How to Treat Diabetic Neuropathy

Diabetic Nerve Pain: A Diabetes Complication

diabetic nerve pain There are four types of diabetic neuropathy: peripheral, proximal, autonomic, and focal. Of these, the sensory neuropathies (peripheral and proximal neuropathies) are the most common, affecting our experience of temperature, touch, and pain.

Autonomic neuropathy affects nerves involved in involuntary actions in the body such as emptying of the stomach, intestines, and bladder. Motor neuropathy affects the nerves in movement, a condition that is rare in diabetes.

Peripheral neuropathy affects the feet and hands and is the most common form of diabetic neuropathy. It usually is bilateral, that is, it affects both sides of the body, but it can affect only one side.

Diabetic amyotrophy affects the nerves in the thighs and may affect both legs. Charcot joint may occur if the bones in the feet develop fractures and the foot becomes misaligned. Because of neuropathy, you may not feel the pain of the fracture. The foot can then lose muscle support and may eventually become deformed.

Diabetic Neuropathy Treatments:  Medications

When you make a plan with your physician, you will most likely be in the "control pain" mode. Some people have described diabetic neuropathy of the lower extremities as pins and needles and numbness, which can change to the shooting pain of icicles through your feet or legs.

As the condition worsens, you may lose your ability to feel pain even when the neurologist pricks you with a pin during his medical examination. As with many complications of diabetes, people with diabetic neuropathy symptoms of less than 6 months duration, which are associated with alterations in glycemic control, have a better prognosis when compared to people with chronic conditions lasting more than 6 months.

When I was first diagnosed with diabetic neuropathy, the first drug of choice was gabapentin (Neurontin), which is an anticonvulsant. Since then, the US Food and Drug Administration (FDA) has approved a second-generation agent, pregabalin (Lyrica) specifically for the treatment of diabetic peripheral neuropathy.

There are side effects to any medication, so make sure you ask when you're talking to your doctor about diabetic neuropathy medications.

In research, gabapentin was found to be efficacious for the treatment of pain and sleep interference associated with diabetic peripheral neuropathy. It also exhibited a positive effect on mood and quality of life.

One of the most popular families of medications for diabetic neuropathy is tricyclic antidepressants, which have been studied over the years. They have been found to be reliable for relieving pain in people with and without depression.

Arranged in order from the most potent anticholinergic effects, the most common medications are amitriptyline, imipramine, nortriptyline, and desipramine. This is good to know because if you have side effects on one tricyclic, you can try another.

They are usually given at night starting low and building to a therapeutic dose.

Another FDA-approved option is duloxetine (Cymbalta), a serotonin-norepinephrine reuptake inhibitor. In approving the agent for the treatment of diabetic peripheral neuropathy, the FDA cited safety and efficacy. Duloxetine is also used to treat other neuropathic pain as well. 

Opioids are often used to control the breakthrough of refractory pain. They are more controversial for the treatment of chronic pain because of the well documented risk of misuse and abuse, usually for recreational use. The only opioid that is FDA-approved for diabetic peripheral neuropathy tapentadol extended-release (ER) (Nucynta). (Opioids are often used for severe chronic pain cases.  Another of our sites, Practical Pain Management, has thorough resources on opioids and other chronic pain medications.)

[Editor's Note: In 2012, the FDA-approved a non-medication treatment for diabetic neuropathy: Sensus Pain Management device.  The device treats uses low frequency electric impulses through the body (transcutaneous electrical nerve stimulation, or TENS) to help improve circulation and nerve damage. According to the makers, NeuroMetrix, "the device is worn on the calf, works at the press of a single button, and is equipped with a rechargeable battery that should last about two weeks based on the recommended once-daily, hour-long treatment sessions."]

Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to be effective in controlling neuropathy in a number of studies. Ibuprofen and sulindac have been studied and have demonstrated their effectiveness in controlling pain.

However, caution should be exercised when diabetics take these medications because of the risk of nephrotoxity, although in the studies of these anti-inflammatory medications none was noted.

Not all agents for pain control come in pill form. Topical capsaicin cream stimulates the release and subsequent depletion of substance P from sensory fibers. Studies on whether this cream works vary, with some positive results, and some showing no benefit from its use.

Weighing the results of research, capsaicin cream appears to be effective for many people. Poor compliance is common with its use because it needs to be applied often, and frequently burns, causing initial exacerbation of symptoms and redness at the site of application.

American Diabetes Association Diabetic Neuropathy Medication Recommendations

The ADA has some recommendations on medications for diabetic neuropathy.  According to them, NSAIDs offer pain relief. Tricyclic antidepressants remain a commonly used medication. After six weeks of treatment, many patients report significant relief independent of mood but correlating to increasing medication dosage.

The ADA also says that topical creams can then be added if neuropathy pain persists. Anticonvulsants are also a first line medication with very good results for people with diabetic neuropathy.

Updated on: August 14, 2019
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