Diabetic neuropathy

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 26 Nov 2025

Last updated: 15 Apr 2025

Diabetic neuropathy (DN) in people with both type 1 and 2 diabetes is a complex consequence of hyperglycemia-induced alterations in multiple biochemical pathways. Other metabolic and vascular factors, particularly hypertriglyceridemia, are also important.

The clinical presentation comprises a broad constellation of symptoms and deficits, involving sensory, motor, and autonomic nerve fibers, and multiple organ systems.

Diabetic peripheral neuropathy is the most common chronic complication of diabetes, characterized by the presence of peripheral nerve dysfunction, diagnosed after the exclusion of other causes. Pain is the most troubling symptom for most patients, but many patients are completely asymptomatic.

Treatment has traditionally focused on control of hyperglycemia as a means of slowing progression or delaying onset, on targeting potential pathogenetic mechanisms, and on pain reduction.

Although pain is generated principally by peripheral nerve injury, there is evidence that the central nervous system may play a significant role in the disinhibition and amplification of pain. The most effective drugs in treating painful DN are centrally acting.

Definição

Diabetic neuropathy (DN) is a highly prevalent complication of diabetes (type 1 or type 2) and is characterized by the presence of symptoms and/or signs of peripheral nerve dysfunction and/or autonomic nerve dysfunction. It is diagnosed after the exclusion of other causes. Frequently, however, people with DN are asymptomatic.

História e exame físico

Principais fatores diagnósticos

asymptomatic
pain (peripheral)
loss of sensation (peripheral)
dysesthesia (peripheral)
reduced or absent ankle reflexes (peripheral)
painless injuries (peripheral)
resting tachycardia (autonomic)
impaired heart rate variability (autonomic)
urinary frequency, urgency, nocturia, incontinence, hesitancy, weak stream, or retention (autonomic)
erectile dysfunction (autonomic)
decreased sexual desire and increased pain during intercourse (autonomic)
orthostatic hypotension (autonomic)

Detalhes completos

Otros factores de diagnóstico

constipation (autonomic)
fecal incontinence (autonomic)
anhidrosis, heat intolerance, dry skin, or hyperhidrosis (autonomic)
hypoglycemia unawareness (autonomic)
weakness (peripheral)
history of recent falls (peripheral)
gait ataxia (peripheral)
nausea, postprandial vomiting, bloating, loss of appetite, early satiety (autonomic)
heartburn and dysphagia for solids (autonomic)
profuse and watery diarrhea (autonomic)
specific mononeuropathy (peripheral)
cranial neuropathy (peripheral)
pain over lower thoracic or abdominal wall (peripheral)
thigh muscle atrophy, pain, and weakness (peripheral)

Todos los datos

Factores de riesgo

poorly controlled hyperglycemia
prolonged duration of diabetes
older age (e.g., >70 years)
tall stature
hypertension
dyslipidemia with elevated triglycerides
coexistence of multiple cardiovascular disease (CVD) risk factors (type 2 diabetes)
renal disease
obesity
immune dysregulation
smoking
genetic

Todos los datos

Pruebas diagnósticas

Primeras pruebas diagnósticas para solicitar

clinical diagnosis
fasting blood glucose
HbA1c
serum thyroid-stimulating hormone
serum vitamin B12
renal function tests
serum lipid profile
LFTs
CBC and erythrocyte sedimentation rate
serum/urine immunoelectrophoresis

Todos los datos

Tests to avoid

MRI spine or brain

Todos los datos

Pruebas diagnósticas que deben considerarse

2-hour plasma glucose
nerve conduction studies (nerve conduction velocity [NCV])
electromyography (EMG)
quantitative sensory testing (QST)
skin biopsy
cardiovascular reflex testing
corneal confocal microscopy
heart rate variability (HRV)
gastric emptying studies
gastroduodenoscopy
barium meal
gastrointestinal manometry
hydrogen breath tests
gastric ultrasonography
gastric MRI
anorectal manometry
fecal fat
d-xylose test
urine culture
cystometry, voiding cystometrogram
postvoid urinary tract ultrasound
video-urodynamics
Testosterone (morning)

Todos los datos

Algoritmo de tratamiento

En curso

diabetic peripheral neuropathy

cranial neuropathies

limb or truncal mononeuropathies

diabetic amyotrophy

diabetic autonomic neuropathy

Colaboradores

Autores

Rayaz A. Malik, BSc (Hons), MSc, MBChB, FRCP, PhD

Professor of Medicine

Organizational Official for the Human Research Protection Program

Weill Cornell Medicine - Qatar

Doha

Qatar

Divulgaciones

RAM has been reimbursed for being on the advisory board for an epidemiologic study on cardiovascular disease in type 2 diabetes and to give educational lectures on treatment of diabetes undertaken by Novo Nordisk. RAM has been reimbursed for educational lectures for Sanofi Aventis, Lilly, and Proctor and Gamble (P&G). RAM has received an investigator-initiated grant to study long COVID from P&G. RAM is an author of references cited in this topic.

Uazman Alam, BSc, MBChB, MPHe, PhD

Reader and Consultant Physician

University of Liverpool

Liverpool

Divulgaciones

UA has received honoraria from Procter & Gamble, Viatris, Grunenthal, Eli Lilly, and Sanofi for educational meetings. UA has also received investigator-led funding from Procter & Gamble.

Shazli Azmi, MBchB, MRCP

Consultant Physician

Diabetes and Endocrinology

Central Manchester Foundation Trust

University of Manchester

Manchester

Divulgaciones

SA has received honoraria for educational meetings from AstraZeneca, Sanofi, Menarini, Eli Lilly, and Procter & Gamble.

