Synopsis
Recognise metabolic and alcohol-related nerve injury, prevent ulceration and autonomic harm, address nutrition and dependence, and treat pain without overlooking an atypical second neuropathy.
- Distal symmetrical diabetic polyneuropathy usually begins in toes with sensory loss, burning or allodynia, spreads proximally and later affects hands when leg involvement is advanced.
- Loss of protective sensation may be painless and is more dangerous than pain: inspect feet, pulses, skin, deformity and footwear and place risk into the NICE diabetic-foot pathway.
- Diabetes also causes autonomic neuropathy, entrapment neuropathies, radiculoplexus neuropathy and cranial mononeuropathies; asymmetry or proximal wasting is not routine stocking neuropathy.
Key red flags
Inability to detect monofilament pressure, temperature or injury identifies ulcer risk even if the patient reports no neuropathic pain.
Investigation priorities
Detect ulceration, callus, deformity, infection, ischaemia and loss of protective sensation and assign risk.
Management branches
Diabetes or alcohol-related sensory loss affects the feet.
- Inspect bare feet, interdigital spaces, nails, callus, deformity, temperature and footwear, assess pulses and protective sensation and ask about prior ulcer or amputation.
- Refer ulcer, infection, ischaemia or suspected active Charcot change at the urgency specified by the NICE diabetic-foot pathway and offload where advised.
Key medicines
DuloxetineFor painful diabetic neuropathy, commonly start 30 mg once daily and increase to 60 mg daily if tolerated under current BNF guidance.
PregabalinBegin with a low divided daily dose, adjust for renal function and titrate only to the lowest exposure that gives meaningful functional benefit.