consensus recommendations for screening, diagnosis, and treatment.
In a paper published in Diabetes Research and Clinical Practice, they say painful DSPN may develop in 13-26% of diabetes patients, and up to half of patients with DSPN may be asymptomatic.
In the guidelines, developed by 14 diabetes specialists and a neurologist, they say diagnosis of DSPN is based on neuropathic symptoms and signs, such as pain, paresthesias, and numbness particularly in the feet and calves.
And since the efficacy of current treatments for DSPN is limited, they say early detection and prevention of the condition in national diabetes plans is imperative.
Their management recommendations, based on a Delphi process focus on three key areas of optimising diabetes treatment, using drug therapies to influence the underlying neuropathic process and symptomatic treatment of neuropathic pain with analgesics and non-drug interventions.
For screening there was strong agreement that patient history should encompass neuropathic pain characteristics, assessment of pain severity and interference with daily activities and sleep.
Among the recommendations on diagnosis, the experts agreed that bilateral impairment of vibration sensation with tuning fork and/or pinprick test may be appropriate as minimal criteria for diagnosis of DSPN in clinical practice. They also advise consideration of other causes of polyneuropathy such as drug-induced, by history.
The first principle for management should be achieving optimal diabetes treatment through lifestyle modification, intensive glucose control and multifactorial cardiovascular risk intervention.
The second ‘cornerstone’ of management should be pathogenetically oriented treatment of symptomatic DSPN with agents such as the antioxidant α-lipoic acid and the vitamin B1 derivative benfotiamine, they suggested.
First line therapy for managing symptoms of neuropathic pain could include gabapentin or pregabalin and the antidepressants such as duloxetine and amitriptyline , they advised.
Second line treatment of painful DSPN might include opioids such as tramadol, with topical capsaicin also an option.
The expert group added that combination treatments such as antidepressants + gabapentinoids, or combinations with opioids may also be used.
Non-pharmacological treatment options included psychological support, behavioural treatment, acupuncture, physical measures and transcutaneous electrical and electromagnetic stimulation (TENS).
However they acknowledged that the efficacy of available treatments for DSPN was limited, and the therapeutic armamentarium to manage DSPN “remains an area of substantial unmet medical need.”
“The evidence for interventions in DSPN, as derived from systematic reviews on which recommendations are based, is often inconclusive. Therefore, therapeutic algorithms need to be harmonised and constantly updated to foster suitable and efficacious treatments in everyday routine,” they advised.