COMMENTARY

Diabetic Neuropathy: New Insights With Professor Solomon Tesfaye

Solomon Tesfaye, MD

Disclosures

September 23, 2014

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My name is Professor Solomon Tesfaye. I am a consulting physician in Sheffield, United Kingdom, and Honorary Professor of Diabetic Medicine at the University of Sheffield.

I was greatly honored during this European Association for the Study of Diabetes (EASD) meeting to have been awarded the Camillo Golgi Prize for outstanding contributions to the research on the complications in diabetes. I gave a lecture, which you can view on the EASD website.[1] It's free. You can look at the whole lecture with all the slides, but I'll give you a little flavor of what I said yesterday.

Diabetic neuropathy unfortunately is still very common in the UK. Retinopathy is no longer the commonest cause of working-age blindness. This news came this year in March.[2] We were all delighted, because ever since I was a junior research fellow, everybody told me that retinopathy is the commonest cause of blindness. In the UK, we have eye screening on an annual basis using retinal photography, and the patients are referred to the ophthalmologist at the earliest signs of problems that can be treated, so we have managed to make it not the commonest cause of blindness.

The situation is different for neuropathy. Amputations are rising in the UK. Next year, 7000 amputations are going to be performed, much more than last year.[3] Why is this? It's because we are diagnosing diabetic neuropathy very late.

A recent study from Germany showed that in patients with impaired fasting glucose and impaired glucose tolerance—together, prediabetes—there was more neuropathy than in patients with newly diagnosed diabetes.[4] At first this might seem unusual, but the diagnosis of diabetes is made according to cut-off points that are based on the development on retinopathy. In fact, neuropathy precedes retinopathy, because we have also shown that it is driven not only by glucose but also by vascular risk factors. Therefore, we need to detect this condition early.

Currently we are using monofilament, which is very crude, in the diagnosis of the condition, when it's too late to reverse. Recently in the United States, a company has come up with the DPNCheck™ (NeuroMetrix Inc.; Waltham, Massachusetts), which can diagnose neuropathy in five minutes. It's a point-of-care device, and has recently been shown to be a good way of diagnosing neuropathy.[5] There are also the Sudoscan (Impeto Medical; Paris, France) and confocal microscopy of the eye, but at least it gives you a quantitative measure of neuropathy.

It would be nice to use the point-of-care test to detect neuropathy early, rather than using just the clinical methods that diagnose the condition very late. We need to know whether these are early markers by doing prospective studies. Do these devices predict the development of clinical neuropathy down the line? That is still to be determined.

The other message of my presentation is that diabetic neuropathy is not just a peripheral neuropathy, but in fact involves the spinal cord. It involves the thalamus. There is increased in the vascularity in those with painful diabetic neuropathy. There is evidence of a reduction in the function of the neurons in the thalamus by using MR spectroscopy in diabetic neuropathy.

So, "diabetic peripheral neuropathy" is a misnomer. It affects the entire central nervous system. It is not a peripheral neuropathy.

If you want to hear more, please visit the EASD website. You can listen to the entire lecture or parts of my lecture at your leisure. Thank you for your very kind attention.

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