Current concepts in the management of diabetic polyneuropathy

Abstract

Diabetic sensorimotor polyneuropathy (DSPN) is encountered in approximately one-third of people with diabetes. This, in turn, might markedly impoverish their quality of life, mainly owing to neuropathic pain and foot ulcerations. Painful DSPN might be as frequent as 25% in diabetes patients. Symptoms as a result of DSPN typically comprise pain, paresthesia and numbness in the distal lower limbs. Asymptomatic DSPN might reach 50% among patients with this condition. Unfortunately, DSPN is still not adequately diagnosed and treated. Its management has three priorities: (i) lifestyle improvement, near-normoglycemia and multifactorial cardiovascular risk intervention; (ii) pathogenesis-oriented pharmacotherapy; and (iii) symptomatic alleviation of pain. Intensive diabetes therapy showed evidence for favorable effects on the incidence and deterioration of DSPN in type 1 diabetes, but not type 2 diabetes. Among pathogenesis-oriented treatments, alipoic acid, actovegin, benfotiamine and epalrestat are currently authorized to treat DSPN in several countries. Symptomatic therapy uses analgesics, notably antidepressants, opioids and anticonvulsants, reducing pain by ≥50% in approximately 50% of individuals, but might be limited, particularly by central nervous system-related adverse events. Local treatment with the capsaicin 8% patch might offer an alternative. In addition to pain relief, therapy should improve sleep, mobility and quality of life. In conclusion, multimodal treatment of DSPN should consider the individual risk profile, pathogenetic treatment and pain management using pharmacotherapy (combinations, if required), as well as non-pharmacological options.

Skin AGEs and diabetic neuropathy

“…Finally, longer follow-up of patients with early increases in skin AGEs is highly welcome. Clarification of all these issues will help our decisions on the implementation of AGEs measurement in everyday reality, with the aim to improve outcomes of DPN, a still valid strategic priority [46][47][48][49].…”

Microvascular Complications of Diabetes Mellitus: Focus on Diabetic Retinopathy (DR) and Diabetic Foot Ulcer (DFU)

“…DFUs are frequently infected. The most common germs involved are staphylococci and streptococci, but deep infections are usually polymicrobial including gram positive, gram negative and even anaerobic germs [98,99]. Chronic hyperglycemia and chronic hypoxia predispose to severe infections [99].…”

“…Evaluation of sensory neuropathy is very important to establish whether the patient has lost the protective sensation, making him prone to accidental trauma. Hot/cold discrimination, pain perception, light touch and vibration perception, as well as protective sensation must be tested [95][96][97][98][99]. The latter is best assessed by the 10 g Semmes Weinstein monofilament or the measurement of the vibration perception threshold (VPT) with a neurothesiometer [93-95, 102, 103].…”

“…The latter is best assessed by the 10 g Semmes Weinstein monofilament or the measurement of the vibration perception threshold (VPT) with a neurothesiometer [93-95, 102, 103]. Tendon reflexes and muscular strength are also a part of the examination [95][96][97][98][99]. Finally, sudomotor dysfunction (reduced sweat production) is best examined by the Neuropad indicator test, which is based on a colour change from blue to pink [96,97].…”

“…Similarly, one may measure the toe-brachial index (TBI), given that small digital arteries are rarely calcified: TBI<0.7 confirms the diagnosis of PAD [108]. More sophisticated evaluation (ultrasound, angiography) are used when necessary, especially to guide interventional treatment [95][96][97][98][99].…”