Diabetic peripheral neuropathy (DPN) is a heterogeneous group of lesions. The most common form is distal symmetric polyneuropathy: stocking and glove, first small fibres (burning, dysaesthesia), then large fibres (numbness, loss of balance). ADA 2026 warns: up to 50% of DPN cases may be asymptomatic. It is precisely the asymptomatic form that surrenders the foot to ulceration: no pain — no early presentation.
Screening in T2DM starts at diagnosis and is annual (12.17). Assessment: history plus small fibres (temperature or pinprick) plus large fibres (vibration with a 128 Hz tuning fork) plus, annually, the 10 g monofilament — a test for loss of protective sensation (LOPS), the main component of ulcer risk. ADA 2026 accepts the Ipswich touch test as an addition. Electroneuromyography is not needed routinely: it is for an atypical picture (acute/subacute onset, asymmetry, motor predominance). The MoH RK 2022 protocol puts ENG on the annual list — this is a "broader" local practice than the ADA position; the discrepancy is named.
Diabetes does not have a monopoly on neuropathy. Before attaching the label, look for alcohol, neurotoxic drugs, B12 deficiency (especially with long-term metformin — ADA explicitly includes B12 in the differential list), hypothyroidism, CKD, paraprotein, HIV, hepatitis C. Metformin is not "banned because of neuropathy" here: the point is not to miss the deficiency.
Pain. Optimal glycaemia prevents DPN in type 1 diabetes more convincingly than it reverses it in T2DM (12.20: level A for type 1, level C for slowing in type 2). For pain, ADA 2026 (12.22, level A) puts gabapentinoids, serotonin–norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants and sodium channel blockers in the first row; combinations are acceptable. Opioids, including tramadol and tapentadol, should not be used for neuropathic pain in diabetes except in rare circumstances (level B). This is not "inhumane", it is a balance of harm: the CDC and AAN find no data on long-term benefit of opioids in chronic pain and document dependence, overdoses and fractures.
Autonomic neuropathy. Symptom screening starts at the diagnosis of T2DM (12.19): orthostatic dizziness, early satiety, erectile dysfunction, changes in sweating. Cardiovascular autonomic neuropathy in its advanced form means resting tachycardia >100 and orthostatic hypotension (a fall in systolic >20 or diastolic >10 mmHg without an appropriate increase in heart rate). It is associated with mortality independently of other cardiovascular factors — this is an observational association, which ADA formulates as an association, not as a proven effect of "cure CAN — cure death".
The foot. Recommendation 12.23: a comprehensive evaluation at least annually. With LOPS or a previous ulcer/amputation — foot inspection at every visit (12.25, level A). The International Working Group on the Diabetic Foot (IWGDF) stratification that ADA gives in Table 12.1. PAD here means peripheral artery disease:
| Category | Ulcer risk | Examination frequency |
|---|---|---|
| 0 | no LOPS, no PAD | annually |
| 1 | LOPS or PAD | every 6–12 months |
| 2 | LOPS+PAD / LOPS+deformity / PAD+deformity | every 3–6 months |
| 3 | LOPS or PAD plus a history of ulcer/amputation/kidney failure | every 1–3 months |
Peripheral neuropathy was a component cause of 78% of ulcers in a multicentre study cited by ADA; the triad "neuropathy + minor trauma + deformity" was present in more than 63% of participants. This is an observational structure of causes, not an RCT of "remove the deformity — there will be no ulcer", but it explains why one should look at footwear and calluses and not only at the monofilament.
The conclusion. Neuropathy is dangerous not because of pain. It is dangerous because of silence. The 10 g monofilament is a cheap test that changes the frequency of examinations and the referral for orthopaedic footwear.