Type 2 diabetes mellitus with diabetic neuropathy represents a significant complication affecting approximately half of all people with diabetes in the UK. Diabetic neuropathy—nerve damage caused by prolonged exposure to elevated blood glucose—most commonly affects the feet and legs, causing symptoms ranging from tingling and numbness to severe pain. Left unmanaged, it can lead to serious complications including foot ulceration and amputation. However, with optimal blood sugar control, appropriate medication, and vigilant foot care, progression can be slowed and symptoms effectively managed. This article explores the causes, symptoms, diagnosis, and evidence-based treatment options available through the NHS.

What Is Type 2 Diabetes Mellitus with Diabetic Neuropathy?

Type 2 diabetes mellitus is a chronic metabolic condition characterised by elevated blood glucose levels resulting from insulin resistance and relative insulin deficiency. When poorly controlled over time, persistently high blood sugar can damage various organs and tissues throughout the body, including the peripheral nervous system.

Diabetic neuropathy refers to nerve damage caused by prolonged exposure to elevated glucose levels. It represents one of the most common complications of type 2 diabetes, affecting approximately 50% of people with diabetes at some point during their condition (NHS). The pathophysiology involves multiple mechanisms: chronic hyperglycaemia leads to metabolic changes within nerve cells, oxidative stress, inflammation, and microvascular damage to the small blood vessels (vasa nervorum) that supply nerves with oxygen and nutrients.

There are several types of diabetic neuropathy, but peripheral neuropathy is the most prevalent form. This typically affects the feet and legs first, before potentially progressing to the hands and arms in a characteristic 'glove and stocking' distribution. Other forms include autonomic neuropathy (affecting internal organs), proximal neuropathy (affecting thighs, hips, or buttocks), and focal neuropathy (affecting specific nerves).

The development of diabetic neuropathy is strongly associated with both the duration of diabetes and the degree of glycaemic control. Additional modifiable risk factors include poorly controlled blood pressure, abnormal lipid levels, smoking, and excessive alcohol consumption. According to NICE guidance (NG28), maintaining optimal blood glucose levels significantly reduces the risk of developing neuropathy and can slow its progression in those already affected. Early recognition and management are essential to prevent serious complications such as foot ulceration, infection, and in severe cases, amputation.

Symptoms and Early Warning Signs of Diabetic Neuropathy

The symptoms of diabetic neuropathy vary considerably depending on which nerves are affected and the extent of damage. Many individuals experience a gradual onset of symptoms, whilst others may initially have no noticeable signs—making regular screening particularly important.

Common symptoms of peripheral diabetic neuropathy include:

• Tingling or burning sensations, often described as 'pins and needles', typically starting in the toes

• Numbness or reduced ability to feel pain or temperature changes, which can be dangerous as injuries may go unnoticed

• Sharp, shooting, or stabbing pains, frequently worse at night and affecting sleep quality

• Increased sensitivity to touch (allodynia), where even light contact with bedsheets causes discomfort

• Muscle weakness, particularly in the feet and ankles, leading to difficulty walking or changes in gait

• Loss of balance and coordination, increasing fall risk

• Foot problems such as ulcers, infections, or deformities due to loss of protective sensation

Autonomic neuropathy affects the nerves controlling internal organs and may cause:

• Bladder problems (urinary retention or incontinence)

• Digestive issues (gastroparesis, constipation, or diarrhoea)

• Sexual dysfunction (erectile dysfunction in men, vaginal dryness in women)

• Abnormal sweating patterns

• Difficulty recognising hypoglycaemia (reduced awareness of low blood sugar)

• Cardiovascular symptoms such as dizziness upon standing (postural hypotension) or resting tachycardia

Early warning signs are often subtle. Patients may notice minor changes in sensation, occasional cramping, or unexplained foot discomfort. Any new or progressive neurological symptoms in someone with type 2 diabetes warrant prompt medical assessment, as early intervention can prevent deterioration and serious complications.

Certain features ('red flags') suggest alternative causes of neuropathy and require urgent specialist assessment: asymmetric symptoms, acute or subacute onset (over days to weeks), predominant motor weakness, cranial nerve involvement, or systemic features such as unexplained weight loss or fever. If you experience any of these, contact your GP promptly for further investigation.

How Diabetic Neuropathy Is Diagnosed in the UK

Diagnosis of diabetic neuropathy in the UK follows a systematic clinical approach, combining patient history, physical examination, and specific diagnostic tests. NICE recommends that all adults with type 2 diabetes should be screened annually for diabetic neuropathy as part of their routine diabetes care (NG28).

