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3 . 2022

Modern methods of diagnosis and treatment of diabetic polyneuropathy

Abstract

Diabetic sensorimotor polyneuropathy (DPN) is encountered in approximately one-third of people with diabetes. This, in turn, might markedly decrease their quality of life, mainly owing to neuropathic pain and foot ulcerations. Painful DPN might be as frequent as 25% in diabetes patients. Symptoms as a result of DPN typically comprise pain, paresthesia and numbness in the distal lower limbs. Asymptomatic DPN might reach 50% among patients with this condition. Unfortunately, DPN is still not adequately diagnosed and treated. Its management has three priorities: 1) lifestyle improvement, achieving near-normoglycemia and cardiovascular risk factors intervention; 2) pathogenesis-oriented pharmacotherapy and 3) symptomatic alleviation of pain.

Those triumvirate of Sanity-Based Medicine – symptomatic, disease-modifying and etiology-oriented treatment reinforce each other in DPN management: lifestyle improvement and multifactorial cardiovascular risk intervention is impossible without symptomatic orthostatic hypotension correction and alleviation of pain. Pathogenesis-oriented pharmacotherapy with α-lipoic acid, ipidacrin, benfotiamine wouldn’t be so effective without lifestyle improvement and achieving near-normoglycemia. Nevertheless, disease-modifying therapy improving the function of peripheral nerve fibers may finally substitute symptomatic treatment of neuropathic pain and autonomic disorders.

Intensive diabetes therapy showed evidence for favorable effects on the incidence and deterioration of DPN in type 1 diabetes, but not type 2 diabetes. Among pathogenesis-oriented treatments, α-lipoic acid, actovegin, benfotiamine and epalrestat are currently authorized to treat DPN in several countries.

Symptomatic therapy uses analgesics, notably antidepressants, opioids and anticonvulsants, reducing pain by ≥50% in approximately 50% of individuals, but might be limited, particularly by central nervous system-related adverse events. Local treatment with the capsaicin 8% patch might offer an alternative. In addition to pain relief, therapy should improve sleep, mobility and quality of life. In conclusion, multimodal treatment of DPN should consider the individual risk profile, pathogenetic treatment and pain management using pharmacotherapy (combinations, if required), as well as non-pharmacological options.

Opioid epidemic in USA and Europe showed tremendous misuse and multiple side effects of prescribed opioids for the treatment of chronic noncancer pain. Besides the abuse and overdose those drugs cause sleep apneas, orthostatic hypotension, decreased GI-motility e. t. c. Thus, gabapentin and SSNRI (selective serotonin and noradrenaline reuptake inhibitor) stay the first line symptomatic therapy for neuropatic pain in Russia. Capsaicin 8% patch in DPN showed low efficacy and local adverse effects, but lidocaine 5% patches are currently in use. Botulinotherapy is becoming more popular for the correction of neuropathic pain syndrome.

In addition to the main analgesic effect, it is necessary that the therapy improve sleep, patients’ ability to move independently and quality of life. Thus, the complex treatment of DPN should be carried out taking into account the individual risk profile and include pathogenetic and analgesic therapy (combined if necessary), as well as non-drug interventions.

Keywords:diabetic polyneuropathy; diagnosis; pharmacotherapy; cognitive reconstruction

Funding. The study had no sponsor support.

Conflict of interest. The author declares no conflict of interest.

For citation: Barinov A.N. Modern methods of diagnosis and treatment of diabetic polyneuropathy. Endokrinologiya: novosti, mneniya, obuchenie [Endocrinology: News, Opinions, Training]. 2022; 11 (3): 47–60. DOI: https://doi.org/10.33029/2304-9529-2022-11-3-47-60 (in Russian)

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CHIEF EDITOR
CHIEF EDITOR
Ametov Alexander S.
Honored Scientist of the Russian Federation, Doctor of Medical Sciences, Professor, Head of Subdepartment of Endocrinology, Head of the UNESCO Network Chair on the subject «Bioethics of diabetes as a global problem» of the Russian Medical Academy of Continuous Professional Education (Moscow)
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