Recommended Care
• All patients with T2DM should be assessed for diabetic neuropathy at the time of initial diagnosis and annually
• Diagnose sensorimotor nerve damage by history and examination (10 g monofilament with or without temperature, non-traumatic pin-prick, vibration [128 Hz tuning fork], ankle reflexes), and/or simple quantitative testing (e. g. biothesiometer vibration perception). Use serum B12, thyroid function tests, creatinine/urea, and alcohol abuse and medication history to exclude other causes.
• Diabetic Neuropathy Symptom Score (NSS) and Neuropathy Disability Score (NDS) in T2DM population has been found to be a useful resource in evaluating diabetic sensorimotor polyneuropathy as an important bed side tool.
• Diagnose symptomatic (painful) diabetic neuropathy by excluding other possible causes of the symptoms. Manage by stabilizing blood glucose control, and treatment with tricyclic antidepressants, if simple analgesia is not successful. If a one month trial of tricyclic therapy is not successful, further treatment options include pregabalin/gabapentin and duloxetine, then tramadol and oxycodone.
• Weight gain and lifestyle measures need a reinforcement with the use of antidepressants and gabapentin and pregabalin.
• Further management normally requires referral to a pain control team. Be aware of the psychological impact of continuing symptoms, particularly if sleep is disturbed. In patients with diabetic neuropathy and co-morbid depression, anxiety and sleep loss, duloxetine should be preferred.
• A visual record of simple graphic tool to measure response to therapy must be mandated, which will save patients from over/unnecessary treatment.
• Tools e. g. pain scale should be encouraged in clinical practice.
• Diagnose erectile dysfunction by history (including medication history), exclusion of endocrine conditions (measure prolactin and testosterone), and a trial of a phosphodiesterase type-5 (PDE5) inhibitor (where not contraindicated by nitrate therapy). Consider other approaches such as intra-urethral or intracavernosal drugs and sexual and relationship counselling, where PDE5 inhibitors fail or cannot be used.
• Discourage use of alternative medicines as they can cause further complications.
• Diagnose gastroparesis by history, trial of a prokinetic drug (metoclopramide, domperidone) and if troublesome, by gastric emptying studies.
• Diagnose CV autonomic neuropathy by resting heart rate and heart rate response to provocation tests (lying-standing, Valsalva, deep breathing), and by lying and standing BP. Inform anaesthetists when relevant, where this is present.
• Every patient must undergo a simple assessment e. g. questionnaire-based assessment for depression.