DIABETIC NEUROPATHY - Diabetic neuropathy is a common and serious complication of diabetes. Diabetic neuropathy most often damages nerves in your legs and feet. Diabetic neuropathy is a type of nerve damage that can occur if you have diabetes. High blood sugar (glucose) can injure nerves throughout your body. Depending on the affected nerves, symptoms of diabetic neuropathy can range from pain and numbness in your legs and feet to problems with your digestive system, urinary tract, blood vessels and heart. Some people have mild symptoms. But for others, diabetic neuropathy can be quite painful and disabling. The exact cause likely differs for each type of neuropathy. Uncontrolled high blood sugar damages nerves and interferes with their ability to send signals, leading to diabetic neuropathy. High blood sugar also weakens the walls of the small blood vessels (capillaries) that supply the nerves with oxygen and nutrients. However, a combination of factors may lead to nerve damage.

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Diabetic Neuropathy

by Drugs.com

Overview

Diabetic neuropathy is a type of nerve damage that can occur if you have diabetes. High blood sugar (glucose) can injure nerves throughout your body.

Diabetic neuropathy most often damages nerves in your legs and feet.

Depending on the affected nerves, symptoms of diabetic neuropathy can range from pain and numbness in your legs and feet to problems with your digestive system, urinary tract, blood vessels and heart.

Some people have mild symptoms. But for others, diabetic neuropathy can be quite painful and disabling.

Diabetic neuropathy is a common and serious complication of diabetes. But you can often prevent diabetic neuropathy or slow its progress with tight blood sugar control and a healthy lifestyle.

Symptoms

There are four main types of diabetic neuropathy. You can have one or more than one type of neuropathy.

Your symptoms will depend on the type you have and which nerves are affected. Usually, symptoms develop gradually.

You may not notice anything wrong until considerable nerve damage has occurred.

Peripheral neuropathy

Peripheral neuropathy is the most common type of diabetic neuropathy. It affects the feet and legs first, followed by the hands and arms.

Signs and symptoms of peripheral neuropathy are often worse at night, and may include:

·          Numbness or reduced ability to feel pain or temperature changes

·         Tingling or burning sensation

·         Sharp pains or cramps

·          Increased sensitivity to touch — for some people, even the weight of a bedsheet can be painful

·         Muscle weakness

·          Loss of reflexes, especially in the ankle

·          Loss of balance and coordination

·          Serious foot problems, such as ulcers, infections, and bone and joint pain

Autonomic neuropathy

The autonomic nervous system controls your heart, bladder, stomach, intestines, sex organs and eyes.

Diabetes can affect nerves in any of these areas, possibly causing:

·          A lack of awareness that blood sugar levels are low (hypoglycemia unawareness)

·         Bladder problems, including urinary tract infections or urinary retention or incontinence

·         Constipation, uncontrolled diarrhea or both

·          Slow stomach emptying (gastroparesis), causing nausea, vomiting, bloating and loss of appetite

·          Difficulty swallowing

·          Increased or decreased sweating

·          Problems controlling body temperature

·         Changes in the way your eyes adjust from light to dark

·         Increased heart rate at rest

·         Sharp drops in blood pressure after sitting or standing that may cause you to faint or feel lightheaded

·          Erectile dysfunction

·          Vaginal dryness

·          Decreased sexual response

Radiculoplexus neuropathy (diabetic amyotrophy)

Radiculoplexus neuropathy affects nerves in the thighs, hips, buttocks or legs. It's more common in people with type 2 diabetes and older adults. Other names for this type are diabetic amyotrophy, femoral neuropathy or proximal neuropathy.

Symptoms are usually on one side of the body, but sometimes may spread to the other side. You may have:

·         Severe pain in a hip and thigh or buttock that occurs in a day or more

·         Eventual weak and shrinking thigh muscles

·         Difficulty rising from a sitting position

·         Abdominal swelling, if the abdomen is affected

·        Weight loss

Most people improve at least partially over time, though symptoms may worsen before they get better.

Mononeuropathy

Mononeuropathy, or focal neuropathy, is damage to a specific nerve in the face, middle of the body (torso) or leg.

It's most common in older adults. Mononeuropathy often strikes suddenly and can cause severe pain. However, it usually doesn't cause any long-term problems.

