Diabetic neuropathy

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, diabetic neuropathy symptoms 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 serious diabetes complication that may affect as
many as 50% of people with diabetes. But you can often prevent diabetic
neuropathy or slow its progress with consistent blood sugar management
and a healthy lifestyle.
 Types
There are four main types of diabetic neuropathy. You can have one type 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 is wrong until
considerable nerve damage has occurred.

1. Peripheral neuropathy
2. Autonomic neuropathy
3. Proximal neuropathy
4. Mononeuropathy
 Peripheral neuropathy
• This type of neuropathy may also be called distal symmetric
peripheral neuropathy. It's 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 a
bedsheet's weight can be painful
• 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 or bowel problems
• Slow stomach emptying (gastroparesis), causing nausea, vomiting
and loss of appetite
• Changes in the way your eyes adjust from light to dark
• Decreased sexual response
 Proximal neuropathy (diabetic polyradiculopathy)
• This type of neuropathy — also called diabetic amyotrophy —
often affects nerves in the thighs, hips, buttocks or legs. It can
also affect the abdominal and chest area. Symptoms are
usually on one side of the body, but may spread to the other
side. You may have:
• Severe pain in a hip and thigh or buttock
• Eventual weak and shrinking thigh muscles
• Difficulty rising from a sitting position
• Severe stomach pain
 Mononeuropathy (focal neuropathy)
• There are two types of mononeuropathy — cranial and
peripheral. Mononeuropathy refers to damage to a specific
nerve. Mononeuropathy may also lead to:
• Difficulty focusing or double vision
• Aching behind one eye
• Paralysis on one side of your face (Bell's palsy)
• Numbness or tingling in your hand or fingers, except your pinkie
(little finger)
• Weakness in your hand that may cause you to drop things
 Causes
• The exact cause of each type of neuropathy is unknown. 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.
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) of 25 or more 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:
• Hypoglycemia unawareness. Blood sugar levels below 70 milligrams per deciliter (mg/dL) normally cause
shakiness, sweating and a fast heartbeat. But if you have autonomic neuropathy, you may not notice these
warning signs.
• Loss of a toe, foot or leg. Nerve damage can make you lose feeling in your feet, so even minor cuts can turn
into sores or ulcers without your realizing it. In severe cases, an infection can spread to the bone or lead to
tissue death. Removal (amputation) of a toe, foot or even the lower leg may be necessary.
• 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).
• 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, which may lead
to dizziness and fainting.
• Digestive problems. If nerve damage strikes your digestive tract, you can have constipation or diarrhea, or
both. Diabetes-related nerve damage can lead to gastroparesis, a condition in which the stomach empties too
slowly or not at all, which causes bloating and indigestion.
• 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.
 • 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
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.
• Sensory testing. This noninvasive test is used to tell how your nerves respond to vibration
and changes in temperature.
• Nerve conduction testing. This test measures how quickly the nerves in your arms and legs
conduct electrical signals. It's often used to diagnose carpal tunnel syndrome.
• Muscle response testing. Called electromyography, this test is often done with nerve
conduction studies. It measures electrical discharges produced in your muscles.
• Autonomic testing. 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. Good blood sugar management may even improve some of your current
symptoms. Your doctor will figure out the best target range for you based on factors including your
age, how long you've had diabetes and your overall health.
Blood sugar levels may need to be individualized. But, in general, the American Diabetes
Association recommends the following target blood sugar levels for most people with diabetes:
• Between 80 and 130 mg/dL, which is 4.4 and 7.2 millimoles per liter (mmol/L) before meals
• Less than 180 mg/dL (10.0 mmol/L) two hours after 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
• Other important ways to help slow or prevent neuropathy from getting worse include keeping your
blood pressure under control, maintaining a healthy weight and getting regular physical activity.
 • Relieving pain
Many prescription medications are available for diabetes-related nerve pain, but they don't
work for everyone. When considering any medication, talk to your doctor about the benefits
and possible side effects to find 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). Gabapentin (Gralise, Neurontin) also is an option. Side effects may
include drowsiness, dizziness and swelling.
• Antidepressants. Some antidepressants ease nerve pain, even if you aren't depressed.
Tricyclic antidepressants may help with mild to moderate nerve pain. Drugs in this class
include amitriptyline, desipramine (Norpramin) and imipramine (Tofranil). Side effects can
be bothersome and include dry mouth and drowsiness.
• Serotonin and norepinephrine reuptake inhibitors (SNRIs) are another type of
antidepressant that may help with nerve pain and have 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 include nausea, sleepiness,
dizziness, decreased appetite and constipation.
• Sometimes, an antidepressant may be combined with an anti-seizure drug. These drugs
can also be used with pain-relieving medication, such as an over-the-counter medication
including acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others) or a skin
patch with lidocaine (a numbing substance).