Diabetic Neuropathies: Diagnosis and Management

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 your 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?

What to expect from your doctor

Your doctor is likely to ask you a number of questions, such as:

• 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?

Learn more: Diabetic Autonomic Neuropathy