Skip to main content
SpringerLink
Log in

Clinical Management of Diabetic Neuropathy

An Overview

  • Chapter
Clinical Management of Diabetic Neuropathy

Part of the book series: Contemporary Endocrinology ((COE,volume 7))

Abstract

Current estimates suggest there are 14 million people in the United States with diabetes mellitus and the number of afflicted individuals is increasing by 5% per year (1). In 1992, the direct and indirect costs in the United States of diabetes was $92 billion. Neuropathy is a common complication of diabetes and occurs in approximately 50% of diabetic patients during the course of their disease (2). Neuropathic sequelae, including foot infections, nonhealing foot ulcers, and amputations, make diabetic neuropathy the most morbid and costly diabetic complication (3). In this chapter, we will discuss the management strategies we used in our clinics for patients with diabetic neuropathy. As background material, the authors will first briefly review the classification and pathogenesis of diabetic neuropathy (for a more complete discussion of these topics, the reader is referred to Greene and colleagues, ref 2). Then, the therapeutic approach we have used for the care of patients with diabetic neuropathy will be discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 219.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Herman WH, Sinnock P, Brenner E, Brimberry JL, Langford D, Nakashima A, Sepe SJ, Teutsch SM, Mazze RS. An epidemiologic model for diabetes mellitus: incidence, prevalence, and mortality. Diabetes Care 1984;7:367–371.

    Article  PubMed  CAS  Google Scholar 

  2. Greene DA, Feldman EL, Stevens MJ, Sima AAF, Albers JW, Pfeifer MA. Diabetic Neuropathy. In: Porte Jr D, Sherwin R, Rifkin H, eds. Diabetes Mellitus Appleton & Lange, East Norwalk, CT, 1997, pp. 1009–1076.

    Google Scholar 

  3. Ward JD. The cost of diabetic neuropathy. Pharmacoeconomics 1995;8(Suppl. l):52–54.

    Article  PubMed  Google Scholar 

  4. Feldman EL, Greene DA, Stevens MJ. Diabetic neuropathy. In: Rose BD, ed. UpToDate™ (CDROM), 1996.

    Google Scholar 

  5. Dyck PJ, Litchy WJ, Lehman KA, Hokanson JL, Low PA, O’Brien PC. Variables influencing neuropathic endpoints. the Rochester Diabetic Neuropathy Study of Healthy Subjects. Neurol 1995;45:1115–1121.

    Article  CAS  Google Scholar 

  6. Dyck PJ, Kratz KM, Lehman KA. The Rochester Diabetic Neuropathy Study: design, criteria for types of neuropathy, selection bias, and reproducibility of neuropathic tests. Neurol 1991;41:799–807.

    Article  CAS  Google Scholar 

  7. Dyck PJ, Karnes JL, O’Brien PC. The Rochester Diabetic Neuropathy Study: reassessment of tests and criteria for diagnosis and staged severity. Neurol 1992;42:1164–1170.

    Article  CAS  Google Scholar 

  8. Pirart J. Diabetes mellitus and its degenerative complications; a prospective study of 4400 patients observed between 1947 and 1973. Diabetes Care 1978;1:168–188.

    Google Scholar 

  9. Young MJ, Boulton AJM, Macleod AF, Williams DRR, Sonksen PH. A multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom hospital clinic population. Diabetologia 1993;36:150–154.

    Article  PubMed  CAS  Google Scholar 

  10. Bondy C, Zhou J. Insulin-like growth factor system gene expression in the postpubertal human ovary. Ann NY Acad Sci 1993;687:65–76.

    Article  PubMed  CAS  Google Scholar 

  11. Maser RE, Steenkiste AR, Dorman JS, Nielsen VK, Bass EB, Manjoo Q, Drash AL, Becker DJ, Kuller LH, Greene DA, Orchard TJ. Epidemiological correlates of diabetic neuropathy. Report from Pittsburgh Epidemiology of Diabetes Complications Study. Diabetes 1989;38:1456–1461.

