Issue 169 Item 14 Diabetic Neuropathy Easily Goes Unrecognized in Primary Care

Diabetic neuropathy is underdiagnosed in everyday clinical practice, according to a study of 7,378 patients assessed at more than 2,000 primary care physician offices and endocrinology clinics.

Dr.. William Herman, professor of internal medicine and epidemiology at the University of Michigan, Ann Arbor said that, “most patients have an insensate foot or feet and do not complain about a lack of sensation, so “unless you look for diabetic neuropathy and systematically test, you can miss the diagnosis.”

Each physician in the study enrolled up to four patients with type 2 diabetes. Most of the doctors worked in primary care offices (88%); the remainder (12%) practiced in endocrinology clinics. The study is part of an ongoing trial of insulin glargine (Lantus, Aventis) in 14,000 primary care patients with type 2 diabetes not responding to oral agents. Aventis sponsored both studies.

The physician’s judgment as to whether a patient had neuropathy was compared with results of a monofilament foot exam. Physicians tested the plantar surface of the patient’s big toe with two sizes of monofilament. Patients able to feel both monofilaments were considered normal (no neuropathy). Those who could feel the larger (5.07 gauge) but not the smaller (3.61 gauge) had non-severe neuropathy. Those who could feel neither monofilament had severe neuropathy. Only 0.74% of patients reported feeling the smaller, but not the larger, monofilament; these patients were excluded based on this “nonsense” result.

Of the 7,378 patients in the study, 4,628 (63%) did not have neuropathy. Physicians correctly identified the lack of neuropathy in 92% of these patients. Physician perception was less accurate for identifying patients with neuropathy. Monofilament testing indicated that 2,209 (30%) of the patients had non-severe neuropathy and 541 (7%) had severe neuropathy; doctors correctly identified 31% of the non-severe cases and 66% of the severe cases.

The findings suggest that primary care physicians are overlooking earlier, less severe cases of neuropathy and thus missing opportunities for early intervention such as custom footwear, Dr. Herman said.

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