Painful and non-painful diabetic neuropathy, diagnostic challenges and implications for future management (original) (raw)

Painful and non‐painful diabetic polyneuropathy: Clinical characteristics and diagnostic issues

Journal of Diabetes Investigation, 2019

Diabetic neuropathy (DN) is a common complication of diabetes and can be either painful or non-painful. It is challenging to diagnose this complication, as no biomarker or clear consensus on the clinical definition of either painful or non-painful DN exists. Hence, a hierarchical classification has been developed categorizing the probability of the diagnosis into: possible, probable or definite, based on the clinical presentation of symptoms and signs. Pain is a warning signal of tissue damage, and non-painful DN therefore represents a clinical and diagnostic challenge because it often goes unnoticed until irreversible nerve damage has occurred. Simple clinical tests seem to be the best for evaluation of DN in the general care for diabetes. Screening programs at regular intervals might be the most optimal strategy for early detection and interventions to possibly prevent further neuronal damage and to lower the economic burden of this complication. DEFINITIONS AND CLASSIFICATION OF DIABETIC NEUROPATHY The phenotype of DN is heterogeneous. The most common form of DN is a chronic symmetrical length-dependent sensorimotor polyneuropathy, termed diabetic polyneuropathy (DPN), which accounts for 75-90% of all DN cases. Other types of DN include autonomic neuropathy, diabetic radiculoplexopathy (formerly called diabetic amyotrophy), mononeuropathies and treatment-induced neuropathies (Figure 1;Table 1) 4,12,16. In the following, we will focus on DPN, which can be either painful

Halting the March of Painful Diabetic Neuropathy

2015

Aki Hietaharju, MD, PhD Tampere University Hospital Department of Neurology and Rehabilitation PO Box 2000, 33521 Tampere, Finland Email: aki.hietaharju@pshp.fi D iabetes is a worldwide epidemic with a global prevalence of 8.3 %, and its prevalence is likely to increase in tandem with the global epidemic of obesity. Diabetic neuropathy is th most common complication of diabetes, and risk of developing it increases with the duration of diabetes. On the other hand, even patients with impaired glucose tolerance develop painful neuropathic symptoms and damage to small nerve fibers. Symptoms of diabetic polyneuropathy manifest earlier in type 2 diabetes than in type 1 diabetes. In type 2 diabetes, 8% of patients have neuropathy at the time of diagnosis, and up to 50% of older type 2 diabetic patients have evidence of a distal neuropathy. Poor glycemic control is the most important risk factor for diabetic neuropathy, and according to high-quality evidence, enhanced glucose control signif...

Advances in the Diagnosis and Treatment of Painful Diabetic Neuropathy

European Endocrinology, 2008

Symptoms of painful diabetic neuropathy (PDN) occur in 30-40% of patients with diabetic neuropathy. 1 It is most commonly associated with distal symmetrical neuropathy affecting the lower limbs (especially toes and feet), and patients present with burning, stabbing and tingling sensations. PDN is extremely distressing and significantly reduces the Hassan Fadavi is undertaking his PhD in the Cardiovascular Research Group at the University of Manchester. His main research interests include defining the basis of ethnic differences in the development of diabetic neuropathy and the diagnosis and treatment of diabetic foot ulceration.

Painful diabetic neuropathy: Diagnosis and management

Diabetes & Metabolism, 2011

The prevalence of painful diabetic peripheral neuropathy (PDN) is about 20% in patients with type 2 diabetes and 5% in those with type 1. Patients should be systematically questioned concerning suggestive symptoms, as they are not usually volunteers. As PDN is due to small-fibre injury, the 10 g monofilament pressure test as well as the standard electrophysiological procedures may be normal. Diagnosis is based on clinical findings: type of pain (burning discomfort, electric shock-like sensation, aching coldness in the lower limbs); time of occurrence (mostly at rest and at night); and abnormal sensations (such as tingling or numbness). The DN4 questionnaire is an easy-to-use validated diagnostic tool. Three classes of drugs are of equal value in treating PDN: tricyclic antidepressants; anticonvulsants; and selective serotonin-reuptake inhibitors. These compounds may be prescribed as first-line therapy following pain assessment using a visual analogue scale. If the initial drug at its maximum tolerated dose does not lead to a decrease in pain of at least 30%, another drug class should be prescribed; if the pain is decreased by 30% but remains greater than 3/10, a drug from a different class may be given in association.

