New ADA Guidelines for Diabetic Neuropathy

Updated position statement issued by the American Diabetes Association for managing diabetic neuropathies focused on preventing and early screening as the primary goals.

With Andrew J.M. Boulton, MD, DSc and Elena A. Christofides, MD

 American Diabetic Association (ADA) released a new position statement to improve the management of diabetic neuropathy, particularly distal symmetric polyneuropathy (DSPN) and cardiovascular autonomic neuropathy (CAN), based on an evidence-based review of the data now available. The updated guidelines were published in Diabetes Care.1

The authors focused on the need for prevention of diabetic neuropathies, which are the most commonly encountered complication in patients with both type 1 and type 2 diabetes since resulting nerve damage cannot be reversed by currently available treatments.

Likewise, the timely and accurate diagnosis of diabetic neuropathies followed by appropriate treatment remains critical, according to Andrew J.M. Boulton, MD, DSc, from the University of Manchester and the Royal Infirmary in Manchester, the United Kingdom, who was a co-chair of the panel that wrote the position statement.

New ADA guidelines focus on prevention and screening for diabetic neuropathy.

He told EndocrineWeb, “Early diagnosis of diabetic neuropathy with appropriate education, podiatry referral if indicated, and regular review may help to reduce the incidence of foot ulcerations, and ultimately amputations.” This recommendation was intended as an update for a complication of diabetes that is both highly prevalent and often overlooked by clinicians.

“In a symptom-driven society, screening for somatic neuropathy in asymptomatic diabetic patients is often neglected,” said Dr. Boulton. “To simply ask the patient if they have symptoms will miss 50% of diabetic peripheral neuropathies, and many of these patients are at increased risk.”

Limited Value Given Narrow Focus of Position Statement

“I think that this statement formally lists the medications that are approved for diabetic neuropathy in one place, but I feel that the things that are left out are significant,” Elena A. Christofides, MD, CEO of Endocrinology Associates in Columbus, Ohio, told EndocrineWeb; she further noted that the information in the position statement was rather limited.

“I would be concerned that clinicians reading this statement might falsely conclude that it contains all the available information, and it does not,” she said.

"An emphasis on prevention and screening of diabetic neuropathies as early as possible1 was a key focus of the ADA position statement," Dr. Boulton said. With increased screening of all patients with diabetes, the authors expect later complications to be reduced significantly.

Other key recommendations highlighted by Dr. Boulton included:

  • Monitoring autonomic symptoms and erectile dysfunction, which is common in patients with autonomic neuropathies;
  • Reducing the use of non-steroidal anti-inflammatory drugs and opioids as first-line treatments for painful neuropathies in favor of alternatives such as pregabalin, duloxetine, and gabapentin;
  • Considering peripheral somatic neuropathies when determining the cause of unsteadiness and falls; and
  • Screening for impaired glucose tolerance in any patient not known to have diabetes who experiences classical neuropathic painful symptoms.

While acknowledging the validity of these recommendations, Dr. Christofides was concerned that the statement did not go far enough. “We do have drugs that have been approved now for diabetic neuropathy, pregabalin, and duloxetine, whereas in 2005 we didn’t,” noted Dr. Christofides. “What’s more significant [in this position statement] are the things that are not covered.”

“The authors have ignored the contribution of advanced glycosylation end-products, colloquially known as AGEs) to the disease pathogenesis,” Dr. Christofides continued, and “they have also failed to address the contribution of B-vitamin metabolism abnormalities to the pathogenesis of neuropathies as a general class of illnesses.”

“In addition, there was no mention of data that shows regeneration of nerves fibers and improvement of disease progression and patient quality of life using activated forms of B-vitamins known as methylcobalamin, or MeCbl,” she said.

“Finally, the authors left out hyperbaric oxygen and laser light therapy, which are non-pharmacologic symptomatic treatments that have been used with success in peripheral diabetic neuropathy,” Dr. Christofides pointed out.

Subtype-Specific Recommendations for Diabetic Neuropathy

The ADA statement presented specific management guidelines for certain subtypes of DN, particularly DSPN, which makes up 75% of diabetic neuropathies, and CAN, the most prevalent autonomic neuropathy. Without proper management, DSPN may lead to foot ulceration, Charcot neuroarthropathy, and an increased risk of falls, and possibly, bone fractures. CAN, meanwhile, is a known risk factor for both cardiovascular and all-cause mortality.

Additionally, the statement provided information on less common autonomic neuropathies,1 such as gastrointestinal and urogenital neuropathies, and atypical neuropathies, including mononeuropathies, diabetic radiculoplexus neuropathy, and treatment-induced neuropathies.

“Contrary to popular opinion, there are treatments for many of the symptoms and signs of autonomic neuropathy, and one example is the use of low dose broad spectrum antibiotics to reduce bacterial overgrowth in diabetic diarrhea secondary to autonomic neuropathy,” Dr. Boulton told EndocrineWeb.

“Moreover, the PDE5 inhibitors have revolutionized the management of erectile dysfunction as a side effect of diabetes, and studies have shown a good response rate in patients, even those with complications to drugs, such as sildenafil, vardenafil, and tadalafil.”

Continue Reading:
Medications to Treat Diabetic Peripheral Neuropathy
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