Executive summary
- Think peripheral neuropathy in a distal, symmetrical “stocking” or “glove-and-stocking” sensory pattern with numbness, tingling, burning pain, impaired vibration sense, or reduced ankle reflexes.
- The first GP task is cause-finding rather than reflex referral: diabetes, alcohol, B12 deficiency, thyroid disease, renal disease, coeliac disease, paraproteinaemia, and medicines are common possibilities.
- Urgent assessment is needed if symptoms are rapidly progressive, accompanied by weakness, gait imbalance, sphincter symptoms, severe pain, or asymmetry suggesting a non-routine neuropathy pattern.
Assessment and baseline investigations
- History: clarify tempo, pain, numbness, falls, hand dysfunction, autonomic symptoms, alcohol intake, toxin exposure, diabetes risk, family history, and relevant medicines.
- Examination: assess gait, power, reflexes, proprioception, vibration sense, skin integrity, pulses, and foot ulcer risk rather than documenting “paraesthesia” alone.
- Useful baseline tests: HbA1c and/or fasting glucose, vitamin B12, thyroid function, renal function, ESR, coeliac-directed testing when indicated, and serum protein electrophoresis with immunofixation when the cause is not obvious.
- Medication review matters: ask specifically about chemotherapy exposure, excess alcohol, and drugs with recognised neuropathy risk.
When to refer
- Refer for neurological assessment if no clear cause is found after baseline work-up, if the distribution is atypical, or if there is progression despite treatment of reversible causes.
- Escalate urgently for acute or subacute progression, associated weakness, marked imbalance, bowel/bladder disturbance, or systemic red flags.
- Primary care management is still valuable: optimise diabetes control, address alcohol excess, treat deficiency states, reduce falls/foot-ulcer risk, and treat neuropathic pain in line with the separate NICE neuropathic-pain pathway.
Frequently asked questions
What are the highest-yield first tests in distal symmetrical neuropathy?
In primary care, start by looking for common reversible causes: HbA1c or glucose testing, vitamin B12, thyroid function, renal function, ESR, and—when the cause remains unclear—serum protein electrophoresis with immunofixation.
When is this no longer routine primary care follow-up?
Rapid progression, weakness, gait instability, sphincter disturbance, severe asymmetry, or a non-length-dependent pattern should push the case out of the routine pathway and towards urgent neurological assessment.
Should I refer every patient with neuropathy symptoms?
No. NICE supports an initial primary care work-up for common causes. Referral becomes appropriate when the pattern is atypical, the person is progressing, or the underlying cause is not identified.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.