Callaghan Brian C, Price Raymond S, Feldman Eva L
Department of Neurology, University of Michigan, Ann Arbor.
Department of Neurology, University of Pennsylvania, Philadelphia.
JAMA. 2015 Nov 24;314(20):2172-81. doi: 10.1001/jama.2015.13611.
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.
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.
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.
周围神经病变是一种高度流行且具有病态影响的疾病，影响着2%至7%的人群。患者经常遭受疼痛，并有跌倒、溃疡和截肢的风险。我们旨在回顾远端对称性多发性神经病变（周围神经病变最常见的亚型）的近期诊断和治疗进展。
目前的证据支持对远端对称性多发性神经病变患者进行有限的常规实验室检查。病因不明的患者应进行全血细胞计数、综合代谢指标检测、维生素B12测定、血清蛋白电泳及免疫固定、空腹血糖测定和葡萄糖耐量试验。存在不对称、非长度依赖性、运动为主、急性或亚急性起病以及明显自主神经受累等非典型特征时，应咨询神经科医生或神经肌肉专科医生。电诊断测试和神经轴的磁共振成像会给诊断评估带来相当大的成本，但缺乏支持其使用的证据。有力证据支持使用三环类抗抑郁药、5-羟色胺去甲肾上腺素再摄取抑制剂和电压门控钙通道配体治疗神经性疼痛。强化血糖控制可大幅降低1型糖尿病患者远端对称性多发性神经病变的发生率，但对2型糖尿病患者无效。
存在改善远端对称性多发性神经病变患者符合指南的检测的机会。此外，电诊断测试的作用需要进一步明确，并且需要采取干预措施减少该人群中磁共振成像的使用。尽管有几种有效的药物可用于治疗神经性疼痛，但疼痛仍未得到充分认识和治疗。需要新的疾病修饰药物来预防和治疗周围神经病变，尤其是在2型糖尿病中。
