Painful diabetic neuropathy: Diagnosis and management

doi:10.1016/j.diabet.2011.06.003

Diabetes & Metabolism

Volume 37, Issue 5, November 2011, Pages 377-388

https://doi.org/10.1016/j.diabet.2011.06.003 Get rights and content

Abstract

The prevalence of painful diabetic peripheral neuropathy (PDN) is about 20% in patients with type 2 diabetes and 5% in those with type 1. Patients should be systematically questioned concerning suggestive symptoms, as they are not usually volunteers. As PDN is due to small-fibre injury, the 10 g monofilament pressure test as well as the standard electrophysiological procedures may be normal. Diagnosis is based on clinical findings: type of pain (burning discomfort, electric shock-like sensation, aching coldness in the lower limbs); time of occurrence (mostly at rest and at night); and abnormal sensations (such as tingling or numbness). The DN4 questionnaire is an easy-to-use validated diagnostic tool. Three classes of drugs are of equal value in treating PDN: tricyclic antidepressants; anticonvulsants; and selective serotonin-reuptake inhibitors. These compounds may be prescribed as first-line therapy following pain assessment using a visual analogue scale. If the initial drug at its maximum tolerated dose does not lead to a decrease in pain of at least 30%, another drug class should be prescribed; if the pain is decreased by 30% but remains greater than 3/10, a drug from a different class may be given in association.

Résumé

La neuropathie douloureuse concerne environ 20 % des diabétiques de type 2 et 5 % des diabétiques de type 1. Elle doit être systématiquement cherchée par l’interrogatoire car les patients n’en parlent pas spontanément. C’est une complication qui concerne les petites fibres. Elle peut donc s’accompagner d’un test au monofilament et d’un électromyogramme normaux. Le diagnostic est clinique : type de douleur (brûlure, décharge électrique, froid douloureux…), horaire de survenue (plutôt au repos, plutôt la nuit), sensations anormales (fourmillement, engourdissement…). Le questionnaire DN4 est un outil diagnostique simple et validé. Trois classes médicamenteuses ont fait la preuve d’une efficacité équivalente : les antiépileptiques, les anti-dépresseurs tricycliques et les inhibiteurs mixtes de la recapture de la sérotonine et de la noradrénaline. Elles peuvent donc être prescrites en première intention, après évaluation de la douleur sur une échelle numérique. À dose maximale tolérée, si le traitement initial n’a pas permis de diminuer la douleur de 30 %, une autre classe doit être choisie. Si la douleur a diminué de 30 % mais reste supérieure à 3/10, deux classes peuvent être associées.

Section snippets

Epidemiology

The acute presentation of PDN is rare, and the chronic variant is by far the most common form, presenting as part of the CSPDN [1].

Pathophysiology

Diabetic polyneuropathy always involves damage to the small neural fibres [47], [48]. However, a distinction must be made with the small myelinated (A-delta) fibres that are associated with sensitivity to cold and prick, and the small unmyelinated (C) fibres that are responsible for sensitivity to heat and pain (Table S1; see supplementary material associated with this article online). These small fibres are not assessed by electrophysiological procedures. Autonomic fibres (sympathetic and

Chronic sensorimotor diabetic peripheral neuropathy and foot at risk for ulceration

CSPDN is distal, symmetrical and often asymptomatic. The subjective symptoms are usually discrete or absent, although the diagnosis can be made on examination using the Neuropen [13]. Resembling a small pen, this device has a 10 g monofilament that tests the touch/pressure sensation (large nerve fibres) at one end, and a blunt needle at the other end for assessing sharpness/pain sensation (small fibres) (Table S1; see supplementary material associated with this article online). The Neuropen

Drug treatments

There is now a consensus among experts that the analgesic efficacy of drug treatments for neuropathic pain is independent of the aetiology of neuropathy. However, most trials of neuropathic pain have been conducted in DPN and postherpetic neuralgia. A number of drug classes are available for treatment, but there are still only a few large-scale comparative studies (see the evidence-grading system for drugs in Appendix S3 in the supplementary material associated with this article online).

The

Therapeutic recommendations

Treatments for PDN aim to decrease pain intensity (symptomatic treatment) and, wherever possible, improve QoL (Table 2 and Appendix 1). Such treatments are not intended to act on abnormal sensations (dysaesthesia), but only on pain. Patients need to be informed that the complete disappearance of pain is rarely achieved.

Pain intensity (as determined by a visual analogue scale, for example) and its consequences have to be evaluated before starting treatment and at each step of titration. A

Disclosure of interest

A. Hartemann: Lilly, Pfizer, Sanofi-Aventis. N. Attal: Pfizer, Boehringer Ingelheim/Lilly, Grunenthal, Daiichi. D. Bouhassira: Pfizer, Boehringer, Astra-Zeneca, Johnson & Johnson, Grunenthal, Pierre Fabre, Astellas, Esteve, Medtronic, Newron, Sanofi-MSD and Sanofi-Aventis. I. Dumont: none. H. Gin: Lilly, Boehringer-Ingelheim, Pfizer. S. Jeanne: Lilly. G. Saïd: Lilly. J.L. Richard: Lilly, Johnson and Johnson, Quigley Pharma.

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