    Article  PubMed  CAS  Google Scholar 

  12. Fedele D, Comi G, Coscelli C, Cucinotta D, Feldman EL, Ghirlanda G, Greene DA, Negrin P, Santeusanio F, Italian Diabetic Neuropathy Committee. A multicenter study on the prevalence of diabetic neuropathy in Italy. Diabetes Care 1997; 620:836–843.

    Article  Google Scholar 

  13. Feldman EL, Stevens MJ, Thomas PK, Brown MB, Canal N, Greene DA. A practical two-step quantitative clinical and electrophysiological assessment for the diagnosis and staging of diabetic neuropathy. Diabetes Care 1994;17:1281–1289.

    Article  PubMed  CAS  Google Scholar 

  14. Moss SE, Klein R, Klein BEK. The prevalence and incidence of lower extremity amputation in a diabetic population. Arch Intern Med 1992;152:610–616.

    Article  PubMed  CAS  Google Scholar 

  15. Brand PW. The diabetic foot. In: Ellenberg M, Rifkin H, eds. Diabetes Mellitus. Medical Examination Publishing, New York, 1983, pp. 829–849.

    Google Scholar 

  16. Greene DA, Sima AAF, Stevens MJ, Feldman EL, Lattimer SA. Complications: neuropathy, pathogenetic considerations. Diabetes Care 1992;15:1902–1925.

    Article  PubMed  CAS  Google Scholar 

  17. Feldman EL, Stevens MJ, Greene DA. The pathogenesis of diabetic neuropathy. J Clin Neurosci 1997; 4:365–370.

    CAS  Google Scholar 

  18. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977–986.

    Article  Google Scholar 

  19. Greene DA, Lattimer SA. Sodium-and energy-dependent uptake of myo-inositol by rabbit peripheral nerve. J Clin Invest 1982;70:1009–1018.

    Article  PubMed  CAS  Google Scholar 

  20. Greene DA, Lattimer SA. Impaired rat sciatic nerve sodium-potassium adenosine triphosphatase in acute streptozocin diabetes and its correction by dietary myo-inositol supplementation. J Clin Invest 1983;72:1058–1063.

    Article  PubMed  CAS  Google Scholar 

  21. DelMonte MA, Rabbani R, Diaz TC, Lattimer SA, Nakamura J, Brennan MC, Greene DA. Sorbitol, myo-inositol, and rod outer segment phagocytosis in culture hRPE cells exposed to glucose. Diabetes 1991;40:1335–1345.

    Article  PubMed  Google Scholar 

  22. Tuck RR, Schmelzer JD, Low PA. Endoneurial blood flow and oxygen tension in the sciatic nerves of rats with experimental diabetic neuropathy. Brain 1984;107:935–950.

    Article  PubMed  Google Scholar 

  23. Low PA, Tuck RR, Takeuchi M. Nerve microenvironment in diabetic neuropathy. Dyck PJ, Thomas PK, Asbury AK, Winegrad AI, Porte D, eds. In: Diabetic Neuropathy. Saunders, Philadelphia, 1987, pp. 266–278.

    Google Scholar 

  24. Dyck PJ, Lais A, Karnes JL, O’Brien P, Rizza R. Fiber loss is primary and multifocal in sural nerves in diabetic polyneuropathy. Ann Neurol 1986;19:425–439.

    Article  PubMed  CAS  Google Scholar 

  25. Johnson PC, Doll SC, Cromey DW. Pathogenesis of diabetic neuropathy. Ann Neurol 1986;19:450–457.

    Article  PubMed  CAS  Google Scholar 

  26. van Dam PS, Van Asbeck BS, Erkelens DW, Marx JJ, Gispen WH, Bravenboer B. The role of oxidative stress in neuropathy and other diabetic complications. Diabetes/Metab Rev 1995;11:181–192.

    Article  Google Scholar 

  27. Gallo G, Pollack ED. Cyclic remodelling of growth cone lamellae and the effect of target tissue. Dev Brain Res 1995;85:140–145.

    Article  CAS  Google Scholar 

  28. Cameron NE, Cotter MA. Potential therapeutic approaches to the treatment or prevention of diabetic neuropathy: evidence from experimental studies. Diab Med 1993;10:593–605.