Clinical assessment begins with:

• Detailed medical history: Healthcare professionals enquire about symptoms such as pain, numbness, tingling, or balance problems, as well as reviewing diabetes duration and glycaemic control

• Medication review: To identify other potential causes of neuropathy (certain medications, alcohol use, vitamin deficiencies). People taking metformin who present with neuropathy symptoms should be assessed for vitamin B12 deficiency, as metformin can reduce B12 absorption (MHRA 2022)

• Physical examination of the feet: Visual inspection for ulcers, deformities, calluses, or signs of infection, plus assessment of foot pulses and, where peripheral arterial disease is suspected, ankle-brachial pressure index (ABPI)

Neurological examination includes several standardised tests:

• 10g monofilament test: A nylon filament is pressed against specific points on the foot to assess protective sensation. Inability to feel the monofilament indicates significant sensory loss and high ulceration risk

• Vibration perception testing: Using a 128 Hz tuning fork placed on bony prominences (typically the big toe) to assess vibration sense

• Ankle reflex testing: Reduced or absent reflexes may indicate neuropathy

• Pinprick sensation: To evaluate small fibre function

• Assessment of proprioception: Testing position sense and balance

Annual foot screening includes risk stratification and, where appropriate, referral to a foot protection service or multidisciplinary foot care service in accordance with NICE guidance (NG19). In primary care, these bedside tests are usually sufficient for diagnosis. However, if the presentation is atypical, progresses rapidly, or other causes are suspected, referral to a specialist diabetes service or neurology may be appropriate for further investigation.

Additional investigations may include:

• Nerve conduction studies and electromyography (EMG): To assess nerve function objectively and exclude other neuropathies

• Blood tests: HbA1c (glycated haemoglobin), vitamin B12, thyroid function, and renal function to identify contributory factors

• Autonomic function tests: For suspected autonomic neuropathy

Accurate diagnosis enables appropriate management planning and helps identify patients at high risk of foot complications who require enhanced monitoring and podiatry input.

Treatment Options for Diabetic Neuropathy

Treatment of diabetic neuropathy focuses on three main objectives: optimising glycaemic control to prevent progression, managing neuropathic pain, and preventing complications. There is currently no cure for established nerve damage, but symptoms can be effectively managed and further deterioration minimised.

Pharmacological management of neuropathic pain:

NICE clinical guidelines (CG173) recommend a stepwise approach to managing painful diabetic peripheral neuropathy in adults. First-line treatment is:

• Duloxetine (serotonin-norepinephrine reuptake inhibitor): Licensed specifically for diabetic peripheral neuropathic pain at 60 mg once daily. Duloxetine is the recommended first-line option for painful diabetic neuropathy (NICE CG173; BNF)

If duloxetine is contraindicated, not tolerated, or ineffective, consider:

• Amitriptyline (tricyclic antidepressant): Starting at 10 mg at night, gradually titrated upwards. It works by modulating pain pathways in the central nervous system. Common side effects include dry mouth, drowsiness, and constipation. Caution is needed in cardiovascular disease. Note: amitriptyline is used off-label for neuropathic pain in the UK (BNF; MHRA/EMC SmPC)

• Gabapentin or pregabalin (anticonvulsants): These medications reduce abnormal nerve signalling. Dosing requires gradual titration and adjustment in renal impairment. Both gabapentin and pregabalin are Schedule 3 controlled drugs in the UK. Important safety information (MHRA): gabapentin and pregabalin carry risks of misuse, dependence, and respiratory depression, particularly when used with opioids or in patients with respiratory disease. They may cause sedation and increase fall risk, especially in older adults. Doses must be adjusted in renal impairment (BNF; MHRA Drug Safety Update)

If first-line treatments are ineffective or poorly tolerated, combination therapy or referral to specialist pain services may be considered. Tramadol may be considered only for short-term rescue therapy if acute exacerbations of neuropathic pain occur; long-term opioid use is not recommended due to limited efficacy in neuropathic pain and significant risks including dependence (NICE CG173).

Topical treatments such as capsaicin cream may be considered in some cases; specialist 8% capsaicin patches are available via specialist services for localised neuropathic pain (check current UK licensing and SmPC).

Non-pharmacological approaches:

• Foot care education: Daily inspection, appropriate footwear, prompt treatment of minor injuries

• Podiatry services: Regular assessment and treatment, particularly for high-risk patients

• Physiotherapy: To maintain strength, balance, and mobility

• Transcutaneous electrical nerve stimulation (TENS): Evidence for TENS is limited, but it may provide symptomatic relief for some patients

• Psychological support: Chronic pain can significantly impact mental health; cognitive behavioural therapy may be beneficial

Management of autonomic neuropathy is symptom-specific and often requires specialist input. Treatment may involve medications for gastroparesis, bladder dysfunction, or postural hypotension (such as fludrocortisone, midodrine, or compression hosiery), alongside lifestyle modifications (e.g., small frequent meals, adequate hydration, rising slowly from sitting or lying).

Regular medication review is essential to assess efficacy, manage side effects, and adjust treatment as needed. Patients should be informed that neuropathic pain medications typically require several weeks to achieve maximum benefit.

