Synopsis
Detect diabetic nerve injury before ulceration or organ dysfunction, exclude treatable alternatives, relieve neuropathic pain safely, and protect function through multidisciplinary follow-up.
- Distal symmetrical sensorimotor polyneuropathy usually begins in the toes with length-dependent numbness, burning, electric pain or loss of protective sensation.
- A 10 g monofilament identifies loss of protective sensation but does not exclude small-fibre painful neuropathy when the result is normal.
- Check pulses, skin, footwear, deformity, callus and previous ulcer at every formal foot assessment because neuropathy converts pressure into unnoticed injury.
- Diabetes is common but not exclusive: consider vitamin B12 deficiency, alcohol, CKD, thyroid disease, medicines, paraproteinaemia, entrapment and inflammatory neuropathy.
- Autonomic involvement can affect blood pressure, heart rate, sweating, stomach emptying, bowel habit, bladder, sexual function and awareness of hypoglycaemia.
- Optimise glucose safely and address smoking, alcohol, blood pressure, lipids and nutrition; overly rapid glycaemic improvement can occasionally provoke acute painful neuropathy.
- NICE offers amitriptyline, duloxetine, gabapentin or pregabalin as initial non-specialist options for neuropathic pain, selected by comorbidity and patient preference.
- Review analgesic benefit by pain, sleep and function, and plan deprescribing; gabapentinoids carry dependence, withdrawal, sedation and respiratory-depression risks.
Key red flags
Rapid evolution, pronounced weakness, asymmetry, a sensory level, cranial signs or sphincter change requires urgent neurological reassessment rather than routine diabetes follow-up.
Investigation priorities
Define distribution, protective sensation, motor involvement and immediate ulcer risk.
Management branches
A person attends annual diabetes review or reports sensory symptoms, pain, balance change or unnoticed injury.
- Ask about pain, numbness, balance, falls, skin injury and footwear, then inspect both feet, palpate pulses and test protective sensation using the local NICE-aligned technique.
- Classify foot risk from neuropathy, vascular supply, deformity, callus, previous ulcer or amputation and renal replacement therapy, and arrange the required foot-protection follow-up.
- Give specific daily inspection, footwear and temperature-injury advice, with a same-day route for a new blister, colour change, swelling, break in skin or discharge.
Key medicines
DuloxetineFor licensed diabetic peripheral neuropathic pain, the starting and recommended maintenance dose is 60 mg once daily with or without food; review response after two months and follow the exact current product information.Avoid in hepatic impairment causing liver dysfunction, severe renal impairment and uncontrolled hypertension as specified by the SmPC. Review serotonergic interactions, bleeding risk, hyponatraemia, suicidality and withdrawal; taper rather than stopping suddenly.