Frustratingly, disease-modifying treatments for diabetic neuropathy remain elusive. Glycaemic control has a robust effect on preventing neuropathy in individuals with type 1 but not in those with type 2 diabetes, which constitute the vast majority of patients. Encouragingly, recent evidence points to new metabolic risk factors and mechanisms, and thus also at novel disease-modifying strategies, which are desperately needed. Obesity has emerged as the second most important metabolic risk factor for neuropathy (diabetes being the first) from consensus findings of seven observational studies in populations across the world. Moreover, dyslipidaemia and altered sphingolipid metabolism are emergent novel mechanisms of nerve injury that may lead to new targeted therapies. Clinical history and examination remain critical components of an accurate diagnosis of neuropathy. However, skin biopsies and corneal confocal microscopy are promising newer tests that have been used as outcome measures in research studies but have not yet demonstrated clear clinical utility. Given the emergence of obesity as a neuropathy risk factor, exercise and weight loss are potential interventions to treat and/or prevent neuropathy, although evidence supporting exercise currently outweighs data supporting weight loss. Furthermore, a consensus has emerged advocating tricyclic antidepressants, serotonin-noradrenaline (norepinephrine) reuptake inhibitors and gabapentinoids for treating neuropathic pain. Out-of-pocket costs should be considered when prescribing these medications since their efficacy and tolerability are similar. Finally, the downsides of opioid treatment for chronic, non-cancer pain are becoming increasingly evident. Despite these data, current clinical practice frequently initiates and continues opioid prescriptions for patients with neuropathic pain before prescribing guideline-recommended treatments.

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糖尿病性神经病变：未来会怎样？

令人沮丧的是，糖尿病神经病变的疾病缓解治疗仍然难以捉摸。血糖控制对预防 1 型糖尿病患者的神经病变具有强大的作用，但对于占绝大多数患者的 2 型糖尿病患者则没有。令人鼓舞的是，最近的证据指出了新的代谢风险因素和机制，因此也指出了迫切需要的新的疾病缓解策略。根据对世界各地人群的七项观察性研究的共识结果，肥胖已成为神经病变的第二大重要代谢风险因素（糖尿病是第一个）。此外，血脂异常和鞘脂代谢改变是新出现的神经损伤机制，可能导致新的靶向治疗。临床病史和检查仍然是准确诊断神经病变的关键组成部分。然而，皮肤活检和角膜共聚焦显微镜是有前途的新测试，已被用作研究中的结果测量，但尚未证明明确的临床实用性。鉴于肥胖成为神经病变的危险因素，运动和减肥是治疗和/或预防神经病变的潜在干预措施，尽管目前支持运动的证据超过了支持减肥的数据。此外，已达成共识，主张使用三环类抗抑郁药、5-羟色胺-去甲肾上腺素（去甲肾上腺素）再摄取抑制剂和加巴喷丁类药物治疗神经性疼痛。开这些药物时应考虑自付费用，因为它们的疗效和耐受性相似。最后，阿片类药物治疗慢性非癌症疼痛的弊端正变得越来越明显。尽管有这些数据，但目前的临床实践经常在开出指南推荐的治疗方法之前为患有神经性疼痛的患者开具并继续使用阿片类药物处方。