Symptoms usually go away without treatment over a few weeks or months. Your specific signs and symptoms depend on which nerve is involved. You may have pain in the:

·         Shin or foot

·         Lower back or pelvis

·         Front of thigh

·         Chest or abdomen

Mononeuropathy may also cause nerve problems in the eyes and face, leading to:

·         Difficulty focusing

·         Double vision

·         Aching behind one eye

·         Paralysis on one side of your face (Bell's palsy)

Sometimes mononeuropathy occurs when something is pressing on a nerve (nerve compression).

Carpal tunnel syndrome is a common type of compression neuropathy in people with diabetes.

It can cause numbness or tingling in your hand or fingers, except your pinkie (little finger). Your hand may feel weak, and you may drop things.

When to see a doctor

Call your doctor for an appointment if you have:

·          A cut or sore on your foot that is infected or won't heal

·         Burning, tingling, weakness or pain in your hands or feet that interferes with daily activities or sleep

·         Changes in digestion, urination or sexual function

·         Dizziness

These signs and symptoms don't always mean you have nerve damage. But they can be a sign of another condition that requires medical care.

Early diagnosis and treatment of any health condition gives you the best chance for controlling your diabetes and preventing future problems.

Causes

Damage to nerves and blood vessels

The exact cause likely differs for each type of neuropathy.

Researchers think that over time, uncontrolled high blood sugar damages nerves and interferes with their ability to send signals, leading to diabetic neuropathy.

High blood sugar also weakens the walls of the small blood vessels (capillaries) that supply the nerves with oxygen and nutrients.

However, a combination of factors may lead to nerve damage, including:

·          Inflammation in the nerves caused by an autoimmune response. The immune system mistakes nerves as foreign and attacks them.

·         Genetic factors unrelated to diabetes may make some people more likely to develop nerve damage.

·          Smoking and alcohol abuse damage both nerves and blood vessels and significantly increase the risk of infection.

Risk factors

Anyone who has diabetes can develop neuropathy, but these risk factors make you more likely to get nerve damage:

·       Poor blood sugar control. Uncontrolled blood sugar puts you at risk of every diabetes complication, including nerve damage.

·       Diabetes history. Your risk of diabetic neuropathy increases the longer you have diabetes, especially if your blood sugar isn't well-controlled.

·       Kidney disease. Diabetes can damage the kidneys. Kidney damage sends toxins into the blood, which can lead to nerve damage.

·       Being overweight. Having a body mass index (BMI) greater than 24 may increase your risk of diabetic neuropathy.

·        Smoking. Smoking narrows and hardens your arteries, reducing blood flow to your legs and feet. This makes it more difficult for wounds to heal and damages the peripheral nerves.

Complications

Diabetic neuropathy can cause a number of serious complications, including:

·          Loss of a toe, foot or leg. Nerve damage can make you lose feeling in your feet. Foot sores and cuts may silently become severely infected or turn into ulcers. Even minor foot sores that don't heal can turn into ulcers. In severe cases, infection can spread to the bone, and ulcers can lead to tissue death (gangrene). Removal (amputation) of a toe, foot or even the lower leg may be necessary.

·          Joint damage. Nerve damage can cause a joint to deteriorate, causing a condition called Charcot joint. This usually occurs in the small joints in the feet. Symptoms include loss of sensation and joint swelling, instability and sometimes joint deformity. Prompt treatment can help you heal and prevent further joint damage.

·         Urinary tract infections and urinary incontinence. If the nerves that control your bladder are damaged, you may be unable to fully empty your bladder. Bacteria can build up in the bladder and kidneys, causing urinary tract infections. Nerve damage can also affect your ability to feel when you need to urinate or to control the muscles that release urine, leading to leakage (incontinence).

·          Hypoglycemia unawareness. Low blood sugar (below 70 milligrams per deciliter, or mg/dL) normally causes shakiness, sweating and a fast heartbeat. But if you have autonomic neuropathy, you may not notice these warning signs.

·          Sharp drops in blood pressure. Damage to the nerves that control blood flow can affect your body's ability to adjust blood pressure. This can cause a sharp drop in pressure when you stand after sitting (orthostatic hypotension), which may lead to dizziness and fainting.

