Interview with Professor Dan Ziegler

German Diabetes Center, Düsseldorf, Germany

Diabetic polyneuropathy is the most frequent microvascular complication of diabetes, which is observed in approximately one third of all individuals with diabetes.
The consensus report gives distinct and condensed practical recommendation algorithms for the physician to diagnose the condition as early as possible.
The most important aspect of this consensus report is the holistic approach, considering not only, for example, symptomatic pain treatment, but also including the concept of pathogenetically-oriented pharmacotherapy.

Why is diabetic neuropathy considered a “forgotten complication”? And what was the rationale for executing this Consensus Conference?

Diabetic polyneuropathy is the most frequent microvascular complication of diabetes, which is observed in approximately one third of all individuals with diabetes, and perhaps half of these have neuropathic symptoms, including pain, while the other half remain largely asymptomatic. This is one of the reasons for the high rate of undiagnosed neuropathy, which can be up to 80%.

The second reason is that both physicians and patients tend to consider cardiovascular diseases like myocardial infarction and stroke, rather than neuropathy, the major threat caused by diabetes.

Another issue is that the available guidelines on the diagnosis and treatment of diabetic polyneuropathy are either heterogenous, or even confusing or incomplete, by focusing only on certain aspects of the condition. We therefore took a holistic approach to provide consensus recommendations, covering all relevant areas and defining algorithms for screening, diagnosis, and treatment of polyneuropathy that are relevant specifically for clinical practice, based on the available evidence and also on the experts’ personal experience where evidence was lacking.

What are the challenges associated with the screening and diagnosis of diabetic neuropathy?

And one challenge is that half of the patients remain asymptomatic and therefore need to be examined and not only asked for symptoms. Another problem is that different nerve fibres are involved, such as large or small fibers and a single test is usually not sufficient to diagnose the neuropathy. So in many settings, you need a set of tests, but there are many of them and they are not sufficiently standardized, so that the question arises as to which tests are most appropriate. In this regard, the consensus report gives distinct and condensed practical recommendations and algorithms for the physician to be able to decide which test should be preferred and how exactly they should be used in clinical practice to diagnose the condition as early as possible.

What differentiates the consensus report from other international guideline documents or former guidelines? And why is it important for clinical practice to follow the recommendations?

I think the most important aspect is the holistic approach, considering not only, for example, symptomatic pain treatment, but also including the concept of pathogenetically-oriented pharmacotherapy. Another advantage is the use of a structured consensus finding process by applying the Delphi Method. Last but not least, we give recommendations owed to the current topic of the COVID-19 pandemic, against the background of the increased risk of in-hospital mortality, foot complications, and amputations among diabetes patients with COVID-19. So, I hope that these straightforward and distinct recommendations will be useful for physicians in their daily clinical routine when diagnosing and treating patients with diabetic polyneuropathy.

Screening, diagnosis and management of diabetic sensorimotor polyneuropathy in clinical practice: International expert consensus recommendations