|Year : 2018 | Volume
| Issue : 3 | Page : 83-84
Diabetic neuropathy in the Middle East and North Africa region: A call for action
Department of Medicine, Hamad Medical Corporation, Doha, Qatar
|Date of Web Publication||4-Oct-2018|
Dr. Mohsen Eledrisi
Department of Medicine, Hamad Medical Corporation, P.O. Box 3050, Doha
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Eledrisi M. Diabetic neuropathy in the Middle East and North Africa region: A call for action. Libyan J Med Sci 2018;2:83-4
The number of people affected with diabetes is increasing worldwide. It is projected that the Middle East and North Africa (MENA) region will have one of the highest rates of increase in the prevalence of diabetes in the coming decades. This increase in the number of individuals with diabetes is expected to be associated with an increase in the rate of complications related to the disease. Diabetic neuropathy is the most common complication of diabetes and covers different conditions that can affect several parts of the nervous system. Proper diagnosis of diabetic neuropathy remains crucial for clinicians in order to identify high-risk patients for the development of foot ulceration, Charcot neuroarthropathy, and subsequent lower limb amputations. Diabetic neuropathies are generally classified into three types: diffuse neuropathy, which includes distal symmetric peripheral neuropathy and autonomic neuropathy, mononeuropathy, and radiculopathy. Distal symmetric peripheral neuropathy is the most common form, accounting for about 75% of diabetic neuropathies. Painful diabetic neuropathy can occur with many of the above-mentioned types of neuropathies, is associated with significant morbidity, and can negatively impact quality of patient's life. Epidemiological data on painful diabetic neuropathy show variable prevalence rates likely due to inconsistent definitions, different tools used for the diagnosis, poor ascertainment, and the limited number of population-based studies.
In this issue, Garoushi et al. provide a systematic review and meta-analysis on the prevalence of painful diabetic neuropathy in the MENA region. After an extensive review, the authors found only five qualified papers on the subject and concluded that the prevalence of painful diabetic neuropathy is 43.3%. This systematic review is important and raises several thoughts and questions. It is noted that the prevalence rates of painful diabetic neuropathy were very variable among the studied countries, ranging from 14% in Turkey to 65.3% in Saudi Arabia. This wide variation across the studies may be explained by different patient characteristics, subjectivity of the used diagnostic tools, inclusion of patients with Type 1 diabetes as well as patients with Type 2 diabetes, variable periods of duration of diabetes, and different levels of glucose control. The diagnostic tools used in the included studies were mainly the douleur neuropathique 4 (DN4) questionnaire and Leeds assessment of neuropathic symptoms and signs (LANSS) pain scale. These two tests use different criteria to define neuropathic pain and depend mainly on subjective description of patient's symptoms. Other population studies used different diagnostic tools such as the neuropathy symptom score and the neuropathy disability score. Making the diagnosis of diabetic neuropathy based solely on these subjective tests can be problematic, particularly that most of the studies included in the systematic review by Garoushi et al. did not provide objective information on physical examination to confirm the diagnosis of neuropathy. In addition, it is not known how much agreement do these subjective tools have and how they perform as there are no head-to-head comparison data. Another thought-provoking observation is that reported symptoms of painful diabetic neuropathy do not always coincide with findings of neuropathy when using objective diagnostic tests. On the other hand, a large percentage of patients with peripheral diabetic neuropathy are asymptomatic which puts them at risk of further complications if their disease is not recognized early. In addition, the studies included in the systematic review did not provide information on whether other diagnostic tests were performed to exclude causes of neuropathy other than diabetes; this is important to ascertain that patients' neuropathic symptoms are truly related to diabetes.
Painful diabetic neuropathy continues to be underreported by patients, and a significant percentage of patients do not receive any treatment from their physicians. Part of proper care of patients with diabetes should include assessment for distal symmetric neuropathy, the most common form of diabetic neuropathy. This includes a careful history and physical examination that comprises either temperature or pinprick sensation (to assess small-fiber function), vibration sensation using a 128-Hz tuning fork (to assess large-fiber function), and 10-g monofilament testing to assess the risk for feet ulceration and amputation. Therefore, the diagnosis of distal symmetric diabetic neuropathy remains mainly clinical. Some clinicians perform subjective assessment for patients who have symptoms of peripheral diabetic neuropathy using available patient survey tools such as DN4 questionnaire, LANSS scale, or neuropathy symptom score. These tools may be helpful but should not be used alone for the diagnosis of peripheral diabetic neuropathy. Other causes of neuropathy should be excluded before attributing the condition to diabetes; some of these disorders include metabolic conditions such as hypothyroidism and chronic kidney disease, nutritional causes such as Vitamin B12 deficiency and postgastroplasty, systemic diseases such as paraproteinemia and vasculitis, infections such as HIV and Hepatitis B virus, and medications. Treatment of painful diabetic neuropathy aims at reducing patient's symptoms and improving quality of life. Professional evidence-based guidelines on the management of painful diabetic neuropathy are available. Prevention of diabetic neuropathy remains crucial through adequate glucose control and lifestyle interventions.
In conclusion, the diagnosis and management of diabetic neuropathy continue to be a challenge for clinicians. Early recognition through careful medical history and proper physical examination remains the cornerstone of identifying diabetic neuropathy in order to implement timely plans for prevention and management. Health-care professionals are urged to appreciate the importance of screening and prevention of diabetic neuropathy in order to avoid its devastating consequences.
| References|| |
Pop-Busui R, Boulton AJ, Feldman EL, Bril V, Freeman R, Malik RA, et al.
Diabetic neuropathy: A position statement by the American Diabetes Association. Diabetes Care 2017;40:136-54.
Boulton AJ. The pathway to foot ulceration in diabetes. Med Clin North Am 2013;97:775-90.
Albers JW, Pop-Busui R. Diabetic neuropathy: Mechanisms, emerging treatments, and subtypes. Curr Neurol Neurosci Rep 2014;14:473.
Bril V, England J, Franklin GM, Backonja M, Cohen J, Del Toro D, et al.
Evidence-based guideline: Treatment of painful diabetic neuropathy: Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology 2011;76:1758-65.
Abbott CA, Malik RA, van Ross ER, Kulkarni J, Boulton AJ. Prevalence and characteristics of painful diabetic neuropathy in a large community-based diabetic population in the U.K. Diabetes Care 2011;34:2220-4.
Garoushi S, Johnson MI, Tashani OA. Point prevalence of painful diabetic neuropathy in the Middle East and North Africa (MENA) region: A systematic review with meta-analysis. Libyan J Med Sci 2018;2:85-94. [Full text]
Davies M, Brophy S, Williams R, Taylor A. The prevalence, severity, and impact of painful diabetic peripheral neuropathy in type 2 diabetes. Diabetes Care 2006;29:1518-22.