·          Digestive problems. If nerve damage strikes your digestive tract, you can have constipation or diarrhea, or bouts of both. Diabetes-related nerve damage can lead to gastroparesis, a condition in which the stomach empties too slowly or not at all. This can interfere with digestion and severely affect blood sugar levels and nutrition. Signs and symptoms include nausea, vomiting and bloating.

·          Sexual dysfunction. Autonomic neuropathy often damages the nerves that affect the sex organs. Men may experience erectile dysfunction. Women may have difficulty with lubrication and arousal.

·          Increased or decreased sweating. Nerve damage can disrupt how your sweat glands work and make it difficult for your body to control its temperature properly. Some people with autonomic neuropathy have excessive sweating, particularly at night or while eating. Too little or no sweating at all (anhidrosis) can be life-threatening.

Prevention

You can prevent or delay diabetic neuropathy and its complications by keeping tight control of your blood sugar and taking good care of your feet.

Blood sugar control

Use an at-home blood sugar monitor to check your blood sugar and make sure it consistently stays within target range.

It's important to do this on schedule. Shifts in blood sugar levels can accelerate nerve damage.

The American Diabetes Association recommends that people with diabetes have the A1C test at least twice a year.

This blood test indicates your average blood sugar level for the past two to three months. If your blood sugar isn't well-controlled or you change medications, you may need to get tested more often.

Foot care

Follow your doctor's recommendations for good foot care.

Foot problems, including sores that don't heal, ulcers and even amputation, are a common complication of diabetic neuropathy.

But you can prevent many of these problems by having a comprehensive foot exam at least once a year, having your doctor check your feet at each office visit and taking good care of your feet at home.

To protect the health of your feet:

·          Check your feet every day. Look for blisters, cuts, bruises, cracked and peeling skin, redness, and swelling. Use a mirror or ask a friend or family member to help examine parts of your feet that are hard to see.

·          Keep your feet clean and dry. Wash your feet every day with lukewarm water and mild soap. Avoid soaking your feet. Dry your feet and between your toes carefully by blotting or patting with a soft towel.

    Moisturize your feet thoroughly to prevent cracking. Avoid getting lotion between your toes, however, as this can encourage fungal growth.

·         Trim your toenails carefully. Cut your toenails straight across, and file the edges carefully so there are no sharp edges.

·          Wear clean, dry socks. Look for socks made of cotton or moisture-wicking fibers that don't have tight bands or thick seams.

·          Wear cushioned shoes that fit well. Always wear shoes or slippers to protect your feet from injury. Make sure that your shoes fit properly and allow your toes to move. A podiatrist (foot doctor) can teach you how to buy properly fitted shoes and to prevent problems such as corns and calluses.

If problems do occur, your doctor can help treat them to prevent more-serious conditions. Even small sores can quickly turn into severe infections if left untreated.

If you qualify for Medicare, your plan may cover the cost of at least one pair of shoes each year. Talk to your doctor or diabetes educator for more information.

Diagnosis

A doctor can usually diagnose diabetic neuropathy by performing a physical exam and carefully reviewing your symptoms and medical history.

Your doctor will check your:

·        Overall muscle strength and tone

·        Tendon reflexes

·        Sensitivity to touch and vibration

Also, at every visit, your doctor should check your feet for sores, cracked skin, blisters, and bone and joint problems.

The American Diabetes Association recommends that all people with diabetes have a comprehensive foot exam at least once a year.

Along with the physical exam, your doctor may perform or order specific tests to help diagnose diabetic neuropathy, such as:

·          Filament test. Your doctor will brush a soft nylon fiber (monofilament) over areas of your skin to test your sensitivity to touch.

·         Quantitative sensory testing. This noninvasive test is used to tell how your nerves respond to vibration and changes in temperature.

·         Nerve conduction studies. This test measures how quickly the nerves in your arms and legs conduct electrical signals. It's often used to diagnose carpal tunnel syndrome.

·         Electromyography (EMG). Often performed along with nerve conduction studies, EMG measures the electrical discharges produced in your muscles.

·          Autonomic testing. If you have symptoms of autonomic neuropathy, special tests may be done to determine how your blood pressure changes while you are in different positions, and whether you sweat normally.

Treatment

Diabetic neuropathy has no known cure. The goals of treatment are to:

·          Slow progression of the disease

·          Relieve pain

·          Manage complications and restore function

Slowing progression of the disease

Consistently keeping your blood sugar within your target range is the key to preventing or delaying nerve damage. Doing so may even improve some of your current symptoms.

