Management of Diabetic Peripheral Neuropathy

Neuropathies are among the most common of all the long-term complications of diabetes, affecting up to 50% of patients.1–5 There are many subgroups of neuropathies; readers are referred to recent reviews for discussion of the autonomic neuropathies6 and the mononeuropathies.7 This article will focus on the most common of all the peripheral neuropathies: the somatic neuropathies affecting the lower extremities. Detailed discussions of all aspects of these neuropathies were recently published as a technical review5 and will be included in a forthcoming American Diabetes Association statement. In the past, a lack of awareness and inappropriate management of diabetic peripheral neuropathy (DPN) has led to much unnecessary morbidity and substantial health care costs. At least half of all foot ulcers, the end stage of such neuropathy, should be preventable by appropriate management and patient education. However, lack of time and inappropriate or inadequate information may lead to suboptimal care. Diabetic somatic neuropathies do represent a paradox: at one extreme there are patients with severe neuropathic pain who on examination may have only a minimal deficit, whereas at the other extreme are patients with insensate feet who are asymptomatic and may first present with foot ulcers. This review will provide an overview of DPN and a detailed guide to the management of pain in patients with significant symptomatology.