Diabetic neuropathy

Your health care provider can usually diagnose diabetic neuropathy by performing a physical exam and carefully reviewing your symptoms and medical history.

Your health care provider typically checks your:

• Overall muscle strength and tone
• Tendon reflexes
• Sensitivity to touch, pain, temperature and vibration

Along with the physical exam, your health care provider may perform or order specific tests to help diagnose diabetic neuropathy, such as:

• Filament testing. A soft nylon fiber (monofilament) is brushed 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.
• Electromyography. Called needle testing, this test is often done along 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 your sweating is within the standard range.

Diabetic neuropathy has no known cure. The goals of treatment are to:

• Slow progression
• 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 health care provider 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 need to be individualized. But, in general, the American Diabetes Association (ADA) recommends the following target blood sugar levels for most people with diabetes:

• 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

The American Diabetes Association (ADA) generally recommends an glycated hemoglobin (A1C) of 7.0% or lower for most people with diabetes.

Mayo Clinic encourages slightly lower blood sugar levels for most younger people with diabetes, and slightly higher levels for older people with other medical conditions and who may be more at risk of low blood sugar complications. 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

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 health care provider 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 ADA recommends starting with pregabalin (Lyrica). Gabapentin (Gralise, Neurontin) also is an option. Side effects may include drowsiness, dizziness, and swelling in the hands and feet.

• 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, nortriptyline (Pamelor) and desipramine (Norpramin). Side effects can be bothersome and include dry mouth, constipation, drowsiness and difficulty concentrating. These medications may also cause dizziness when changing position, such as from lying down to standing (orthostatic hypotension).

  Serotonin and norepinephrine reuptake inhibitors (SNRIs) are another type of antidepressant that may help with nerve pain and have fewer side effects. The ADA recommends duloxetine (Cymbalta, Drizalma Sprinkle) 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 medication available without a prescription. For example, you may find relief from acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others) or a skin patch with lidocaine (a numbing substance).

Managing complications and restoring function

To manage complications, you may need care from different specialists. These may include a specialist who treats urinary tract problems (urologist) and a heart specialist (cardiologist) who can help prevent or treat complications.

The treatment you'll need depends on the neuropathy-related complications you have:

• Urinary tract problems. Some drugs affect bladder function, so your health care provider 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) can help some bladder problems. 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 — eating smaller, more frequent meals may help. Diet changes and medications may help relieve gastroparesis, diarrhea, constipation and nausea.

• Low blood pressure on standing (orthostatic hypotension). Treatment starts with simple lifestyle changes, such as not using alcohol, drinking plenty of water, and changing positions such as from sitting to standing slowly. Sleeping with the head of the bed raised 4 to 6 inches helps prevent high blood pressure overnight.

  Your health care provider may also recommend compression support for your abdomen and thighs (abdominal binder and compression shorts or stockings). 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 benefit from vaginal lubricants.

These measures can help you feel better overall and reduce your risk of diabetic neuropathy:

• Keep your blood pressure under control. If you have high blood pressure and diabetes, you have an even greater risk of complications. Try to keep your blood pressure in the range your health care provider 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 vegetables, fruits and whole grains. Limit portion sizes to help achieve or maintain a healthy weight.

• Be active every day. Exercise helps lower blood sugar, improves blood flow and keeps your heart healthy. Aim for 150 minutes of moderate or 75 minutes of vigorous aerobic activity a week, or a combination of moderate and vigorous exercise. It's also a good idea to take a break from sitting every 30 minutes to get a few quick bursts of activity.

  Talk with your health care provider or physical therapist before you start exercising. If you have decreased feeling in your legs, some types of exercise, such as walking, may be safer than others. If you have a foot injury or sore, stick with exercise that doesn't require putting weight on your injured foot.

• Stop smoking. Using tobacco in any form makes you more likely to develop poor circulation in your feet, which can cause problems with healing. If you use tobacco, talk to your health care provider about finding ways to quit.

There are many alternative therapies that may help with pain relief on their own or in combination with medications. But check with your health care provider before using any alternative therapy or dietary supplement to make sure that you don't have any potential interactions.

For diabetic neuropathy, you may want to try:

• 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.
• Acetyl-L-carnitine. This nutrient is naturally made in the body and is available as a supplement. It may ease nerve pain in some people.
• Transcutaneous electrical nerve stimulation (TENS). This prescription therapy may help prevent pain signals from reaching the brain. transcutaneous electrical nerve stimulation (TENS) delivers tiny electrical impulses to specific nerve pathways through small electrodes placed on the skin. Although safe and painless, 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 might require more than one session.

Living with diabetic neuropathy can sometimes be challenging. Support groups can offer encouragement and advice about living with diabetic neuropathy. Ask your health care provider if there are any in your area, or for a referral to a therapist. The ADA offers online support through its website. If you find yourself feeling depressed, it may help to talk to a counselor or therapist.

If you don't already see a specialist in treating metabolic disorders and diabetes (endocrinologist), you'll likely be referred to one if you start showing signs of diabetes complications. You may also be referred to a specialist in brain and nervous system problems (neurologist).

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.
• Make a list of any symptoms you're having, including any that may seem unrelated to the reason for the appointment.
• Make a list of key personal information, including any major stresses or recent life changes.
• Make a list of all medications, vitamins, herbs and supplements you're taking and the doses.
• Bring a record of 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 health care provider tells you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Make a list of questions to ask your health care provider.

Some basic questions to ask may include:

• Is diabetic neuropathy the most likely cause of my symptoms?
• Do I need tests to confirm the cause of my symptoms? How do I prepare for these tests?
• Is this condition temporary or long lasting?
• If I manage 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 a certified diabetes care and education specialist, a registered dietitian, or other specialists?

What to expect from your doctor

Your health care provider is likely to ask you a number of questions, such as:

• How effective is your diabetes management?
• 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's challenging about managing your diabetes?
• What might help you manage your diabetes better?