If you experience any suspected side effects from your medication, you can report them via the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk or by searching for 'Yellow Card' in the Google Play or Apple App Store.

Managing Blood Sugar to Prevent Nerve Damage

Optimal glycaemic control represents the cornerstone of preventing diabetic neuropathy and slowing its progression in those already affected. Large-scale clinical trials have demonstrated that maintaining blood glucose levels as close to normal as safely possible significantly reduces the risk of developing microvascular complications, including neuropathy. Comprehensive management of other cardiovascular risk factors—particularly blood pressure and lipid levels—also contributes to reducing microvascular risk.

NICE recommends individualised HbA1c targets for adults with type 2 diabetes (NG28), typically:

• 48 mmol/mol (6.5%) for those managed by lifestyle and diet alone or with a single glucose-lowering medication not associated with hypoglycaemia

• 53 mmol/mol (7.0%) for most people on medications that may cause hypoglycaemia

• Less stringent targets may be appropriate for older adults, those with multiple comorbidities, or limited life expectancy

Achieving and maintaining target HbA1c requires a comprehensive approach:

Lifestyle modifications:

• Dietary management: Following a balanced diet with controlled carbohydrate intake, emphasising whole grains, vegetables, lean proteins, and healthy fats. Referral to a diabetes specialist dietitian can provide personalised guidance

• Regular physical activity: At least 150 minutes of moderate-intensity aerobic exercise weekly, plus resistance training (UK Chief Medical Officers' Physical Activity Guidelines). Exercise improves insulin sensitivity and aids weight management

• Weight management: Even modest weight loss (5–10% of body weight) can significantly improve glycaemic control in overweight individuals

• Smoking cessation: Smoking exacerbates vascular damage and neuropathy risk

Pharmacological management:

Medications are selected based on individual patient factors, including renal function, cardiovascular risk, and patient preference. Options include metformin (first-line), SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, sulfonylureas, and insulin (NICE NG28; BNF).

Self-monitoring and education:

Structured diabetes education programmes (such as DESMOND for type 2 diabetes) empower patients with knowledge and skills for effective self-management. NICE guidance (NG28) advises that self-monitoring of blood glucose (SMBG) should not be routinely offered to adults with type 2 diabetes unless they are on insulin, at risk of hypoglycaemia (for example, on sulfonylureas), during intercurrent illness, or for specific diagnostic or educational purposes. Your diabetes care team will advise whether SMBG is appropriate for you.

Consistent glycaemic control over years reduces neuropathy risk substantially, making it a vital long-term investment in preventing debilitating complications.

When to Seek Medical Advice for Diabetic Neuropathy

Knowing when to seek medical advice is crucial for preventing serious complications of diabetic neuropathy. Both routine monitoring and prompt attention to new symptoms play important roles in comprehensive diabetes care.

Routine care and annual screening:

All individuals with type 2 diabetes should attend annual diabetes reviews, which include screening for neuropathy through foot examination and neurological assessment. These appointments provide opportunities to discuss any concerns, review medications, and adjust management plans.

Seek prompt medical advice if you experience:

• New or worsening numbness, tingling, or pain in your feet, legs, hands, or arms

• Any foot injury, blister, cut, or sore, even if minor—reduced sensation means injuries can worsen rapidly without pain as a warning

• Changes in foot appearance: redness, swelling, warmth, discolouration, or unusual odour

• Persistent pain that interferes with daily activities or sleep, despite over-the-counter pain relief

• Difficulty walking, frequent falls, or significant balance problems

• Signs of infection: fever, spreading redness, discharge from wounds, or feeling generally unwell

Seek same-day assessment (contact your GP or foot protection service/multidisciplinary foot care service) for:

• Any new foot ulcer or open wound

• Suspected foot infection (redness, warmth, swelling, discharge, or systemic symptoms)

• Suspected acute Charcot foot: sudden swelling, redness, and warmth in the foot without preceding injury. This requires urgent same-day referral to a multidisciplinary foot care service for assessment (ideally within 24 hours) and immediate offloading to prevent joint damage (NICE NG19)

• Severe, uncontrolled pain not responding to prescribed medications

• Sudden loss of sensation or motor function

Emergency care (999 or A&E) is required for:

• Signs of severe infection or sepsis: high fever, confusion, rapid heartbeat, severe pain with rapidly spreading redness, or feeling extremely unwell

• Suspected acute limb ischaemia: sudden severe pain, pallor (very pale or white foot), pulselessness, paraesthesia, or paralysis

Patients with established diabetic neuropathy should have enhanced foot care, including regular podiatry appointments, and may be referred to a foot protection service or specialist multidisciplinary foot care team depending on their level of risk (NICE NG19). Never hesitate to contact your GP or diabetes care team with concerns—early intervention prevents serious complications and preserves quality of life. Between appointments, daily foot inspection and adherence to foot care advice are essential preventive measures.

Frequently Asked Questions