Recognizing neuropathy in your patient is important for early intervention to prevent progression and other complications.

The most common form of diabetic neuropathy is the metric distal sensory neuropathy. This presents symmetric neuropathic symptoms and a glove and stocking distribution.

It develops falling long-standing hyperglycemia and involves damage to small nerve fibers resulting in lots of pain and thermal sensensation. It can also damage large nerve fibers, resulting in loss of touch and vibration perception. It can damage sensory fibers which causes paresthesias and pain.

Unfortunately there is no treatment to reverse neuropathy, though prevention is key.

For all patients with diabetes you should perform a visual inspection of their feet at each visit. To ensure that they have no ulcers or calluses and that their shoes fit appropriately.

You should also assess for loss of protective sensation. This has been shown to increase the patient’s risk of developing foot ulcers, which can be a serious complication of diabetes.

Most commonly performed test to assess for intact sensation, is the 10 grand monofilament test. In this test a nylon monofilament is applied to the plantar surface of the foot, with enough force to cause the filament to buckle, designed to be 10 g of force.

This should be performed for areas on the plantar surfaces. The site’s most likely to be affected in diabetic neuropathy.

Other tests that should be performed include assessment of vibratory sense, using a 128 Hz tuning fork. This should be placed on the tip of the great toe.

If the patient is unable to detect a vibration while the examiner still feels vibration, this test is considered abnormal. Assessment for intact peripheral pulses should also be done at every visit. If there is concern for loss of protective function or vascular disease, referral to a podiatrist should be considered for evaluation of proper footwear or other interventions to decrease risk of ulceration.

Diabetes can also cause autonomic neuropathies. These may be difficult to diagnose, but can significantly impair quality of life. The autonomic neuropathy can affect multiple systems throughout the body.

One of the most concerning complications of autonomic neuropathy is hypoglycemia unawareness. Where patients no longer get autonomic symptoms associated with low blood sugar.They are at risk of loss of consciousness or seizures, related to severe hypoglycemic events.

Autonomic neuropathy‘s can also involve the cardiovascular system. This cause resting tachycardia or postural dizziness.

Autonomic neuropathy in the gastrointestinal system causes gastroparesis, diabetic diarrhea or chronic constipation. Erectile dysfunction is a common consequence of autonomic neuropathy and some patients may also know hyper hidrosis. Particularly with increased sweating of the upper body and decreased sweating in the lower body.

Treatment of the autonomic neuropathy is aimed at managing symptoms in order to improve patient’s quality of life. For hypoglycemia and awareness, a continuous glucose monitor can be life-saving. This will alarm as blood sugars start dropping, allowing patients to treat their low blood sugar before they become confused. Many of these patients also need higher glucose targets, to minimize the risk of developing hypoglycemia.

For patients with orthostatic hypotension. Increasing salt intake in the use of compression stockings can be helpful. If these interventions are not enough to control symptoms fludrocortisone may be helpful. Patients with gastroparesis may benefit from dietary changes consuming several small meals throughout the day.

Medication that may provide some benefit include metoclopramide which acts to stimulate gastric motility and domperidone, which is an option for patients who do not respond to or unable to tolerate metoclopramide. This is not available in the US but is available in Canada and other countries.

Erectile dysfunction due to autonomic neuropathy is difficult to treat but patients may benefit from PDE five inhibitors. Recognizing neuropathy is the first step in helping your patients to manage their symptoms so sure to ask about symptoms at each visit and treat as needed.

For more information about diabetic neuropathy numbness treatment you should check this article.