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DIABETIC NEUROPATHY OVERVIEW
Diabetic neuropathy is a type of nerve damage because of diabetes.As a diabetes specialist, I hear about neuropathy commonly from my type 1 and type 2 diabetes patients. Diabetic neuropathy is so common that up to 26% of patients already have diabetic neuropathy at the time of a diabetes diagnosis. A generalized type of neuropathy is the most common type of diabetic neuropathy. There are many non-medicinal and medicinal options such as gabapentin/Neurontin, Cymbalta, and Lyrica (not a first-line medication) to treat neuropathy. We will review the signs and symptoms of neuropathy, risk factors as well as all the treatment options available.
What are the early signs of diabetic neuropathy?
Diabetic neuropathy signs and symptoms, unfortunately, are loss of sensation, numbness, tingling and/or burning pain in the feet. Early diagnosis of diabetes and good control of blood sugar levels with a good diabetes care plan can reduce the risk of developing diabetic neuropathy. We will talk in detail about the signs and symptoms of diabetic neuropathy in the sections below.
What are the treatment options for diabetic neuropathy?
Treatment of diabetic neuropathy is possible, and include several levels of care. These are control of blood glucose levels, prevention of injury, and management of painful symptoms. We will review those in detail in the subsequent sections of this article.
What other risk factors for diabetic neuropathy, and what causes diabetic neuropathy?
The biggest risk factor in patients with diabetes is uncontrolled blood sugars. A diabetic specialist known as an endocrinologist and a diabetes coach should be on your side very early on starting from the time of diagnosis to control high blood sugars to prevent the start of progression of diabetic neuropathy.
Other factors can further increase the risk of developing diabetic neuropathy, including:
• Coronary heart disease
• Elevated triglyceride(a type of cholesterol) levels
• Being overweight (a body mass index >25)
• High blood pressure
Detailed overview of diabetic neuropathy symptoms:
In my diabetes care center and also in the literature, most common the reported symptoms are numbness, tingling, pain that tends to be worst at rest, at night and during the sleep and improve with activity, such as walking. Some people initially have very painful feet, while others have very few or no symptoms.
Diabetic neuropathy commonly affects both sides of the body. If symptoms are not present on both sides, diabetes specialists will typically look for other causes of neuropathy. Symptoms are typically noticed initially in the toes. When the disease progresses, symptoms will gradually move up the legs. Hands are not affected until the symptoms in the legs past the mid calves area. In time, the ability to sense pain will be lost, which significantly increases the risk of injury. Unfortunately, these injuries are the initial culprit for a diabetic ulcer that can lead to amputation if not taken care of properly.
How do diabetic ulcers develop?
Unfortunately, when you do not feel the pain, hot or cold, the risk of unnoticed injury goes up. Injuries that would typically cause pain in normal individuals such as stepping on a nail or splinter, unfit shoes that can cause blisters, etc. do not necessarily cause pain if you have neuropathy. That is why it is very important to check the bottom of your feet daily; otherwise, a small lesion can develop into a large ulcer. By the time you notice, it may be too late. If the infection goes into the bone, doctors may not be able to save the limb. Although your doctor may check the bottom of your feet and your sensing inability, you should be primarily responsible for checking your own feet daily or at least a few times a week. And if you see something, report to your diabetes specialist or diabetes coach immediately.
How do diabetes doctors detect neuropathy?
Most of the time, the diagnosis is clear based on the patient’s history; however, some examination findings can also help detect diabetic neuropathy. Some of the signs could be:
1. Diabetes specialist may ask you to close your eyes and move your toes up and down, and you may not feel it. Sometimes they may put a vibrating tuning fork close, and you may not feel the vibration.
2. Diabetes doctors may likely touch your feet, and you may not feel that light touch.
3. Your doctor may check your Achilles tendon reflex and find that it is reduced.
More extensive testing can be done if the diagnosis is in doubt, such as nerve conduction studies, nerve biopsy, or imaging tests. However, these types of exhausting tests are not usually needed to diagnose diabetic neuropathy.
How do we treat diabetic neuropathy?
In our diabetes care center, we emphasize three important facts that help improve diabetic neuropathy.
1. You should follow your diabetes coach and diabetes doctor’s instructions for tight control of blood sugar levels.
2. You should be attentive in the care of your feet to prevent an ulcer.
3. Your doctor may prescribe you medications to reduce the pain caused by diabetic neuropathy.
Although diabetic neuropathy may not be reversible, preventing the progression of diabetic neuropathy is important. On the other hand, improving diabetes can also improve your diabetic neuropathy in months if not within weeks. One caveat to this is that diabetic patients should be aware of is that when blood sugars rapidly improve, underlying diabetic neuropathy can temporarily or paradoxically worsen for a few weeks to follow. Neuropathy symptoms dramatically improve if the patient can maintain the diabetes control. You should seek help from your diabetes coach and your diabetes doctor on a daily, weekly, monthly basis instead of every 3 to 6 months.
If your diabetes is currently not controlled and medications that are given to you are not helping, you should seek the opinion of an endocrinologist/diabetes specialist immediately to avoid wasting any more time.
If you have type 1 diabetes, you may need an insulin pump and continuous glucose monitoring device or remote glucose monitoring in order to control your blood sugars strictly.
For patients with type 2 diabetes, although insulin pumps and continuous glucose monitoring are still good options, they may have more medication, diabetes coaching and lifestyle management options available.
