Diabetic neuropathies

Songkit Supakornnumporn MD (Dr. Supakornnumporn of University Hospitals Case Medical Center and Case Western Reserve University has no relevant financial relationships to disclose.)
Bashar Katirji MD (Dr. Katirji of Case Western Reserve University and Director of the Neuromuscular Center and EMG Laboratory at University Hospitals Case Medical Center has no relevant financial relationships to disclose.)
Louis H Weimer MD, editor. (Dr. Weimer of Columbia University has received consulting fees from Roche.)
Originally released March 8, 1996; last updated October 11, 2016; expires October 11, 2019

This article includes discussion of diabetic neuropathies, diabetic polyneuropathy, and diabetic peripheral polyneuropathy. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Neuropathies include a variety of disorders that afflict diabetics fairly exclusively and are characterized by variable degrees of peripheral nerve damage. The author emphasizes the diversity of the resulting clinical syndromes. In terms of arresting or reversing the commonest type, chronic diabetic sensory-motor polyneuropathy, unfortunately no progress has been made. Other types of neuropathy in the diabetic, such as proximal diabetic neuropathy, sometimes respond to immunomodulatory and/or anti-inflammatory treatments. Several randomized controlled studies show the efficacy of some of the newer anticonvulsant medications such as pregabalin, or antidepressants, such as duloxetine, in the treatment of diabetic neuropathic pain.

Key points

 

• Diabetes is the leading cause of peripheral polyneuropathy.

 

• Peripheral nerve dysfunction in diabetics may be caused by other common causes of neuropathies.

 

• Although chronic distal sensorimotor polyneuropathy is the most common type of diabetic neuropathy, other generalized and focal diabetic neuropathies are commonly encountered in neurologic clinical practice.

 

• Optimal glucose control remains the most important prevention and treatment strategies in diabetic polyneuropathy.

Historical note and terminology

Diabetes mellitus has 4 major systemic complications: (1) neuropathy, (2) retinopathy, (3) nephropathy, and (4) vasculopathy. Diabetic neuropathy is defined as the presence of symptoms and signs of peripheral nerve dysfunction in patients with insulin-dependent or noninsulin-dependent diabetes mellitus. In addition, diabetes remains the leading cause of peripheral polyneuropathy in developed countries.

Diabetic neuropathies consist of a variety of syndromes resulting from different types of damage to peripheral or cranial nerves. These complications of diabetes have been recognized for at least 2 centuries. In the late 1800s, a series of papers appeared in which many of the subtypes of diabetic neuropathies were defined (Althaus 1885; Leyden 1887; Auche 1890; Pryce 1893). Included in these descriptions are patients not only with diabetic sensorimotor polyneuropathy but also others with proximal diabetic, truncal, median, and ulnar neuropathies. Bruns focused further on the entity of proximal diabetic neuropathy (Bruns 1890). Diabetic polyneuropathy was recognized as having various manifestations; Leyden identified 3 subtypes: painful, ataxic, and paralytic. Autopsy studies on several patients showed peripheral nerve degeneration (Leyden 1887; Auche 1890). By the early 1900s Kraus proposed a classification of diabetic neuropathies into polyneuropathy and mononeuropathy as well as motor, sensory, and cranial types (Kraus 1922). The contemporary classification of diabetic neuropathies is shown in Table 1 (Thomas 1997; Boulton et al 2005; Tesfaye et al 2010).

Table 1. Classification of Diabetic Neuropathies

Generalized neuropathies

 

• Chronic sensorimotor polyneuropathy
• Autonomic neuropathy
• Hyperglycemic neuropathy
• Acute painful sensory neuropathy
• Treatment-related neuropathy
• Coexisting chronic inflammatory demyelinating polyneuropathy

Focal and multifocal neuropathies

 

• Cranial neuropathies
• Truncal neuropathy
• Proximal diabetic neuropathy (diabetic amyotrophy, diabetic radiculoplexopathy)
• Focal limb mononeuropathies

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