Diabetic neuropathy may be linked to metabolic risk factors

Neuropathy is a common, disabling complication of diabetes, and its incidence in India is growing as the prevalence of diabetes—especially type 2 diabetes—continues to rise nationally. India has the world’s largest diabetic population, with an estimated 62 million people diagnosed with the condition, according to the Indian Council of Medical Research-India Diabetes study (Diabetologia. 2011;54(12):3022-3027).


“This works out to 17.3 million people with neuropathy in India. Reaching out to so many people itself, is one of the great challenges in India.”
-V. Mohan, MD, FRCP, PhD, DSc, FNASc, FASc, FNA, Chennai, India, president and chief of diabetes research, Madras Diabetes Research Foundation, Chennai, India, and chairman and chief diabetologist of Dr. Mohan’s Diabetes Specialties Centre


“Based on the Chennai Urban Rural Epidemiological Study (CURES) that we have done both in urban Chennai as well as in rural areas in Tamil Nadu, among diabetic patients, the prevalence of diabetic neuropathy is 26.1% in urban areas and 29.4% in rural areas,” explained diabetologist V. Mohan, MD, FRCP, PhD, DSc, FNASc, FASc, FNA, of Chennai, India, in an exclusive interview with mdCurrent-India. “This works out to 17.3 million people with neuropathy in India. Reaching out to so many people itself, is one of the great challenges in India,” said Mohan, who is president and chief of diabetes research, Madras Diabetes Research Foundation, Chennai, India, and chairman and chief diabetologist of Dr. Mohan’s Diabetes Specialties Centre, WHO Collaborating Centre for Non Communicable Diseases Prevention & Control, IDF Centre of Education.

Key Point: Treatment of diabetic neuropathy is limited to glucose control and pain management. Adequate glucose control is not sufficient to hinder neuropathic progression. The identification of modifiable risk factors for neuropathy will guide clinical studies to develop new treatments for diabetic neuropathy. Components of metabolic syndrome have been linked to diabetic neuropathy, but more clinical studies are needed to determine if any of these factors contribute causally to neuropathy.

In a study published recently in Lancet Neurology, Brian C. Callaghan, MD, and colleagues from the University of Michigan, United States, reviewed the current state of diabetic neuropathy, including treatment options and future research directions.

As noted by the authors, diabetic neuropathy most often presents as distal symmetrical polyneuropathy (DSP), characterized by a stocking-and-glove pattern of numbness, tingling, pain or weakness, beginning in the distal extremities with eventual spreading. Aside from the physical discomfort, patients with DSP are at increased risk for falls (due to balance problems) and ulcerations, often resulting in lower-extremity amputations. Other distributions of diabetic nerve injury include[s2If !is_user_logged_in()]…

[/s2If][s2If is_user_logged_in()] small-fibre predominant neuropathy, radiculoplexopathy, and autonomic neuropathy.

Neuropathy and metabolic syndrome

The authors identified several possible mechanisms for diabetic neuropathy that are linked to the components of metabolic syndrome, including changes in intracellular signaling, inflammation, and oxidative stress, resulting from hyperglycemia, insulin resistance, dyslipidemia, visceral adiposity, systemic inflammation, and/or hypertension.

Published clinical studies indicate that tight glucose control can significantly reduce neuropathy caused by type 1 diabetes; however, patients with type 2 diabetes show “only a modest reduction in neuropathy,” according the authors.

For pain management, evidence-based treatment consensus guidelines from the European Federation of Neurological Societies and the American Academy of Neurology recommend gabapentin, pregabalin, tricyclic antidepressants, venlafaxine, and duloxetine as first-line treatments and support opioid analgesics and tramadol as second-line treatments.

Implications for new treatments

As glucose control is not sufficient to hinder neuropathic progression, identifying modifiable risk factors for diabetic neuropathy has become the focus of much research. In particular, the authors detail clinical studies in diabetic patients that revealed an association of neuropathy with the various components of metabolic syndrome and prediabetes.

The authors concluded that “components of the metabolic syndrome, including prediabetes, are potential risk factors for neuropathy, and studies are needed to establish whether they are causally related to neuropathy. These lines of enquiry will have direct implications for the development of new treatments for diabetic neuropathy.”

Sources: Callaghan BC, Cheng HT, Stables CL, et al. Diabetic neuropathy: clinical manifestations and current treatments. Lancet Neurology. 2012;11:521–534.

Anjana RM, Pradeepa R, Deepa M, et al. Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: phase I results of the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study. Diabetologia. 2011;54(12):3022-3027.

Access the original journal information here:
http://www.thelancet.com/journals/laneur/article/PIIS1474-4422%2812%2970065-0/abstract
Journal publishers are independent from mdCurrent-India and may require a subscription or charge a fee to download the full article.

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