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Diabetic neuropathy is a progressive nerve injury caused by chronic hyperglycemia. Distal symmetric polyneuropathy and autonomic neuropathy are the most common types; less common manifestations include mononeuropathy and radiculopathy. Patients with distal symmetric polyneuropathy typically present with sensory loss of the lower extremities and may also have motor weakness, although many affected individuals are asymptomatic. Diagnosis is typically clinical, and management includes glycemic control and daily foot care. Pharmacological therapy may be considered for pain management. In diabetic autonomic neuropathy, clinical presentation, recommended diagnostic studies, and treatment vary depending on the organ system involved. Annual screening for diabetic neuropathy is recommended for all patients with diabetes, starting at the time of diagnosis for patients with type 2 diabetes mellitus (T2DM) and 5 years after diagnosis for patients with type 1 diabetes mellitus (T1DM).
See also “Diabetic gastroparesis.”
- Diabetic polyneuropathy is the most common form of polyneuropathy in high-income countries. 
- ∼ 50% of patients with diabetes develop peripheral neuropathy. 
- Up to 90% of patients with diabetes may develop autonomic neuropathy. 
Epidemiological data refers to the US, unless otherwise specified.
- Frequently asymptomatic, but can lead to the development of additional diabetic complications (e.g., diabetic foot) 
- Types include: 
- Distal symmetric polyneuropathy in diabetes
- Diabetic radioculoplexus neuropathy: most commonly diabetic lumbosacral plexopathy, which manifests as thigh pain and proximal muscle weakness
- Treatment-induced neuropathy in diabetes (insulin neuritis): a rare small-fiber neuropathy triggered by an improvement in blood glucose levels after chronic hyperglycemia
Many individuals with diabetic peripheral neuropathy are asymptomatic and the condition is often detected only during screening or after complications develop. 
- Sensory symptoms
- Motor weakness: e.g., ataxia, balance issues
- Neurological examination may show loss or reduction of:
Approximately 50% of patients with diabetic peripheral neuropathy are asymptomatic. 
- Manage underlying etiologies. 
- Educate patients and caregivers on measures to prevent complications (e.g., ). 
- Provide pain relief if necessary (see “ ”).
- First-line medications include pregabalin, duloxetine, venlafaxine, and amitriptyline. 
- Follow up with patients regularly; adjust medication if pain remains inadequately controlled after 12 weeks of use. 
- For patients with severe or refractory symptoms, consider referral to a pain management specialist.
- Refer to neurology in case of diagnostic uncertainty.
Good glycemic control can prevent the onset and progression of diabetic neuropathy, but it cannot reverse existing nerve damage. 
Diabetic autonomic neuropathy is a type of diabetic neuropathy characterized by damage to small fiber autonomic nerves; multiple organ systems are susceptible. 
Genitourinary autonomic neuropathy 
- Sexual dysfunction (e.g., erectile dysfunction)
- Neurogenic bladder, e.g.:
Cardiovascular autonomic neuropathy 
Gastrointestinal autonomic neuropathy 
Other autonomic neuropathies 
- Perform a focused history based on the suspected affected organ. 
- Obtain diagnostic studies as needed to rule out alternative etiologies and confirm the diagnosis.
- Cardiovascular 
- Gastrointestinal 
- Optimize to achieve . 
- Treat dyslipidemia and hypertension, if present. 
- If possible, discontinue medications that may contribute to symptoms. 
- Consider specialist referral. 
- Treatment varies depending on the organ system(s) affected:
- Genitourinary symptoms: See “Treatment of urinary incontinence” and “Sexual dysfunction.”
- Management of diabetic gastroparesis.” , see “
- Manage orthostatic hypotension. 
- Educate patients on symptoms of diabetic neuropathies.
- Optimize to achieve .
- Encourage smoking cessation.
- Initiate ASCVD prevention.
Screening for diabetic neuropathy
Screening for diabetic peripheral neuropathy 
- Inquire about subjective symptoms of diabetic peripheral neuropathy.
- Assess ankle reflexes and perform a focused examination of sensation.
Screening for diabetic autonomic neuropathy 
- Inquire if patient is experiencing:
- Record resting heart rate: A resting heart rate > 100 bpm suggests cardiovascular autonomic neuropathy.
- Check .
- Assess for decreased heart rate variability by recording an ECG either:
- When the patient rises from seated to standing
- Continuously while the patient takes deep breaths for 1–2 minutes