Peripheral Diabetic Neuropathy Treatments and Medications

Peripheral diabetic neuropathy

is a common complication of Type 1 diabetes and Type 2 diabetes. Peripheral diabetic neuropathy is also referred to as painful diabetic neuropathy (PDN), painful diabetic peripheral neuropathy, or diabetic peripheral neuropathy (DPN). DPN affects up to 50% of people who have either Type 1 or Type 2 diabetes. DPN is a type of nerve damage that develops over time. It can affect the feet and legs, and sometimes the arms and hands. Understanding DPN and how to manage it can be helpful. Let’s take a look at DPN in more detail and what can be done to manage it.

What is peripheral diabetic neuropathy?

Diabetic neuropathy is a complication of diabetes that is defined by nerve damage. Having high blood glucose levels over time (as well as other risk factors like high cholesterol) can cause nerve damage, although DPN can also occur in people with good blood sugar control. The symptoms depend on which type of diabetic neuropathy you have. While this article focuses on peripheral diabetic neuropathy, we will first give a quick overview of the different types of diabetic neuropathy. You may have one or more types of diabetic neuropathy.

Autonomic neuropathy

Affects autonomic nerves that control internal organs. This type of neuropathy can affect blood pressure, heart rate, digestion, bladder, sex organs, sweat glands, and eyes. The nerve damage can also cause hypoglycemia unawareness.

Focal neuropathy

Focal neuropathy (also called mononeuropathy) affects single nerves, usually in your hand (such as carpal tunnel syndrome), head, leg, or torso.

Proximal neuropathy

A rare type of neuropathy that can be very disabling. It tends to affect a hip, buttock, or thigh, on one side.

Peripheral diabetic neuropathy

A dysfunction in the peripheral nervous system—it usually affects the feet and legs, and can also affect the hands and arms. This is the most common type of diabetic neuropathy, affecting up to 50% of people with diabetes.

Symptoms of diabetic peripheral neuropathy may include:

• Tingling/loss of sensation (feeling pins and needles in the feet)

• Numbness in the feet, even when blisters or injuries are present, or when walking

• Painful symptoms (you may feel burning, stabbing, shooting, or sharp pain) and sensitivity

• Feeling very hot or cold in the feet and hands

• Weak muscles in the feet and legs

• Unsteadiness when standing or walking

• Leg or foot ulcers (open sores) which take a long time to heal

Cardiovascular risk factors, such as age, smoking, high blood pressure, obesity, high cholesterol, and peripheral artery disease, increase the risk of painful DPN. Symptoms of pain are often worse at night. Eventually, the pain may stop, but the feelings of coldness and numbness remain.

How is peripheral diabetic neuropathy diagnosed?

Your doctor will perform a physical exam and review your symptoms and medical history. The physical exam will include a foot exam and a neurological exam.

People with diabetes should have their feet and legs examined at every visit. The doctor will check your feet for any problems and ensure you have blood flow and feeling in the area. Your doctor may test you by:

• Using a tuning fork to see if you can feel the vibration

• Touching your feet and toes with a nylon strand (monofilament test) to see if you can feel it

• Examining your gait (how you walk)

• Testing your balance

Your doctor may also order nerve conduction tests and an electromyogram.

Your doctor may also order blood work—such as thyroid tests, kidney tests, and vitamin B12 levels—to see if anything else is causing nerve damage. Sometimes, people who take metformin (a commonly prescribed diabetes drug) have low levels of B12 and will need to take a B12 supplement with their metformin.

Many people who have DPN also have nephropathy and retinopathy, so regular visits with a nephrologist and ophthalmologist are important, too.

Peripheral diabetic neuropathy treatment options

Although there is no cure for DPN, there are several ways to manage or treat the symptoms. Talk to your doctor about different ways to help your pain from DPN. Some non-pharmacological ways to treat DPN include managing your blood glucose, blood pressure, and cholesterol, losing weight if necessary, avoiding alcohol, and stopping smoking.

Peripheral diabetic neuropathy treament

In terms of prescription drugs, first-line treatment includes prescription drugs such as Lyrica (pregabalin), Neurontin (gabapentin), or Cymbalta (duloxetine). Elavil (amitriptyline) is another first-line treatment but should not be used in older adults due to its side effects.

If first-line treatments do not work, doctors may try an antidepressant such as Effexor (venlafaxine) or Pristiq (desvenlafaxine), or an opioid pain medication such as Ultram (tramadol).

Other measures may include topical pain-relief patches such as lidocaine, or a pain-relieving cream like capsaicin. Other options may include isosorbide dinitrate spray and transcutaneous electrical nerve stimulation (TENS).

Peripheral diabetic neuropathy medications

Anticonvulsants

Anticonvulsants such as Lyrica (pregabalin) or Neurontin (gabapentin) may be helpful in treating nerve pain from DPN. Common side effects include dizziness, drowsiness, and weight gain. Lyrica is specifically indicated to treat pain from DPN.

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

SNRIs are antidepressants used to treat major depressive disorder, or depression. They work by increasing levels of serotonin and norepinephrine. SNRIs include Cymbalta (duloxetine), Effexor (venlafaxine), and Pristiq (desvenlafaxine). Cymbalta is the only SNRI that is specifically indicated for DPN. Side effects commonly include dizziness and drowsiness, as well as stomach problems like indigestion, constipation, and nausea.

Tricyclic antidepressants (TCA)

Elavil (amitriptyline) is the only TCA that is recommended to treat pain from DPN. Common side effects include dry mouth, trouble sleeping, dizziness, fatigue, and headache. Elavil should generally be avoided in older adults because it can cause side effects like extreme fatigue and orthostatic hypotension, which is when you get dizzy when going from a sitting down or lying down position to standing up.

Opioid pain medications

Ultram (tramadol) and Nucynta ER (tapentadol extended-release) are sometimes used to treat DPN. Nucynta ER is indicated to treat peripheral diabetic neuropathy. Common side effects include nausea, drowsiness, and constipation.

Lidocaine patches

Lidocaine patches, available in various prescription and over-the-counter (OTC) formulations, can be worn for up to 12 hours and should be removed for 12 hours. They may help the pain from DPN and have few side effects.

Capsaicin

Topical capsaicin cream, available in several OTC products, can help reduce pain. However, some people cannot tolerate the burning side effects. Qutenza is a prescription capsaicin patch that is approved to treat DPN.

Other medications

While the medications listed above are preferred treatments for DPN, sometimes they are not effective or cannot be tolerated. Other options that are considered third-line treatments include selective serotonin reuptake inhibitors (SSRIs) such as Celexa (citalopram), Paxil (paroxetine), or Lexapro (escitalopram), or other opioids (besides Ultram or Nucynta).

What is the best medication for peripheral diabetic neuropathy?

The best medication for peripheral diabetic neuropathy depends on your symptoms, medical conditions, medical history, and other medications you take that could interact with peripheral diabetic neuropathy medication. Your doctor can take this information into consideration and decide which treatment is most appropriate for you. Below is information about some of the most commonly prescribed medications for DPN.

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Best medications for peripheral diabetic neuropathy