    Article  CAS  Google Scholar 

  29. Stevens MJ, Dananberg J, Feldman EL, Lattimer SA, Kamijo M, Thomas TP, Shindo H, Sima AAF, Greene DA. The linked roles of nitric oxide, aldose reductase and (Na+, K+)-ATPase in the slowing of nerve conduction in the streptozotocin diabetic rat. J Clin Invest 1994;94:853–859.

    Article  PubMed  CAS  Google Scholar 

  30. Stevens MJ. Nitric oxide as a potential bridge between the metabolic and vascular hypotheses of diabetic neuropathy. Diab Med 1995;12:292–295.

    Article  CAS  Google Scholar 

  31. Mulder DW, Lambert EH, Bastian JA. The neuropathies associated with diabetes mellitus: a clinical and electromyographic study of 103 unselected diabetic patients. Neurol 1961;11:275–284.

    Google Scholar 

  32. American Diabetes Association and American Academy of Neurology. Report and recommendations of the San Antonio Conference on Diabetic Neuropathy. Diabetes Care 1988;11:592–597.

    Google Scholar 

  33. Dyck PJ, Kratz KM, Karnes JL, Litchy WJ, Klein R, Pach JM, Wilson DM, O’Brien PC, Melton III LJ. The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: The Rochester Diabetic Neuropathy Study. Neurology 1993;43:817–824.

    Article  PubMed  CAS  Google Scholar 

  34. Maser RE, Becker DJ, Drash AL, Ellis D, Kuller LH, Greene DA, Orchard TJ. Pittsburgh Epidemiology of Diabetes Complications Study. Measuring diabetic neuropathy follow-up study results. Diabetes Care 1992;15:525–527.

    Article  PubMed  CAS  Google Scholar 

  35. Bax G, Fagherazzi C, Piarulli F, Nicolucci A, Fedele D. Reproducibility of Michigan Neuropathy Screening Instrument (MNSI). Diabetes 1996;45:1309–1310.

    Google Scholar 

  36. Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes. N Engl J Med 1994;33:854–860.

    Article  Google Scholar 

  37. Duffy JC, Patout CA. Management of the insensitive foot in diabetes: lessons learned from Hansen’s Disease. Milit Med 1990;155:575–579.

    CAS  Google Scholar 

  38. Hollingshead TS. Pathophysiology and treatment of diabetic foot ulcer. Clin Podiatr Med Surg 1991;8:843–855.

    PubMed  CAS  Google Scholar 

  39. Joseph R, Cavuoto JW. The latest theories and treatment for diabetic foot complications. Clin Podiatr Med Surg 1991;8:249–272.

    PubMed  CAS  Google Scholar 

  40. Apelqvist J, Larsson J, Agardh CD. The influence of external precipitating factors and peripheral neuropathy on the development and outcome of diabetic foot ulcers. J Diabet Complications 1990;4:21–25.

    Article  PubMed  CAS  Google Scholar 

  41. Cavanagh PR, Ulbrecht JS. Biomechanics of the foot in diabetes mellitus. In: Levin ME, O’Neal LW, Bowker JH, eds. The Diabetic Foot. Mosby Year Book, St. Louis, 1993, pp. 199–232.

    Google Scholar 

  42. Ulbrecht JS, Perry JE, Hewitt FG, Cavanagh PR. Controversies in footwear for the diabetic foot at risk. In: Kominsky SJ, ed. The Diabetic Foot. Mosby Year Book, Chicago, 1994, pp. 441–453.

    Google Scholar 

  43. Coleman WC. Footwear in a management program for injury prevention. In: Levin ME, O’Neal LW, Bowker JH, eds. The Diabetic Foot Mosby Year Book, St. Louis, 1993, pp. 531–547.

    Google Scholar 

  44. Veves A, Masson EA, Fernando DJS, Boulton AJM. Use of experimental padded hosiery to reduce abnormal foot pressures in diabetic neuropathy. Diabetes Care 1989;12:653–655.

    Article  PubMed  CAS  Google Scholar 

  45. Soulier SM. The use of running shoes in the prevention of plantar diabetic ulcers. J Am Podiatr Med Assoc 1986;76:395–400.

