Expert Insights on Diabetic Peripheral Neuropathy

What do thought leaders have to say about diagnosis and treatment of diabetic peripheral neuropathy? Podiatry Today asked two faculty members from the Great Debates and Updates – Diabetic Foot meeting in San Antonio, TX about the challenges and action steps relevant to current practice.

Q: What do you feel are the biggest misconceptions, or misunderstandings, in medicine about diabetic neuropathy?

Crystal Holmes, DPM shares that she thinks that is a disservice to patients when clinicians say that neuropathy is a lack of sensation, or no sensation.

“Neuropathy is not a lack of sensation but, abnormalities in the nerve function that cause a misrepresentation of sensory stimuli and has, of course, motor and autonomic effects,” she says.  

Rodica Pop-Busui MD, PhD feels that, more so than a misconception, it is a challenge that stands out to her regarding diabetic neuropathy. Specifically, difficulty in understanding diabetic neuropathy’s complex and broad clinical forms, how best to assess the condition, and how often.

“Because it is more complicated, and clinicians have a limited amount of time when managing people with diabetes, it may be overlooked,” she adds.

Q: What other challenges do you feel clinicians face when diagnosing and treating neuropathy? 

Dr. Holmes thinks the biggest thing that physicians face is that there is not a “one-size-fits-all” evaluation and therapy plan for diabetic neuropathy.

“It has to be catered to the patient’s specific needs, concerns and risk factors,” she explains.

Differences in screening and assessing neuropathy, versus an at-risk callus, carry challenges for those caring for patients with diabetes, says Dr. Pop-Busui, the Vice Chair for Clinical & Health Outcomes Research in the Department of Internal Medicine, and Director of Clinical Research, Mentoring and Development of the Caswell Diabetes Institute at the University of Michigan.

“Many clinicians may only assess monofilament testing on the plantar aspects of feet, which is not a measure of neuropathy, and in fact, light touch sensation to a 10 g monofilament will only be impaired in very late stages of neuropathy, missing many people who are at risk of injury due to impaired sensation,” she says. 

Q: What do you feel the DPMs can incorporate right now into their practice regarding diabetic neuropathy?

Being aware of the latest information, medications and recommendations is critical, says Dr. Holmes, a Clinical Professor in the University of Michigan Health System. Being able to have this conversation with your patients, on a regular basis, is also important, she adds.

Dr. Pop-Busui cites several action steps she feels are important: correctly assessing for both large and small fiber function in people with diabetes; assessing proven risk factors including glucose control, and beyond; assessing pain and understanding the evidence regarding effective neuropathic pain management in diabetic neuropathy; and avoiding opioids in all people with diabetes.