ADA Publishes Statement on Diabetic Neuropathies
The April issue of Diabetes Care includes a statement from the American Diabetes Association (ADA) about the classification, diagnosis, and management of diabetic neuropathies. The statement, based on 2 recent technical reviews also published in Diabetes Care, recommends the following:
* Advise patients with diabetes to maintain tight glycemic control. This includes blood glucose and A1C levels. Blood pressure and lipid levels should also be closely monitored and controlled. The clinician should recommend lifestyle changes and/or pharmacologic therapy as needed to accomplish the therapeutic goals.
* Screen patients with diabetes for chronic sensorimotor distal symmetric polyneuropathy (DPN). According to the ADA, the initial screening should be at the time that type 2 diabetes is diagnosed and 5 years after type 1 diabetes is diagnosed. Thereafter, patients should be evaluated at least annually by examining sensory function in their feet and by checking ankle reflexes.The clinician may assess sensory function with 1 or more of the following:
* pinprick
* temperature
* vibration perception (using a 128-Hz tuning fork)
* pressure sensation (using a 10-g monofilament at the distal halluces).In addition, the clinician should ask the patient if he or she has a history of neuropathic symptoms, then carefully examine the feet and lower limbs, checking for ulcers, calluses, and deformities. The patient's footwear should be inspected at each visit as well to detect signs of ill-fitting shoes, which could increase the risk for ulceration. Some patients may need to be referred to a podiatrist for further workup.
* Screen patients with diabetes for autonomic neuropathy. The timing recommended by the ADA is the same as for DPN: when a patient is diagnosed with type 2 diabetes and 5 years after a patient is diagnosed with type 1 diabetes. Screening includes a patient history and examination for signs of autonomic dysfunction. The clinician may decide to assess heart rate variability with tests such as the expiration-to-inspiration ratio and response to the Valsalva maneuver and standing.
If the screening turns out negative, the patient should be retested annually. But if the screening is positive, the clinician should schedule appropriate diagnostic tests and start the patient on symptomatic treatments.
The full statement is available at http://care.diabetesjournals.org/cgi/content/full/28/4/956.
Source: Boulton AJ, Vinik AI, Arezzo JC, et al. Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care 2005; 28:956-62.