    PubMed  CAS  Google Scholar 

  46. Sarma V, Lin Z, Clark L, Rust BM, Tewari M, Noelle RJ, Dixit VM. Activation of the B-cell surface receptor CD40 induces A20, a novel zinc finger protein that inhibits apoptosis. J Biol Chem 1995;270:12,343-12,346.

    Google Scholar 

  47. Jones EW, Edwards R, Finch R. A microbiologic study of diabetic foot lesions. Diab Med 1984;2:213–215.

    Article  Google Scholar 

  48. Lipsky BA, Pecoraro RE, Wheat LJ. The diabetic foot: soft tissue and bone infection. Infect Dis Clin North Am 1990;4:409–432.

    PubMed  CAS  Google Scholar 

  49. Wheat LJ, Allen SD, Henry M, Kernek CB, Siders JA, Kuebler T, Fineberg N, Norton J. Diabetic foot infections: bacteriologic analysis. Arch Int Med 1986;146:1935–1940.

    Article  CAS  Google Scholar 

  50. Feldman EL, Stevens MJ, Greene DA. Treatment of diabetic neuropathy. In: Mazzaferri EL, Bar RS, Kreisberg RA, eds. Advances in Endocrinology and Metabolism. Mosby Year Book, Chicago, 1994, pp. 393–428.

    Google Scholar 

  51. Said G, Goulon-Goeau C, Slama G, Tchobroutsky G. Severe early-onset polyneuropathy in insulindependent diabetes mellitus. A clinical and pathological study. N Engl J Med 1992;326:1257–1263.

    CAS  Google Scholar 

  52. Boulton AJM, Scarpello JHB, Armstrong WD, Ward JD. The natural history of painful diabetic neuropathy —a 4-year study. Postgrad Med J 1983;59:556–559.

    Article  PubMed  CAS  Google Scholar 

  53. Cohen KL, Harris S. Efficacy and safety of nonsteroidal anti-inflammatory drugs in the therapy of diabetic neuropathy. Arch Intern Med 1987;147:1442–1444.

    Article  PubMed  CAS  Google Scholar 

  54. Gregory I, Smeltzer DJ. Psychotherapeutic drugs and electrotherapy. In: Psychiatry. Essentials of Clinical Practice With Examination Questions, Answers, and Comments. Little, Brown and Company, Boston, 1983, pp. 93–138.

    Google Scholar 

  55. Max MB, Culnane M, Schafer SC, Gracely RH, Walther DJ, Smoller B, Dubner R. Amitriptyline relieves diabetic neuropathy pain in patients with normal or depressed mood. Neurology 1987;37:589–596.

    Article  PubMed  CAS  Google Scholar 

  56. Hoogwerf BJ. Amitriptyline treatment of painful diabetic neuropathy: an inadvertent single-patient clinical trial [letter]. Diabetes Care 1985;8:526, 527.

    PubMed  CAS  Google Scholar 

  57. LeWitt PA. Forno LS. Peripheral neuropathy following amitriptyline overdose. Muscle Nerve 1985;8:723, 724.

    Article  PubMed  CAS  Google Scholar 

  58. Davis. JAMA 1977;238:2291.

    Article  PubMed  CAS  Google Scholar 

  59. Sindrup SH, Gram LF, Brosen K, Eshoj O, Mogensen EF. The selective serotonin reuptake inhibitor paroxetine is effective in the treatment of diabetic neuropathy symptoms. Pain 1990;42:135–144.

    Article  PubMed  CAS  Google Scholar 

  60. Sindrup SH, Grodum E, Gram LF, Beck-Nielsen H. Concentration-response relationship in paroxetine treatment of diabetic neuropathy symptoms: a patient-blinded dose-escalation study. Ther Drug Monit 1991;13:408–414.

    Article  PubMed  CAS  Google Scholar 

  61. Rull JA, Quibrera R, Gonzalez-Millan H, Lozano CO. Symptomatic treatment of peripheral diabetic neuropathy with carbamazepine (Tegretol): double blind crossover trial. Diabetologia 1969;5:215–218.

