Diabetic neuropathy Diagnosis and management Indications for screening ADA Q Does the patient have T1DM of 5 years duration? Q Does the patient have T2DM? No to all Consider alternative diagnoses. Yes to any Screen for diabetic peripheral neuropathy starting at diagnosis of T2DM and 5 years after the diagnosis of T1DM, and at least annually thereafter. B Clinical assessment Elicit a careful history and assess either temperature or pinprick sensation (small fiber function) and vibration sensation using a 128-Hz tuning fork (for large-fiber function) for the assessment of distal symmetric polyneuropathy. Obtain annual 10-g monofilament testing in all patients with diabetes to identify feet at risk for ulceration and amputation. B Assess for symptoms and signs of autonomic neuropathy (orthostatic dizziness, orthostatic hypotension, syncope, resting tachycardia, or dry cracked skin in the extremities) starting at diagnosis and at least annually thereafter in patients with evidence of other microvascular complications, particularly kidney disease and diabetic peripheral neuropathy. B Primary prevention Diabetes Canada Q Does the patient have clinical evidence of diabetic neuropathy? No Optimize glycemic control to prevent the onset of neuropathy in patients with T1DM A and T2DM. B Yes Optimize glycemic control to slow the progression of neuropathy in patients with T1DM A and T2DM. B Systemic therapy Diabetes Canada Q Does the patient have neuropathic pain? Q Is the patient interested in pharmacological treatment for neuropathic pain? No to any Continue management and follow-up as clinically appropriate. Yes to all Consider offering the following agents, alone or in combination, for the treatment of patients with painful peripheral neuropathy: gabapentin C or pregabalin B valproate C amitriptyline C duloxetine or venlafaxine. C Consider offering opioid analgesics (tramadol, tapentadol ER, oxycodone ER), taking into account the risks of abuse, dependency, and tolerance, in patients not responding to the above agents. C