Neuropathy

Neuropathy refers to nerve damage. There aremany types of neuropathy such as diabetic, autoimmune, drug-induced, or nerve impingement. These are only a few of the selective examples. Pain related to neuropathy is called neuropathic pain and frequently is described as burning, radiating, tingling, or electrical. Certain conditions in the spine such as spinal stenosis and lower back pain can be associated with neuropathy.

It is very important to diagnose the cause of neuropathy by visiting a specialist at Elite Pain Management.  Different tests including blood work, EMG, imaging are utilized in order to help the patient finds source of their neuropathy.

Diabetic neuropathy is a relatively common condition in the patients having diabetes mellitus with an overall poor glycemic (blood sugar) control leading to numbness and tingling sensations in the feet especially and can involve any part of the body.

The increase in blood sugar levels affect the peripheral nerves running throughout the body. Other nerves involved are autonomic nerves (the nerves controlling the bowel, bladder function and vital functions like respiration, blood pressure and heart rate.

Unfortunately, preventing diabetic neuropathy is impossible, however, its development can be delayed by having a very strict glycemic (blood sugar) control.

Diabetic Neuropathy Treatment

The three main elements for the management of diabetic neuropathy are:

1. Strict glycemic (blood sugar level) control

• Numerous studies done on real patients have clearly shown that a stable and strict glycemic (blood sugar level) control ameliorates the pain, tingling, numbness and loss of vibration sense associated with diabetic neuropathy. It has been supported by the scientific evidence of improvement on the results of the tests being run on the peripheral nerves running throughout the body. Unfortunately, once diabetic neuropathy sets in, it is irreversible. It is just to reiterate that always try to prevent this dreadful complication by maintaining  your blood sugar levels optimally and enjoy your life at the fullest even with diabetes mellitus.

2. Foot care

• Taking care of your feet is the most important step that in the management of diabetic peripheral neuropathy. Since, patients have numbness of feet due to neuropathy; there is increased risk of recurrent unnoticed injury or trauma to the feet that may lead to infections and unfortunately amputations. Here are the few steps that can help prevent the development of complications in the feet due to diabetic neuropathy;
  • Inspecting all the sides of feet on a daily basis especially sole of the feet and spaces in between the toes, and look for dry or cracking skin, ulcers and signs of early infection.
  • Keeping the feet clean and moist.
  • Having regular feet inspection by podiatrist as well as your diabetes doctor.
  • Always looking into the shoes before putting on the shoes to avoid contact with any sharp object lying in the shoes.
  • Avoid walking bare foot.
  • Immediately report to your doctor if you develop any ulcer or infection in the feet.

3. Management of diabetic neuropathy

• Before starting the treatment of diabetic peripheral neuropathy, it is very important to make sure that the pain is because of neuropathy and not from any other cause. Other common causes of pain in the feet and legs in patients having diabetes can be vascular (blood channels) disease or joint disease. Neuropathic pain is usually localized to the feet and shins, whereas pain due to blood channel narrowing (vascular) is more marked in the calves. Vascular pain increases in intensity with walking and is relieved by taking rest.
• Prevention is always better than cure because once peripheral neuropathy has set in it is irreversible and it hampers day to day activities because of pain during the day and especially at night that prevents you from having a sound sleep.
• Although most common type of diabetic peripheral neuropathy presents as numbness, however, painful diabetic neuropathy may also occur but less frequently. It is usually irreversible.
• One of the types of painful diabetic neuropathy associated with either strict glycemic (blood sugar level) control or weight loss is occasionally reversible but you have to consult your doctor in order to get an idea as what type of painful diabetic neuropathy are you suffering from.
• Diabetic amyotrophy – it leads to asymmetrical wasting of the muscles of the thighs with pain and weakness and is usually associated with significant weight loss in patients have poor glycemic control.
• In addition to good glycemic control, a number of medicines are being used for controlling pain and tingling associated with diabetic peripheral neuropathy

Neuropathy Treatment

Antidepressantscomprise a group of medicines that has been used for the treatment of depression and numerous studies have found a very effective role in alleviating pain and tingling associated with diabetic peripheral neuropathy.

• Tricyclic antidepressants – it includes three medicines.  Nortryptyline, amytryptyline, doxepin and desipramine. The dosage of each medicine varies and you must consult your doctor or specialist nurse if you want to start one of these medicines for the pain and tingling bothering you especially at night. It takes almost two to six weeks to relieve the pain and tingling. Common side effects are sleepiness, dryness of mouth and urinary retention (difficulty in passing water). If you have any heart condition, do not use it without your doctor’s advice.

Duloxetine – it is another antidepressant that is being used for diabetic peripheral neuropathy. The optimal dose is 60 mg once at night and you will feel pain relief in the very first week. It can be increased to 120 mg per day but at the cost of unwanted effects. Unwanted effects of duloxetine are nausea, vomiting, sleepiness, dizziness, feeling of spinning, reduced appetite and constipation. It is usually recommended to be taken with meals to avoid nausea.

Medicines for controlling fits (anticonvulsants) –pregabalin, gabapentin and valproate are the commonly used medicines in this group. Pregabalin is started at a dose of 50 mg twice a day and can be increased to maximum of 300 mg per day in two or three divided doses. Unwanted effects are dizziness, feeling of spinning, difficulty in maintaining balance, doubling of vision, blurring of vision, increased sleepiness and confusion. Gabapentin has a controversial role in the management of diabetic peripheral neuropathy and must not be used without consulting your doctor. Typical starting doses are very high and somewhere sound 300 to 600 mg three times a day. Unwanted effects are increased sleepiness, dizziness and difficulty in maintaining balance. Valproate is used in the dose of 500 to 1200 mg per day. Pregnant women must not use it because it can cause abnormalities in the developing fetus.

Capsaicin (0.075%)– it is a naturally occurring component of many hot peppers and relieves pain by decreasing the concentration of a chemical called substance P. It is available as a cream, gel, lotion and can be applied locally as a patch. It is used four times daily and is an effective remedy for pain control in patients having diabetic neuropathy. It is used as add on treatment if the pain is not being adequately controlled by antidepressants or anticonvulsants. Unwanted effects are local burning and skin irritation but they settle with continued use.

Antioxidants – one of the mechanisms causing diabetic neuropathy is increased oxidative stress. Oxidative stress means that few ions/chemicals are released in the body that lead to damage of the nerves causing pain. Alpha-lipoic acid (ALA) is an antioxidant that can be used in a dose of 600 mg per day if the patient is not having adequate pain relief or intolerant (due to side effects) to antidepressants or anticonvulsants. Unwanted effects are nausea, vomiting and feeling of spinning but if used in low dose they can be avoided.

Opioids into use of neuropathy is usually rare. Risk including mental impairment and addiction must be balanced with potential benefit.

Choosing the right medicine for neuropathic pain starts with talking with your specialist at Elite Pain Management.  A multidisciplinary approach including prevention, medications, and behavioural therapy will be discussed after a diagnostic test is completed.

If your pain does not resolve after a brief period, contact us so that we may help diagnose the problem and treat the underlying cause.  Do not let pain persist or else it may become chronic.