Your doctor will determine the best target range for you based on several factors, such as your age, how long you've had diabetes and your overall health.

For many people who have diabetes, the American Diabetes Association generally recommends the following target blood sugar levels:

·          Between 80 and 130 mg/dL (4.4 and 7.2 mmol/L) before meals

·          Less than 180 mg/dL (10.0 mmol/L) two hours after meals

For many people who have diabetes, Mayo Clinic generally recommends the following target blood sugar levels before meals:

·          Between 80 and 120 mg/dL (4.4 and 6.7 mmol/L) for people age 59 and younger who have no other medical conditions

·          Between 100 and 140 mg/dL (5.6 and 7.8 mmol/L) for people age 60 and older, or for those who have other medical conditions, including heart, lung or kidney disease

Keep in mind, your doctor may need to adjust these target ranges to meet your individual health needs.

Other important ways to help slow or prevent disease progression include keeping your blood pressure under control and maintaining a healthy weight and lifestyle.

Relieving pain

Many prescription medications are available for diabetes-related nerve pain, but they don't work for everyone. Side effects are always possible.

When considering any medication, talk to your doctor about the benefits and drawbacks to determine what might work best for you.

Pain-relieving prescription treatments may include:

·          Anti-seizure drugs. Some medications used to treat seizure disorders (epilepsy) are also used to ease nerve pain. The American Diabetes Association recommends starting with pregabalin (Lyrica). Others that have been used to treat neuropathy are gabapentin (Gralise, Neurontin) and carbamazepine (Carbatrol, Tegretol). Side effects may include drowsiness, dizziness and swelling.

·          Antidepressants. Some antidepressants disrupt the chemical processes in the brain that make you feel pain. You don't need to have depression for these medicines to ease nerve pain. Two classes of antidepressants have been used for neuropathy treatment.

Tricyclics, including amitriptyline, desipramine (Norpramin) and imipramine (Tofranil), may provide relief for mild to moderate symptoms. But side effects can be bothersome and include dry mouth, sweating, weight gain, constipation and dizziness.

Serotonin and norepinephrine reuptake inhibitors (SNRIs) may ease pain with fewer side effects.

The American Diabetes Association recommends duloxetine (Cymbalta) as a first treatment. Another that may be used is venlafaxine (Effexor XR).

Possible side effects of SNRIs include nausea, sleepiness, dizziness, decreased appetite and constipation.

Sometimes, an antidepressant may be combined with an anti-seizure drug or pain-relieving medication.

Managing complications and restoring function

Your diabetes health care team will likely include different specialists, such as doctor that treats urinary tract problems (urologist) and a heart doctor (cardiologist), who can help prevent or treat complications.

Treatment depends on the neuropathy-related complication you have:

·          Urinary tract problems. Some medications can interfere with bladder function. Your doctor may recommend stopping or changing medications. A strict urination schedule or urinating every few hours (timed urination) while applying gentle pressure to the bladder area (below your bellybutton) is recommended. Other methods, including self-catheterization, may be needed to remove urine from a nerve-damaged bladder.

·          Digestive problems. To relieve mild signs and symptoms of gastroparesis — indigestion, belching, nausea or vomiting — doctors suggest eating smaller, more-frequent meals, reducing fiber and fat in the diet, and, for many people, eating soups and pureed foods. Diet changes and medications may help relieve diarrhea, constipation and nausea.

·          Low blood pressure on standing (orthostatic hypotension). Treatment starts with simple lifestyle changes, such as avoiding alcohol, drinking plenty of water, and sitting or standing slowly. Sleeping with the head of the bed raised 6 to 10 inches helps prevent swings in blood pressure. Your doctor may also recommend compression stockings and similar compression support for your abdomen (abdominal binder). Several medications, either alone or together, may be used to treat orthostatic hypotension.

·          Sexual dysfunction. Medications taken by mouth or injection may improve sexual function in some men, but they aren't safe and effective for everyone. Mechanical vacuum devices may increase blood flow to the penis. Women may find relief with vaginal lubricants.

