Transient hyperglycemia is often tolerated by normal compensatory physiological function and homeostatic mechanisms of blood sugar control. However, in chronically elevated states, it can have toxic effects such as neuropathy. For patients diagnosed early with type 1 diabetes mellitus, tight glucose control can reduce the risk of diabetic peripheral neuropathy by 78%, while typically, with a later diagnosis of long-standing hyperglycemia or type 2 diabetes, tight glucose control only reduces the risk by 5% to 9%.

Symptoms of burning, numbness, or tingling in the feet that tend to be worse at night are characteristic. Patients with pedal paresthesias and dysesthesia often describe a nonspecific constellation of symptoms resulting in difficulty with ambulation and other basic activities of daily living (ADL). The characteristic polyneuropathy and distal sensory peripheral neuropathy are present in about 80% of DM PN patients. This is often described as a "stocking-glove distribution," and it can take several years to develop.  

Since the protective sensation is lost after sensory impairment, the standard Semmes-Weinstein 5.07 monofilament 10 grams of pressure protective sensation test may be accurately sensed even after a neurotrophic ulcer has developed. Simply timing the duration that a vibrating 128 Hz tuning fork is felt at the dorsal hallux interphalangeal joint (usually 18 seconds) can be used to detect sensory deficits earlier as well as quantify severity. Decreased light touch sensation or loss of ankle reflexes tend to occur earlier in the disease process, while the detectable loss of protective sensation tends to occur later in the disease, sometimes even after a neuropathic ulcer develops. Needle electromyography (EMG) and nerve conduction velocity testing can be both painful and expensive.

Autonomic symptoms

Autonomic neuropathy is also very common in diabetes and can affect the gastrointestinal, cardiovascular, and genitourinary organs. Typical symptoms include:

GI: Abdominal discomfort, dysphagia, nausea, fecal incontinence, constipation, diarrhea

Cardiac: Hypotension, sinus tachycardia, variable heart rate, syncope

Bladder: Weak urinary stream, straining to void, incomplete emptying of bladder, 

Skin: Heat intolerance, gustatory sweating, extreme diaphoresis

Nervous: Carpal tunnel syndrome, radiculopathy, lumbosacral, and cervical neuropathy. In addition, cranial nerves 3,4,6, and 7 may be affected.

The medical history review of systems and medications captures most of the causes of peripheral neuropathy. Electromyography and/or nerve conduction studies are suggested if there are severe or rapidly progressive symptoms or motor weakness. Minor symptoms may not need laboratory workup. Persistent unexplained symptoms may warrant laboratory investigation including serum glucose, glycohemoglobin, complete blood count, erythrocyte sedimentation rate, rapid plasma reagin, serum electrophoresis, and vitamin B12 level. Measurement of intraepidermal nerve fiber density (IENFD) by skin biopsy can be considered in patients with idiopathic cases. The number and morphology of axons within the epidermis can be evaluated, and intraepidermal nerve fiber density is compared to age-dependent normal values.[11][12]

Many patients with neuropathy have mild to moderate numbness symptoms yet still retain protective sensation in their feet. They may only need reassurance and education as to the cause of the numbness. Periodic follow up is important. With improved glycemic control, paresthesias and dysesthesias may diminish within one year. After peripheral arterial disease and radiculopathy are ruled out, painful symptoms that disturb sleep or activities of daily living can be treated with pregabalin, gabapentin, or anti-depressants. These medications have been shown to reduce the symptoms by 30% to 50% in many patients. Some patients also respond to the over-the-counter antioxidant alpha-lipoic acid. Additionally, although classified as a medical food, the prescription containing L-methyl folate, pyridoxal 5'-phosphate, and methylcobalamin for the dietary management of endothelial dysfunction has been shown to improve nerve fiber density and monofilament sensation significantly. Depletion of substance P with topical capsaicin cream may help some patients who can tolerate the initially increased burning.[13][14][15]

Diabetic gastroparesis may be managed with erythromycin and metoclopramide. Tegaserod is a newer agent but is only available on an emergency basis because of serious adverse cardiac effects.

Some patients may benefit from the use of vitamins, especially zinc.

Erectile dysfunction is managed with the phosphodiesterase inhibitors, but not everyone has a response. A penile prosthesis may be of benefit.