Telemedicine for diabetes definitely is a great option for patients who need intensive care have no time seeing a doctor too frequently.
What are the basics for feet care for diabetes?
1. The American Diabetes Association recommends that diabetic patients should have a foot examination once per year. Personally, you should be looking carefully at all parts of your feet, especially the area between the toes. Look for blisters, ulcers, broken skin, ulcers, blisters, areas of increased redness, or warmth. Last but not least also pay attention to changes in callus formation. Calluses are the areas with diminished sensation, which can lead to ulcer formation. Let your diabetes specialist or diabetes coach know if you notice if any of these changes or have any concerns. If you cannot easily examine your own feet, you can ask your partner or use a barrier to examine your feet if you make this a routine, a part of your life that should not be a cumbersome task.
2. You should also avoid activities that can cause damage to your feet.
3. You should avoid your feet being soaked for a long time or using wet or sweaty socks.
4. Try to avoid using hot water and test the temperature of the water with your hand first before you put your feet into hot water.
5. Do not pop blisters.
6. Never cut the cuticles or let anyone cut your cuticles.
7. Trim toenails carefully.
8. If you think he will need help, ask help from a podiatrist.
9. Keep your feet clean by washing your feet daily; however, make sure you dry it well and never keep it wet. Use moisturizing cream and lotion to prevent breaks in the skin due to dryness.
10. If you have diabetic neuropathy seeing a podiatrist at least one time may be a good idea to see if you will need a fitted shoe to prevent calluses and blisters.
How to control diabetic neuropathy pain?
Diabetic neuropathy pain can be very disturbing, especially at night. Sometimes if it is advanced, it may be very difficult to control.
Thankfully, only a small percentage of people with diabetic neuropathy experience severe pain. Those patients generally have had long standing uncontrolled diabetes. Yet, the sensitivity to neuropathy pain varies from patient to patient, and some may feel pain more than others. Such pain can be temporary if it is new and has happened due to a recent health change such as significant weight loss, diabetic ketoacidosis or a rapid control of blood sugars.
In our diabetes care center, we have a variety of treatment options for diabetic neuropathy. Typically we start with medications that have been approved by FDA such as Lyrica, Cymbalta, gabapentin, and alpha-lipoic acid. Some of these medications are not necessarily designed for diabetic neuropathy, and they are also used for the treatment of depression. The dose to be used for the treatment of diabetic neuropathy is typically much less than the doses we used for the treatment of depression. In our diabetes care center, Lyrica seems to work the best however it is a controlled substance, and most of the time, insurance will not cover Lyrica unless the patient has tried generic medications such as gabapentin or amitriptyline.
Most of the time, we start medications to be taken at night time as this is the time that pain is most severe. Also, some of these medications may have side effects such as drowsiness. As a result, taking these medications at night time is the best option for many patients. Sometimes we combine medications such as a combination of amitriptyline and gabapentin/Neurontin. We do not combine Cymbalta with amitriptyline since these are both anti-depression medications. Gabapentin and Lyrica can also be combined if necessary.
How are these medications used?
1. Duloxetine/Cymbalta can be taken once or twice a day with food. You should not be taking Cymbalta if you are on other antidepressant medications. The most common side effects include nausea, sleepiness, dizziness, decreased appetite, and constipation.
2. Neurontin/gabapentin — this medication is most commonly used for seizure prevention. For diabetic neuropathy, it is usually taken by mouth three times per day. The most common side effects are dizziness, drowsiness, and confusion. Gabapentin can be taken with amitriptyline and Cymbalta but not with Lyrica. Most of the time, we give Neurontin/gabapentin at night to prevent pain during sleep.
3. Lyrica/pregabalin — Lyrica/pregabalin is also a seizure medication, just like gabapentin/Neurontin. On the other hand, clinically appears to be much more effective than Neurontin. We also gave Lyrica in our diabetes care center starting at night time with a low dose and gradually increasing the dose within weeks until symptoms are better.
The most common side effects of Lyrica are dizziness, sleepiness, confusion, swelling in the feet and ankles, and weight gain. It is a controlled substance due to these possibly addictive features.we will monitor changes in dosing carefully. Lyrica can be taken with duloxetine, amitriptyline or nortriptyline, but not with gabapentin.
4. Alpha-lipoic acid can also potentially be helpful as an antioxidant medication. Although there are no long-term studies, some short-term studies proved helpful for diabetic neuropathy.
If these oral agents fail is a diabetes specialist, I may prescribe a compounded medication that can include gabapentin and lidocaine and some other medications that can help and pain control. We typically recommend these topical creams be applied twice a day.
Where can you get more information about diabetic neuropathy?
In our diabetes care center, we strive for excellence in controlling diabetes and preventing complications of diabetes. Diabetes coaches and diabetes specialists work hand-in-hand. SugarMDs provide telemedicine for diabetes with remote glucose monitoring. That way, patients do not need to go to the doctor, and they are under constant surveillance. This helps build a report between the patient and the diabetes team without any judgments. In this “judgment-free” zone, patients feel free to ask questions about their health to a diabetes care team that is available 24/7, 365 day a year.
This article also may be updated from time to time with recent developments to keep you updated.
Ahmet Ergin, MD, CDE, ECNU
Endocrinologist and Founder of SugarMDs.