02886nas a2200277   4500000000100000008004100001653002600042653002900068653003000097653003000127653002100157653001100178653002400189653003100213653002100244653003300265653005200298100001700350700001200367700001500379245004700394300001200441490000800453520213300461022001402594       2015                            d10aAntidepressive Agents10aCalcium Channel Blockers10aDiabetes Mellitus, Type 110aDiabetes Mellitus, Type 210aElectrodiagnosis10aHumans10aHypoglycemic Agents10aMagnetic Resonance Imaging10aPolyneuropathies10aPractice Guidelines as Topic10aSerotonin and Noradrenaline Reuptake Inhibitors1 aCallaghan BC1 aPrice R1 aFeldman EL00aDistal Symmetric Polyneuropathy: A Review.  a2172-810 v3143 a<p><strong>IMPORTANCE: </strong>Peripheral neuropathy is a highly prevalent and morbid condition affecting 2% to 7% of the population. Patients frequently experience pain and are at risk of falls, ulcerations, and amputations. We aimed to review recent diagnostic and therapeutic advances in distal symmetric polyneuropathy, the most common subtype of peripheral neuropathy.</p>

<p><strong>OBSERVATIONS: </strong>Current evidence supports limited routine laboratory testing in patients with distal symmetric polyneuropathy. Patients without a known cause should undergo a complete blood cell count, comprehensive metabolic panel, vitamin B12 measurement, serum protein electrophoresis with immunofixation, fasting glucose measurement, and glucose tolerance test. The presence of atypical features such as asymmetry, non-length dependence, motor predominance, acute or subacute onset, and prominent autonomic involvement should prompt a consultation with a neurologist or neuromuscular specialist. Electrodiagnostic tests and magnetic resonance imaging of the neuroaxis contribute substantial cost to the diagnostic evaluation, but evidence supporting their use is lacking. Strong evidence supports the use of tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, and voltage-gated calcium channel ligands in the treatment of neuropathic pain. More intensive glucose control substantially reduces the incidence of distal symmetric polyneuropathy in patients with type 1 diabetes but not in those with type 2 diabetes.</p>

<p><strong>CONCLUSIONS AND RELEVANCE: </strong>The opportunity exists to improve guideline-concordant testing in patients with distal symmetric polyneuropathy. Moreover, the role of electrodiagnostic tests needs to be further defined, and interventions to reduce magnetic resonance imaging use in this population are needed. Even though several efficacious medications exist for neuropathic pain treatment, pain is still underrecognized and undertreated. New disease-modifying medications are needed to prevent and treat peripheral neuropathy, particularly in type 2 diabetes.</p>
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