Management of diabetic neuropathy should begin at the initial diagnosis of diabetes. The primary care physician needs to be alert for the development of neuropathy, or even its presence at the time of initial diabetes diagnosis, because failure to diagnose diabetic neuropathy can lead to serious consequences, including disability and amputation. Therefore, education on foot care needs to be given by the physician. If necessary, the patient should consult a podiatrist. Moreover, patients for an infected diabetic foot ulcer or gangrene should be admitted. Patients with diabetic peripheral neuropathy require more frequent follow-up, with particular attention to foot inspection to reinforce the need for regular self-care. The primary care physician is responsible for educating patients about the acute and chronic complications of diabetes,including the psychological impact of sexual dysfunction in both men and women. The importance of involving a neurologist (preferably with expertise in peripheral neuropathy) in the treatment of patients with diabetic neuropathy cannot be overemphasized.
Of all treatments, tight and stable glycemic control is probably the most important for slowing the progression of neuropathy. Because rapid swings from hypoglycemia to hyperglycemia have been suggested to induce and aggravate neuropathic pain, the stability of glycemic control may be as important as the actual level of control in relieving neuropathic pain. Studies show that tight blood sugar control in patients with type 1 diabetes decreased the risk of neuropathy by 60% in 5 years.Also, tight glycemic control prevents the development of clinical neuropathy overall. However, tight glucose control also increases the risk of severe hypoglycemic episodes, and this should be considered when assessing its risk/benefit ratio.
Diabetic Neuropathic Pain Management
Many medications are available for the treatment of diabetic neuropathic pain. Oral agents include antidepressants and anticonvulsant drugs. Pregabalin is recommended for treatment of diabetic neuropathic pain. The drug has been proven effective and can improve quality of life. Also, gabapentin and sodium valproate should also be considered for diabetic neuropathy pain management. Gabapentin leads to significant pain relief in patients with chronic neuropathic pain; although patients frequently experience adverse side effects, these are usually tolerable. Additionally, dextromethorphan, morphine sulfate, tramadol, and oxycodone should be considered for PDN treatment. No one opioid is recommended over another. Topical therapy with capsaicin or transdermal numbing cream may be useful in some patients, especially those with more localized pain or those in whom interactions with existing oral medications is a concern.
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