Involvement of the peripheral and autonomic nervous systems is one of the complications of diabetes. Clinical diabetic neuropathy is categorized into distinct syndromes according to the neurological distribution, although many overlap syndromes occur. Neuropathies severely decrease patients' quality of life and in turn can have adverse psychological effects. Whilst the primary symptoms of neuropathy can be highly unpleasant, the secondary complications (eg, falls, foot ulcers, cardiac arrhythmias), are even more serious.
Poor glucose control and vascular risk factors appear to be associated with the development of diabetic neuropathy.
First-line pain management
Paracetamol may be trialled as first-line management for neuropathic pain and may be continued throughout any regimen.Second-line pain managementIf paracetamol alone is not adequate for controlling pain, a tricyclic antidepressant (TCA) may be added to the regimen (or paracetamol substituted for a TCA). Nortriptyline is the preferred TCA for neuropathic pain, due to fewer adverse effects than other TCAs. Initiate nortriptyline at 10 mg per day (usually taken at night) and titrate dose upwards until pain is controlled. The dose should not usually exceed 75 mg.Third-line pain management
If second-line pain management is insufficient, an anticonvulsant may be added to the treatment regimen, or the TCA substituted for an anticonvulsant. Referral to, or discussion with, a pain specialist can be considered. Carbamazepine and sodium valproate are both effective for neuropathic pain. Gabapentin has also traditionally been used for neuropathic pain but recent evidence suggests that it has limited effectiveness for this indication For more information see "New evidence shows less benefit of gabapentin for neuropathic pain" . Carbamazepine may be initiated at a dose of 100 mg per day. Increase the dose slowly until pain is controlled, to avoid adverse effects such as nausea, vomiting and dizziness. Regular monitoring is required. Opioids such as methadone or oxycodone may have a limited place in the treatment of neuropathic pain but their use is not advised unless in consultation with a specialist in pain management.
Capsaicin cream and local anaesthetic gels may be trialled throughout a treatment regimen for neuropathic pain, They should not be applied to broken/ulcerated skin.
For more information click here:
Patients with multiple risk factors should be considered at high risk of developing diabetic retinal disease.
Arrange regular retinal screening:
Check visual acuity. Normal vision does not preclude sight threatening retinopathy.
Look for cataracts- more common in diabetes and seen at a younger age and progress more rapidly.
Renal / Diabetic Nephropathy
People with confirmed microalbuminuria should be treated with an ACE inhibitor or an ARB whether or not hypertension is present.
Image: Further info regarding notes see: Figure 3, page 10, NZGG Type 2 Diabetes Management
Assess peripheral circulation with thorough palpation of pedal pulses (dorsalis pedis and posterior tibial). If there are no palpable pulses, and if a Doppler machine is available, calculate ankle brachial index (see below) or consider referral to a vascular specialist. Absent pulses, calf claudication, absence of hair on the feet, altered temperature (a cold foot) and thin, bluish skin are suggestive of peripheral arterial disease.6 A bounding, easily detected pulse in a warm, dry foot is suggestive of autonomic neuropathy, which causes abnormal arterio-venous shunting.
Equipment - Blood pressure cuff and hand-held Doppler machine
1. Take the blood pressure in the arm (brachial pressure)
2. Take the blood pressure in the ankle using the Doppler machine (ankle pressure)
3. Calculate ankle brachial index by dividing systolic ankle pressure by systolic brachial pressure e.g. ankle pressure is 120 mmHg and brachial pressure is 132 mmgHg, ankle brachial index is 120/132 = 0.9
0.9 - 1.2
Risk of vascular foot ulcer is small
Definite vascular disease
0.6 - 0.9
Risk of vascular ulcer moderate, depending on other risk factors
Severe vascular disease
Less than 0.6
Risk of vascular foot ulcer very high
Ankle brachial index may not be able to be reliably calculated in some people with diabetes as the arteries in the ankles may be calcified.
Criteria for referral to a vascular surgeon for a patient with a diabetic foot complication includes the following:
Risk factors for diabetic foot disease include:
* Risk factors for PVD are smoking, hypertension and hypercholesterolaemia.
The cumulative effect of these risk factors for PVD is considered to be at least additive.
Appropriate footwear is recognised in the literature as an important part of management to prevent diabetic foot disease.
Feet should be screened at least annually how to use a 10g monofilament
Further Information BPAC - Screening and management of the diabetic foot
Disclaimer: This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.