    Article  PubMed  CAS  Google Scholar 

  62. Chakrabarti AK, Samantaray SK. Diabetic peripheral neuropathy: nerve conduction studies before, during and after carbamazepine therapy. Aust NZ J Med 1976;6:565–568.

    Article  CAS  Google Scholar 

  63. Rodin EA. Carbamazepine (tegretol). In: Browne TR, Feldman RG, eds. Epilepsy. Diagnosis and Management Little, Brown, Boston, 1983, pp. 203–213.

    Google Scholar 

  64. Saudek CD, Werns S, Reidenberg MM. Phenytoin in the treatment of diabetic symmetrical polyneuropathy. Clin Pharmacol Ther 1977;22:196–199.

    PubMed  CAS  Google Scholar 

  65. Capsaicin Study Group. Effect of treatment with capsaicin on daily activities of patients with painful diabetic neuropathy. Diabetes Care 1992;15:159–165.

    Article  Google Scholar 

  66. Capsaicin Study Group. Treatment of painful diabetic neuropathy with topical capsaicin. Arch Int Med 1991;151:2225–2229.

    Article  Google Scholar 

  67. Ackerman III WE, Colclough GW, Juneja MM, Bellinger K. The management of oral mexiletine and intravenous lidocaine to treat chronic painful symmetrical distal diabetic neuropathy. KMA 1991;89:500,501.

    Google Scholar 

  68. Stracke H, Meyer UE, Schumacher HE, Federlin K. Mexiletine in the treatment of diabetic neuropathy. Diabetes Care 1992;15:1550–1555.

    Article  PubMed  CAS  Google Scholar 

  69. Ameisen JC. Programmed cell death (apoptosis) and cell survival regulation: relevance to AIDS and cancer. AIDS 1994;8:1197–1213.

    Article  PubMed  CAS  Google Scholar 

  70. Kastrup J, Angelo H, Petersen P, Dejard A, Hilsted J. Treatment of chronic painful diabetic neuropathy with intravenous lidocaine infusion. Br Med J 1986;292:173.

    Article  CAS  Google Scholar 

  71. Kastrup J, Petersen P, Dejgard A, Angelo HR, Hilsted J. Intravenous lidocaine infusion—a new treatment of chronic painful diabetic neuropathy? Pain 1987;28:69–75.

    Article  PubMed  CAS  Google Scholar 

  72. Gomez-Perez FJ, Rull JA, Dies H, Rodriquez-Rivera JG, Gonzalez-Barranco, J, Lozano-Castaneda O. Nortriptyline and fluphenazine in the symptomatic treatment of diabetic neuropathy. A double-blind cross-over study. Pain 1985;23:395–400.

    Article  PubMed  CAS  Google Scholar 

  73. Stevens MJ, Feldman EL, Funnell MM, Sima AAF, Greene DA. Optimal methods for detecting early neuropathy and its progression. In: Mogensen, Standl, eds. Diabetes Forum IV. Concepts for the Ideal Diabetes Clinic. 1993, pp. 315–332.

    Google Scholar 

  74. Greene DA, Feldman EL, Stevens MJ. Neuropathy in the diabetic foot: new concepts in etiology and treatment. In: Levin M, O’Neal L, eds. The Diabetic Foot Mosby, New York, 1993, pp. 135–148.

    Google Scholar 

Download references

Authors
  1. Eva L. Feldman MD, PHD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Martin J. Stevens MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Douglas A. Greene MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

    Aristidis Veves MD

Rights and permissions

Reprints and permissions

Copyright information

© 1998 Springer Science+Business Media New York

About this chapter

Cite this chapter

Feldman, E.L., Stevens, M.J., Greene, D.A. (1998). Clinical Management of Diabetic Neuropathy. In: Veves, A. (eds) Clinical Management of Diabetic Neuropathy. Contemporary Endocrinology, vol 7. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-4612-1816-6_6

Download citation

  • DOI: https://doi.org/10.1007/978-1-4612-1816-6_6

  • Publisher Name: Humana Press, Totowa, NJ

  • Print ISBN: 978-1-4612-7296-0

  • Online ISBN: 978-1-4612-1816-6

  • eBook Packages: Springer Book Archive

Publish with us

Policies and ethics

Search

Navigation