Lifestyle and home remedies

These measures can help you feel better overall and reduce your risk of diabetic neuropathy:

·          Keep your blood pressure under control. People with diabetes are more likely to have high blood pressure than are people who don't have diabetes. Having both high blood pressure and diabetes greatly increases your risk of complications because both damage your blood vessels and reduce blood flow. Try to keep your blood pressure in the range your doctor recommends, and be sure to have it checked at every office visit.

·          Make healthy food choices. Eat a balanced diet that includes a variety of healthy foods — especially fruits, vegetables and whole grains — and limit portion sizes to help achieve or maintain a healthy weight.

·         Be active every day. Exercise is one of the best ways to keep your blood sugar under control. It also improves blood flow and keeps your heart healthy. The American Diabetes Association recommends 150 minutes of moderate-intensity exercise a week for most adults with diabetes. Also, it suggests taking a break from sitting every 30 minutes to get a few quick bursts of activity. But talk with your doctor or physical therapist first. If you have decreased feeling in your legs, some types of exercise may be safer than others.

·          Stop smoking. If you have diabetes and use tobacco in any form, you're more likely than are nonsmokers with diabetes to die of heart attack or stroke. And you're more likely to develop circulation problems in your feet. If you use tobacco, talk to your doctor about finding ways to quit.

Alternative medicine

There are also a number of alternative therapies, such as capsaicin cream (made from chili peppers), physical therapy or acupuncture, that may help with pain relief. Doctors frequently use them along with medications, but some may work on their own.

·          Capsaicin. Capsaicin cream, applied to the skin, can reduce pain sensations in some people. Side effects may include a burning feeling and skin irritation.

·         Alpha-lipoic acid. This powerful antioxidant is found in some foods and may help relieve nerve pain symptoms in some people.

·          Transcutaneous electrical nerve stimulation (TENS). Your doctor may prescribe this therapy, which can help prevent pain signals from reaching your brain. TENS delivers tiny electrical impulses to specific nerve pathways through small electrodes placed on your skin. Although safe and painless, TENS doesn't work for everyone or for all types of pain.

·          Acupuncture. Acupuncture may help relieve the pain of neuropathy, and generally doesn't have any side effects. Keep in mind that you may not get immediate relief with acupuncture and will likely require more than one session.

Coping and support

Living with diabetic neuropathy can be difficult and frustrating. If you find yourself feeling depressed, it may help to talk to a counselor or therapist.

Support groups can also offer encouragement and advice about living with diabetic neuropathy.

Ask your doctor if there are any in your area, or for a referral to a therapist. The American Diabetes Association offers online support through its website.

Preparing for an appointment

If you don't already see an endocrinologist, you'll likely be referred to one if you start showing signs of diabetes complications.

An endocrinologist is a doctor who specializes in treating metabolic disorders, such as diabetes.

You may also be referred to a neurologist, which is a doctor who specializes in treating nervous system problems.

To prepare for your appointment, you may want to:

·          Be aware of any pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet.

·          Write down any symptoms you're having, including any that may seem unrelated to the reason for the appointment.

·          Write down key personal information, including any major stresses or recent life changes.

·          Make a list of all medications, vitamins and supplements you're taking.

·          Write down your recent blood sugar levels, if you check them at home.

·          Ask a family member or friend to come with you. It can be difficult to remember everything your doctor tells you during an appointment. Someone who accompanies you may remember something that you missed or forgot.

You may also want to write down questions to ask your doctor. For diabetic neuropathy, some basic questions include:

·          Is diabetes the most likely cause of my symptoms?

·         Do I need tests to confirm the cause of my symptoms? Do these tests require any special preparation?

·          Is this condition temporary or long lasting?

·          If I control my blood sugar, will these symptoms improve or go away?

·          Are there treatments available, and which do you recommend?

·          What types of side effects can I expect from treatment?

·          I have other health conditions. How can I best manage them together?

·          Are there brochures or other printed material I can take with me? What websites do you recommend?

·          Do I need to see other doctors, a certified diabetes educator or a dietitian?

Prevention

What to expect from your doctor

Examples of questions your doctor may ask, include:

·          How is your blood sugar control?

·          When did you start having symptoms?

·          Do you always have symptoms or do they come and go?

·         How severe are your symptoms?

·          Does anything seem to improve your symptoms?

·          What, if anything, appears to make your symptoms worse?

·         What do you find most challenging about managing your diabetes?

·          What might help you manage your diabetes better?

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