What are the recommended screening protocols for diabetic neuropathy in patients with type 1 and type 2 diabetes?

For patients with type 1 and type 2 diabetes, screening for diabetic neuropathy should begin at diagnosis for type 2 diabetes and from 5 years after diagnosis for type 1 diabetes, reflecting the typical disease progression and risk profile. Screening should be performed at least annually thereafter to detect neuropathy early and prevent complications.

The screening protocol includes a clinical foot examination focusing on sensory testing using a 10 g monofilament to assess for peripheral neuropathy, as well as inspection for deformities, callus, ulceration, infection, and signs of peripheral arterial disease. This examination should be done barefoot, removing shoes and socks, to ensure thorough assessment.

Additional assessments may include vibration perception threshold testing and ankle-brachial pressure index measurement to evaluate for peripheral arterial disease, although interpretation requires caution in diabetic patients due to possible arterial calcification.

Risk stratification based on neuropathy presence, foot deformity, peripheral arterial disease, and history of ulceration or amputation guides the frequency of follow-up and referral to multidisciplinary foot care services.

Screening should also consider symptoms and signs of autonomic neuropathy, such as unexplained diarrhoea, bladder emptying problems, or orthostatic hypotension, especially in type 1 diabetes.

Recent expert opinion emphasizes a multidisciplinary approach integrating clinical examination with patient education on foot care and glycaemic control, and suggests that screening protocols may benefit from incorporating newer diagnostic tools and patient-reported symptom assessments to improve early detection and management (Atmaca et al., 2024).

However, UK NICE guidelines remain the standard reference, recommending annual foot assessments including monofilament testing and clinical examination for neuropathy in all adults with diabetes, with earlier and more frequent assessments for those at higher risk ¹,².