Issues and challenges in diabetic neuropathy management: A narrative review

Table 1 Management strategies from the previous literature to prevent progression of diabetic neuropathy in patients

Strategies	Description/indication	Intervention/strategies	Ref.
Glucose level monitoring	Prevents distal symmetric polyneuropathy and cardiovascular autonomic neuropathy developments in patients with T1DM, and delays the progression of distal symmetric polyneuropathy in T2DM patients	Treatments (insulin, anti-diabetic medications, electrical stimulation, and percutaneous nerve stimulation; non-treatments (lifestyle modifications such as glucose-dietary control, exercises, and physiotherapy); pancreas transplant; bariatric surgery	[6,4,132]
Lifestyle modifications	Reduce risk of DN and cardiometabolic causes	Glucose-dietary control; counselling; supervised training programs including physiotherapy/rehabilitation	[4]
Diabetic foot care	Delays or lowers the risk of amputations	Five key elements for prevention of DFUs: (1) Recognition of the at-risk foot; (2) consistent check and examination of the at-risk foot; (3) education of patients, their family, and healthcare providers; (4) routine of wearing suitable footwear; and (5) management of pre-ulceration signs	[47]
Pharmacologic therapeutics	Manage diabetes and neuropathy and treat symptomatic pain	Three suggested phases can be useful: Step 1: Treatment with first-line therapy of TCAs (e.g., amitriptyline), SNRIs (e.g., duloxetine), pregabalin, and gabapentin; step 2: Treatment with second-line therapy including tramadol (weak opioids and SNRIs); step 3: Treatment with last line therapy including strong opioids, cannabinoids, and anticonvulsants	[89,90,133]
		Alternatives (anti-oxidant supplementations): α-lipoic acid; acetyl-L-carnitine vitamin B12

T1DM: Type 1 diabetes mellitus; T2DM: Type 2 diabetes mellitus; TCAs: Tricyclic antidepressants; SNRIs: Serotonin-norepinephrine reuptake inhibitors; DN: Diabetic neuropathy; DFUs: Diabetic foot ulcers.