Mechanisms and Management of Diabetic Painful Distal Symmetrical Polyneuropathy

Diabetes Care, 2013

Although a number of the diabetic neuropathies may result in painful symptomatology, this review focuses on the most common: chronic sensorimotor distal symmetrical polyneuropathy (DSPN). It is estimated that 15–20% of diabetic patients may have painful DSPN, but not all of these will require therapy. In practice, the diagnosis of DSPN is a clinical one, whereas for longitudinal studies and clinical trials, quantitative sensory testing and electrophysiological assessment are usually necessary. A number of simple numeric rating scales are available to assess the frequency and severity of neuropathic pain. Although the exact pathophysiological processes that result in diabetic neuropathic pain remain enigmatic, both peripheral and central mechanisms have been implicated, and extend from altered channel function in peripheral nerve through enhanced spinal processing and changes in many higher centers. A number of pharmacological agents have proven efficacy in painful DSPN, but all are ...

Diabetic Peripheral Neuropathy: Epidemiology, Diagnosis, and Pharmacotherapy

Clinical therapeutics, 2018

Diabetic peripheral neuropathy (DPN) is the commonest cause of neuropathy worldwide, and its prevalence increases with the duration of diabetes. It affects approximately half of patients with diabetes. DPN is symmetric and predominantly sensory, starting distally and gradually spreading proximally in a glove-and-stocking distribution. It causes substantial morbidity and is associated with increased mortality. The unrelenting nature of pain in this condition can negatively affect a patient's sleep, mood, and functionality and result in a poor quality of life. The purpose of this review was to critically review the current literature on the diagnosis and treatment of DPN, with a focus on the treatment of neuropathic pain in DPN. A comprehensive literature review was undertaken, incorporating article searches in electronic databases (EMBASE, PubMed, OVID) and reference lists of relevant articles with the authors' expertise in DPN. This review considers seminal and novel researc...

Painful Diabetic Neuropathy: Epidemiology, Natural History, Early Diagnosis, and Treatment Options

Pain Medicine, 2008

To facilitate the clinician's understanding of the basis and treatment of painful diabetic neuropathy (PDN). PDN is one of several clinical syndromes in patients with diabetic peripheral neuropathy (DPN) and presents a major challenge for optimal management. A systematic review of the literature was undertaken for articles specific to PDN, using Medline databases between 1966 and 2007. The epidemiology of PDN has not been well established and on the basis of available data the prevalence of pain is 10% to 20% in patients with diabetes and from 40% to 50% in those with diabetic neuropathy. It has a significant impact on the quality of life and health care costs. Pathophysiologic mechanisms underlying PDN are similar to other neuropathic pain disorders and are broadly characterized as peripheral and central sensitization. The natural course of PDN is variable, with many patients experiencing spontaneous improvement and resolution of pain. Hyperglycemia-induced pathways result in nerve dysfunction and damage, which lead to hyperexcitable peripheral and central pathways of pain. Glycemic control may prevent or partially reverse DPN and modulate PDN. Quantifying neuropathic pain is difficult, especially for clinical trials, although this has improved recently with the development of neuropathic pain-specific tools, such as the Neuropathic Pain Questionnaire and the Neuropathic Pain Symptom Inventory. Current therapeutic options are limited to symptomatic treatment and are similar to other types of neuropathic pain. A better understanding of the peripheral and central mechanisms resulting in PDN is likely to promote the development of more targeted and effective treatment.

Understanding the impact of painful diabetic neuropathy

Diabetes-metabolism Research and Reviews, 2003

Painful neuropathy is a common and often distressing complication of diabetes. It has considerable impact on the social and psychological well-being of affected individuals. There are two distinct forms of painful neuropathy: an acute and self-limiting form that resolves within a year or a chronic form that can go on for years. There are now a number of drugs available for the treatment of neuropathic pain. However, some may fail to respond to these drugs or may have unacceptable adverse side effects. When this is the case, the patient's quality of life can be severely affected.Health care professionals need to assess the full impact of painful neuropathy. In this article we review a number of instruments that are used to assess the severity of painful neuropathy and its impact on the quality of life. Copyright © 2003 John Wiley & Sons, Ltd.

Importance of pain evaluation for more accurate diagnosis of painful diabetic polyneuropathy

Medicina (Kaunas, Lithuania), 2010

Pain is a common problem in diabetic neuropathy, but relatively little has been published regarding the extent to which it needs to be addressed in clinical practice. To assess neuropathic pain profile and its association with quantitative sensory testing in painful diabetic polyneuropathy. Altogether, 61 consecutive diabetic inpatients with symmetric neuropathic complaints were enrolled. Clinical neurological examination and quantitative sensory testing (QST) were performed. Patients were interviewed using the Neuropathic Pain Scale (NPS) and filled in the McGill Pain Questionnaire (MPQ). Of all patients, 49 (80.3%) had clinical diabetic polyneuropathy. Only 17 of these patients complained of lower extremity pain on an initial interview, while 27 marked it in the MPQ. The intensity of deep and superficial pain did not differ, but patients rated deep pain as more unpleasant than superficial (6.27±2.37 vs. 4.30±1.42 on the NPS, P=0.034). Superficial pain NPS items tended to correlate...