Agradecimientos

Dr Rayaz Malik, Dr Uazman Alam, and Dr Shazli Azmi would like to gratefully acknowledge Dr Rodica Pop-Busui and Dr Eva Feldman, the previous contributors to this topic.

Divulgaciones

RPB declares that she has received speaking honoraria from Pfizer and research support from Amylin Pharmaceuticals; National Institutes of Health/National Heart, Lung, and Blood Institute; National Institute of Health/National Institute of Diabetes and Digestive and Kidney Diseases; American Diabetes Association; and Juvenile Diabetes Research Foundation. RPB and EF are authors of references cited in this topic.

Revisores por pares

Zachary T. Bloomgarden, MD

Clinical Professor

Department of Medicine

Mount Sinai School of Medicine

New York

Divulgaciones

ZTB declares that he has no competing interests.

Rajesh K. Garg, MD

Assistant Professor of Medicine

Harvard Medical School

Division of Endocrinology

Diabetes and Hypertension

Brigham and Women's Hospital

Boston

Divulgaciones

RKG has received consultant fees from Aventis and Novartis, and speaker fees from Novartis.

Edward Jude, MBBS, MD, MRCP, DNB

Consultant and Honorary Senior Lecturer

Tameside General Hospital

Diabetes Centre

Ashton Under Lyne

Lancashire

Divulgaciones

EJ has received funding for conferences and lectures from Pfizer and Boehringer Ingelheim.

Agradecimiento de los revisores por pares

Los temas de BMJ Best Practice se actualizan de forma continua de acuerdo con los desarrollos en la evidencia y en las guías. Los revisores por pares listados aquí han revisado el contenido al menos una vez durante la historia del tema.

Divulgaciones

Las afiliaciones y divulgaciones de los revisores por pares se refieren al momento de la revisión.

Referencias

Nuestros equipos internos de evidencia y editoriales colaboran con colaboradores expertos internacionales y revisores pares para garantizar que brindemos acceso a la información más clínicamente relevante posible.

Artículos principales

Pop-Busui R, Boulton AJ, Feldman EL, et al. Diabetic neuropathy: a position statement by the American Diabetes Association. Diabetes Care. 2017 Jan;40(1):136-54.Texto completo Resumen

Dyck PJ, Albers JW, Andersen H, et al; Toronto Expert Panel on Diabetic Neuropathy. Diabetic polyneuropathies: update on research definition, diagnostic criteria and estimation of severity. Diabetes Metab Res Rev. 2011 Oct;27(7):620-8.Texto completo Resumen

American Diabetes Association Professional Practice Committee. Introduction and methodology: standards of care in diabetes-2025. Diabetes Care. 2025 Jan 1;48(1 suppl 1):S1-5.Texto completo Resumen

Price R, Smith D, Franklin G, et al. Oral and topical treatment of painful diabetic polyneuropathy: practice guideline update summary. Report of the AAN Guideline Subcommittee. Neurology. 2022 Jan 4;98(1):31-43.Texto completo Resumen

Senneville E, Albalawi Z, van Asten SA, et al. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections. Clin Infect Dis. 2023 Oct 2:ciad527.Texto completo Resumen

Artículos de referencia

Una lista completa de las fuentes a las que se hace referencia en este tema está disponible para los usuarios con acceso a todo BMJ Best Practice.

Diferenciales
- Uremia
- Cyanocobalamin deficiency
- Hypothyroidism
Más Diferenciales
Guías de práctica clínica
- Standards of care in diabetes - 2025
- IWGDF guidelines on the prevention and management of diabetes-related foot disease
Más Guías de práctica clínica
Folletos para el paciente
Diabetes: what can I do to keep healthy?
Más Folletos para el paciente
Inicie sesión o suscríbase para acceder a todo el BMJ Best Practice

El uso de este contenido está sujeto a nuestra cláusula de exención de responsabilidad

Diabetic neuropathy

Summary

Definição

História e exame físico

Principais fatores diagnósticos

Otros factores de diagnóstico

Factores de riesgo

Pruebas diagnósticas

Primeras pruebas diagnósticas para solicitar

Tests to avoid

Pruebas diagnósticas que deben considerarse

Algoritmo de tratamiento

diabetic peripheral neuropathy

cranial neuropathies

limb or truncal mononeuropathies

diabetic amyotrophy

diabetic autonomic neuropathy

Colaboradores

Autores

Rayaz A. Malik, BSc (Hons), MSc, MBChB, FRCP, PhD

Divulgaciones

Uazman Alam, BSc, MBChB, MPHe, PhD

Divulgaciones

Shazli Azmi, MBchB, MRCP

Divulgaciones

Agradecimientos

Divulgaciones

Revisores por pares

Zachary T. Bloomgarden, MD

Divulgaciones

Rajesh K. Garg, MD

Divulgaciones

Edward Jude, MBBS, MD, MRCP, DNB

Divulgaciones

Agradecimiento de los revisores por pares

Divulgaciones

Referencias

Artículos principales

Artículos de referencia

Una lista completa de las fuentes a las que se hace referencia en este tema está disponible para los usuarios con acceso a todo BMJ Best Practice.

Diferenciales

Guías de práctica clínica

Folletos para el paciente

Inicie sesión o suscríbase para acceder a todo el BMJ Best Practice

Inicie sesión o suscríbase para acceder a todo el BMJ Best Practice

Inicie sesión para acceder a todo el BMJ Best Practice