Diabetic Neuropathy: New ADA Position Statement for Primary Care

Laurie E. Scudder, DNP, NP; Rodica Pop-Busui, MD, PhD

Disclosures

March 14, 2017

In This Article

Diabetic Neuropathy: New Recommendations for Primary Care

Diabetic neuropathies are the most prevalent chronic complications of diabetes—and they are often devastating for the patient. Estimates of the incidence and prevalence of diabetic neuropathies vary greatly, but several large observational cohorts and other studies suggest that they occur in at least 20% of people with type 1 diabetes after 20 years of disease. Distal symmetrical polyneuropathy (DSPN) may affect at least 10%-15% of patients with newly diagnosed type 2 diabetes, with rates increasing to 50% after 10 years of disease.[1,2,3,4]

The American Diabetes Association recently released a new position statement on diabetic neuropathy. Medscape spoke with the lead author, Rodica Pop-Busui, MD, PhD, about how these recommendations can assist primary care providers (PCPs) in the prevention, early recognition, and appropriate management of neuropathies in patients with diabetes.

Medscape: What types of diabetic neuropathy should PCPs be aware of, and how common are they?

Rodica Pop-Busui, MD, PhD

Dr Pop-Busui: DSPN is the most prevalent form, and the best studied. DSPN is associated with several known severe complications, such as ulcers and infections, which can lead to lower-limb amputations. But even before that, the progressive damage of the various populations of nerve fibers may cause pain and/or lead to progressive loss of sensation, which decreases sense of balance and thermal discrimination; these factors increase the risk for falls or burns and affect patients' daily function.

In addition to DSPN, the autonomic neuropathies, such as cardiovascular autonomic neuropathy, are relevant to clinical practice. More evidence has been unveiled in the past decade to further underline the seriousness of the consequences of diabetic neuropathies.

Medscape: The position statement emphasizes that the key to treatment of diabetic neuropathy is to prevent it in the first place. Are there any new strategies—beyond the recognized importance of adequate glucose control—that PCPs should be instituting in patients with diabetes or prediabetes?

Dr Busui: Evidence is emerging about the role of lifestyle interventions in the prevention of DSPN, which is quite exciting. A couple of studies show that, especially for patients with prediabetes and neuropathy, exercise and some types of diets seem to have a beneficial effect in prevention and possibly even reversal.[5,6,7] However, we don't have the same strength of evidence that we have for the benefit of glucose control in type 1 diabetes. These data have to be confirmed, but lifestyle interventions are cited in the statement as promising therapeutic options.

Medscape: What type of exercise? How much exercise is required?

Dr Busui: We cited studies that tested the types of exercise used in the Diabetes Prevention Program: typically 30 minutes daily of moderate to intense exercise.[6,7] Other studies have looked at more intense exercise, but most studied the level of exercise used in the Diabetes Prevention Program.

Is Prevention Possible?

Medscape: According to the statement, enhanced glucose control is very effective in preventing diabetic peripheral neuropathy in patients with type 1 diabetes, but is less successful in those with type 2. Why is that?

Dr Busui: Patients with type 2 diabetes are typically very different from patients with type 1 diabetes. They also have other risk factors. Most are overweight or obese. Many have hypertension, metabolic syndrome, and the dyslipidemia associated with metabolic syndrome. All of these factors have been shown to be important in inducing nerve fiber damage, and may explain in part why glucose control alone has not been as effective in preventing diabetic neuropathy in patients with type 2 diabetes.

Patients with type 2 diabetes may also live with the disease for years without it being clearly diagnosed. It is thus likely that most of the patients included in interventional studies that looked specifically at glucose control, and captured some measures of neuropathy, may have been already in a more advanced stage of the disease.

In contrast, the Diabetes Control and Complications Trial (DCCT)[1,4] included patients with type 1 diabetes early in their course of disease, with no neuropathy at baseline, hypertension, or other complications, except very minimal retinopathy in a subgroup by study design. In addition, a most comprehensive assessment of neuropathy was conducted in the DCCT cohort at baseline and over time in a standardized fashion. Other trials that included patients with type 2 diabetes, such as ACCORD,[8] UK Prospective Diabetes Study (UKPDS),[9] the Veterans Affairs Diabetes Trial (VADT),[10] or BARI 2D,[11] involved patients with more advanced disease.

Another possibility is that neuropathy has been defined differently in many of these trials, or some very insensitive measures were used. For instance, in the VADT, neuropathy was defined only on the basis of patient-reported symptoms, which have a high degree of subjectivity.

DSPN in patients with type 2 diabetes typically presents at a more advanced stage because these patients have a constellation of risk factors that can induce nerve damage.

DSPN in patients with type 2 diabetes typically presents at a more advanced stage because these patients have a constellation of risk factors that can induce nerve damage. That is probably the main reason that we see less protective benefit from enhanced glucose control in these patients.

Medscape: So, is it correct that the factors that make prevention less successful in patients with type 2 diabetes are essentially the same factors that lead to a larger proportion of these patients progressing to DSPN?

Dr Busui: Yes. And, as I noted, it's also possible that the true duration of disease in those patients may be much longer than years since diagnosis.

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