Orthostatic hypotension may be managed by increased salt and fluid intake and the use of compression stockings. If that fails, steroids may be required. Glycopyrrolate is used to manage sweating but often does not work.

• All infected diabetic foot ulcers need debridement or amputation
• Gastroparesis may be managed by a jejeunostomy tube, especially in patients losing weight.
• A pancreas transplant is an option and has been shown to stabilize autonomic function.
• Physical therapy is a must for all patients with PN, especially those with muscle pain and weakness. In addition, occupational therapy may be necessary when there is a functional loss. Speech therapy is necessary to help patients with dysphagia and the risk of aspiration.

• Alcohol-associated neuropathy
• Nutritional linked neuropathy
• Uremic neuropathy
• Vasculitic linked neuropathy
• Vitamin B-12 deficiency
• Toxic metal neuropathy

Staging

NO: No neuropathy

N1a: Signs but no symptoms of neuropathy

N2a: Mild polyneuropathy or autonomic neuropathy, patient able to walk on heels

N2b: Severe polyneuropathy and patient unable to walk on heels

N3: Disabling polyneuropathy

Poorly treated diabetics have higher morbidity and complications rates associated with PN compared to well-controlled diabetics. PN often leads to skin breakdown, infection, ulceration, and eventually to amputation. Further, the treatment of PN is not satisfactory, and adverse cardiac events are common. Less than a third of patients achieve good pain control. For most patients with PN, the quality of life is poor.

• Amputations of the toes, foot or leg
• Infections of the foot
• Dizziness, falls
• Diarrhea, failure to thrive, dehydration
• Pain
• Cardiovascular neuropathy can cause death

The lower extremities are especially prone to the repetitive microtrauma-induced complications of polyneuropathy. There is an increased propensity to develop not only recurrent neuropathic ulcers but Charcot neuroarthropathy and, to a lesser extent, motor neuropathy. Additionally, as patients age, their nails become dystrophic, and the face of decreased protective sensation, the risk of subungual ulcerations, gangrene, and osteomyelitis increases. Periodic focused examinations are essential. Professional foot care, along with therapeutic shoes and insoles, have helped to reduce the lower limb amputation rates in patients with diabetes mellitus.

Diabetic neuropathy affects many organ systems and is best managed by an interprofessional team. Because there is no cure for the disorder, the key is prevention. All people with diabetes should have a dietary consult and should be educated on what foods they should eat and what to avoid. The diet should be realistic and focused on lowering blood glucose levels. The patients should also enter a rehabilitation program or some exercise. Losing weight not only makes it easier to control blood sugars, but it also lowers blood pressure and lipids. A podiatry consult is vital as protection of the foot is necessary. Further, all people with diabetes should be informed on avoiding trauma and undergoing any invasive procedure on the feet without prior clearance from the endocrinologist. In addition, the patient should be told to avoid cold or hot temperatures.

A dedicated diabetic nurse should educate the patient about all aspects of diabetes and the importance of euglycemia. Patients should be taught how to monitor their blood glucose and how to use portable glucose monitors. The pharmacist should offer education about the medications, their benefits, and adverse effects.

Compliance with diabetic medications is vital. Finally, patients who do develop neuropathy also tend to have nephropathy and retinopathy- hence, all people with diabetes should be referred to a nephrologist and ophthalmologist. There should be open communication between the interprofessional team so that all patients are provided the available standard of care with minimal morbidity. Foot and nail care nurses monitor patients, provide education, and inform the team of the patient's condition. Pharmacists educate patients about the use of medications and the importance of compliance. [16][17] (Level 5)

Outcomes

In general, patients with diabetes mellitus (DM) who are not compliant with treatment or are undertreated, usually tend to have a poorer outcome compared to patients who undergo treatment. The neuropathy frequently results in the breakdown of skin, ulceration, and eventually to an infection. Amputation of the toes and limbs are not uncommon. However, the actual treatment of diabetic neuropathy is not perfect, and often most treatments do not work. Complete relief from symptoms of neuropathy is rare. Overall, the mortality rates are highest in patients with DM with autonomic neuropathy, especially those who have cardiac dysfunction. The overall mortality rates are 15% to 30% over ten years, but there is also significant morbidity from limb amputation. Other symptoms that make the quality of life poor include syncopal attacks, diarrhea, constipation, and continuous pain.[2][18] (Level 5)