Cited by 2,602Pain Mechanisms and TreatmentsPeripheral Neuropathies and DisordersDiabetic Foot Ulcer Assessment and Management

Diabetic neuropathy: A position statement by the American Diabetes Association

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Pop-Busui, Rodica, Boulton, Andrew J.M., Feldman, Eva L., Bril, Vera, Freeman, Roy, Malik, Rayaz A., Sosenko, Jay M., Ziegler, Dan·2017·Diabetes Care

Abstract

Diabetic neuropathies are the most prevalent chronic complications of diabetes. This heterogeneous group of conditions affects different parts of the nervous system and presents with diverse clinical manifestations. The early recognition and appropriate management of neuropathy in the patient with diabetes is important for a number of reasons: 1. Diabetic neuropathy is a diagnosis of exclusion. Nondiabetic neuropathies may be present in patients with diabetes and may be treatable by specific measures. 2. A number of treatment options exist for symptomatic diabetic neuropathy. 3. Up to 50% of diabetic peripheral neuropathies may be asymptomatic. If not recognized and if preventive foot care is not implemented, patients are at risk for injuries to their insensate feet. 4. Recognition and treatment of autonomic neuropathy may improve symptoms, reduce sequelae, and improve quality of life. Among the various forms of diabetic neuropathy, distal symmetric polyneuropathy (DSPN) and diabetic autonomic neuropathies, particularly cardiovascular autonomic neuropathy (CAN), are by far the most studied (1–4). There are several atypical forms of diabetic neuropathy as well (1–4). Patients with prediabetes may also develop neuropathies that are similar to diabetic neuropathies (5–10). Table 1 provides a comprehensive classification scheme for the diabetic neuropathies. View this table: Table 1 Classification for diabetic neuropathies Due to a lack of treatments that target the underlying nerve damage, prevention is the key component of diabetes care. Screening for symptoms and signs of diabetic neuropathy is also critical in clinical practice, as it may detect the earliest stages of neuropathy, enabling early intervention. Although screening for rarer atypical forms of diabetic neuropathy may be warranted, DSPN and autonomic neuropathy are the most common forms encountered in practice. The strongest available evidence regarding treatment pertains to these forms. This Position Statement is based on several recent technical reviews, to which the reader is referred for detailed discussion …

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  • Even in modern cohorts, glucose control is the strongest risk factor for DPN in T1D.

    “and glucose control remains the strongest risk factor for DPN in T1D even in contemporary cohorts.417,542–544,547”

    From American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. (2022) · cites this paper as [543]

    The Prevention > Glucose Control section reports that enhanced glucose control dramatically reduces distal symmetric polyneuropathy incidence in type 1 diabetes. The DSPN section also lists glycemia among associated factors. Neither passage ranks glucose control as the strongest risk factor or establishes that ranking in contemporary cohorts. (LLM, conf=0.84)

    Experimental — accuracy not yet measured
  • Cardiovascular autonomic reflex tests (CARTs) involve several burdensome physiological maneuvers and have limited feasibility in clinical settings.

    “CARTs involve several burdensome physiological maneuvers, including heart rate responses to deep breathing, the Valsalva maneuver, and changes in blood pressure in response to postural change [12].”

    From Cardiovascular autonomic neuropathy defined by indices of heart rate variability is associated with cardiovascular disease: a longitudinal cohort study of participants with type 1 diabetes (2025) · cites this paper as [12]

    The ‘Neuropathy End Points for Research and Clinical Trials’ section lists deep breathing, Valsalva, and standing as cardiovascular autonomic reflex-test maneuvers; the CAN section also describes assessing blood-pressure changes on standing. But the paper calls the reflex tests and maneuvers simple and describes related testing as feasible in the office. It does not support characterizing the maneuvers as burdensome or the tests as having limited clinical feasibility. (LLM, conf=0.87)

    Experimental — accuracy not yet measured
  • CKD and diabetic neuropathy have been widely studied, but the focus has been primarily on cardiac autonomic neuropathies, with few studies evaluating CKD and peripheral neuropathy.

    “CKD and diabetic neuropathy have been widely studied, but the focus has been primarily on cardiac autonomic neuropathies, with few studies evaluating CKD and peripheral neuropathy.26–29”

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Authors
Pop-Busui, R., Boulton, A. J. M., Feldman, E. L., Bril, V., Freeman, R., Malik, R. A., Sosenko, J. M., & Ziegler, D.
Affiliations
  • Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
  • Manchester Royal Infirmary (GB)
  • University of Michigan (US)
  • University of Toronto (CA)
  • Harvard University (US)
  • Cornell University (US)
  • University of Miami (US)
  • Deutsches Diabetes-Zentrum e.V. (DE)
Venue
Diabetes Care
Published
2016-12-10
Volume
40
Issue
1
Pages
136-154
ISSN
  • 0149-5992 (ISSN-L)
  • 1935-5548
OpenAlex
W2561727131
Cited by
2,602
References
236
Citations by year
2026: 312 · 2025: 340 · 2024: 316 · 2023: 318 · 2022: 333 · 2021: 320 · 2020: 271 · 2019: 181 · 2018: 153 · 2017: 53 · 2016: 2 · 2012: 1
FWCI
15.23
Type
journal article
Language
en
Open access
Locations
  • Diabetes Care (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Research Explorer (The University of Manchester) (publishedVersion, other-oa)
Funders
National Institute of Diabetes and Digestive and Kidney Diseases (R01DK107956)
Topics
  • Health Sciences › Medicine › Physiology › Pain Mechanisms and Treatments
  • Health Sciences › Medicine › Neurology › Peripheral Neuropathies and Disorders
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetic Foot Ulcer Assessment and Management
Keywords
diabetic neuropathy, distal symmetric polyneuropathy, diabetic autonomic neuropathy, cardiac autonomic neuropathy, diabetic peripheral neuropathy, neuropathy screening, neuropathy prevention, foot care, prediabetes, neuropathy classification, neuropathy treatment

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