Diabetic Neuropathy

What is diabetic neuropathy?

Neuropathy is damage to nerves that causes pain, numbness and/or tingling. Patients most often describe the pain as a burning type of pain or as if they are persistently walking on a pebble or other sharp item. The most common cause of peripheral neuropathy in the hands or feet is diabetes. 

Diabetes is a disorder of excessively high blood sugar levels in the body. It occurs when the body does not produce enough insulin, which is a hormone that controls blood sugar. Sometimes, the cause is due to the body not responding well enough to the insulin that is produced. Either way, when blood sugars remain high for a long enough period of time, changes to the nerve cells occur and leads to neuropathy.

There are two types of diabetes, which can typically lead to neuropathy. The first type is called Type I. It refers to a kind of diabetes that is typically diagnosed in childhood. Its cause is unknown. The second type of diabetes is usually diagnosed in adulthood. Its cause is chiefly related to obesity. It's called Type II.

Is there a cure for diabetic neuropathy?

Therapy for diabetic neuropathy involves aggressive treatment of diabetes. Treatment consists of medications to control blood sugars, dietary changes, exercise, stress management, and weight loss. Conventional wisdom is that if the diabetes is controlled early, the neuropathy can be reversed. However, diabetic neuropathy is often permanent when treatment for the diabetes is unsuccessful.

For the pain of diabetic neuropathy, goals of treatment are to reduce pain and improve functioning (i.e., the ability to do more life activities, like work).

Therapies & procedures for diabetic neuropathy

Common symptom management therapies include antidepressant medications, anticonvulsant medications, opioid medications, mild aerobic exercise, cognitive behavioral therapy, and chronic pain rehabilitation programs.

Antidepressant medications

Because some antidepressants are heavily advertised for use in diabetic neuropathy, patients are commonly familiar with them. When considering their use, it's important to understand the types of antidepressants and their relative effectiveness.

Roughly, there are three types of antidepressant medications. Serotonin norepinephrine reuptake inhibitors (SNRI’s) are the newest type of antidepressant medications. SNRI’s are typically the ones that are advertised for use in diabetic neuropathy. Selective serotonin reuptake inhibitors (SSRI’s) are the second type and are a little older. They were originally developed for use in depression. They are now sometimes also used for diabetic neuropathy. Tricyclic antidepressants are the third type. They are the oldest type of antidepressants. They too were originally developed for use in depression. However, they also have a long history of use for diabetic neuropathy and other chronic pain disorders.

Surprisingly, the newest type of antidepressant medications, the SNRI’s, are not the most effective.1 The most effective type of antidepressant are the tricyclics. These are the oldest type. They are likely to reduce pain by at least 50%.

The SSRI’s, the second oldest type of antidepressants, are somewhat likely to reduce pain by at least 50%.

The SNRI’s, the newest type of antidepressants – and the ones that are advertised on television and in magazines -- are the least likely to reduce pain by at least 50%.

Anticonvulsant medications

Anticonvulsant medications are medications that were originally developed for the management of seizures. However, they have also been shown to be helpful in managing the pain of diabetic neuropathy.

Tricyclic antidepressants and anticonvulsants are largely equally effective in reducing pain.2, 3 

Opioid medications

Opioid, or narcotic, pain medications are commonly used in clinical practice. However, few research studies support their use for diabetic neuropathy.

Gimbel, et al.,4 showed that the use of opioid medications was statistically better than placebo, but the actual clinical difference was minimal. Those who were treated with an opioid rated their pain on average at a 4 out of 10 whereas those who were treated with a placebo rated their pain at a 5 out of 10. In a small study, Watson, et al.,5 also found a minimally better response.

Opioid medication have significant potential for the development of addiction as well as death.

Mild aerobic exercise

Mild aerobic exercise, such as walking, bicycling, or pool exercises, are an important part of self-managing diabetes. It helps with maintaining blood sugar levels, weight loss, and stress management. It is also helpful in managing the pain of diabetic neuropathy. The American Diabetes Association recommends obtaining at least 150 minutes of aerobic exercise each week.Balducci, et al.,7 showed that mild aerobic exercise is able to reduce the likelihood of developing neuropathy due to diabetes.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a standard and effective treatment for chronic pain syndromes in general.8 A small clinical trial showed that it is effective at reducing pain.9

Chronic pain rehabilitation programs

Chronic pain rehabilitation programs are interdisciplinary programs designed to help patients learn to self-manage chronic pain. Their goals are to reduce pain, reduce secondary problems associated with living with chronic pain, reduce the use of narcotic medications, and return to work or some other meaningful regular activity. They are effective in achieving these goals, and there is high quality research evidence demonstrating their effectiveness.10 However, there are no clinical trials assessing the effectiveness of chronic pain rehabilitation programs solely for neuropathy.

References

1. Wong, M., Chung, J. W., & Wong, T. K. (2007). Effects of treatments for symptoms of painful diabetic neuropathy: A systematic review. British Medical Journal, 335, 87. doi: 10.1136/bmj.39213.565972.AE

2. Chou, R., Carson, S., & Chan, B. K. (2009). Gabapentin versus tricyclic antidepressants for diabetic neuropathy and post-herpetic neuralgia: Discrepancies between direct and indirect meta-analyses of randomized controlled trials. Journal of General Internal Medicine, 24, 178-188.

3. Collins, S. L., Moore, R. A., McQuay, H. J., & Wiffen, P. (2000). Antidepressants and anticonvulsants for diabetic neuropathy and post-herpetic neuralgia: A quantitative systematic review. Journal of Pain and Symptom Management, 20, 449-458.

4. Gimbel, J. S., Richards, P., & Portenoy, R. K. (2003). Controlled-release oxycodone for pain in diabetic neuropathy: A randomized controlled trial. Neurology, 60, 927-934.

5. Watson, C. P., Moulin, D., Watt-Watson, J., Gordon, A., & Eisenhoffer, J. (2003). Controlled-release oxycodone relieves neuropathic pain: A randomized controlled trial in painful diabetic neuropathy. Pain, 105, 71-78.

6. Sigal, R. J., Kenny, G. P., Wasserman, D. H., Castaneda-Sceppa, C., & White, R. D. (2006). Physical activity/exercise and type 2 diabetes. Diabetes Care, 29, 1433-1438.

7. Balducci, S., Iacobellis, G., Parisi, L., Di Biase, N., Calandriello, E., Leonetti, F., & Fallucca, F. (2006). Exercise training can modify the natural history of diabetic peripheral neuropathy. Journal of Diabetes and its Complications, 20, 216-223.

8. Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy and behavior therapy for chronic pain, excluding headache. Pain, 80, 1-13.

9. Otis, J. D., Sanderson, K., Hardway, C., Pincus, M., Tun, C., & Soumekh, S. (2013). A randomized controlled pilot study of a cognitive-behavioral therapy approach for painful diabetic neuropathy. Journal of Pain, 14(5), 475-482.

10. Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

 

Date of publication: April 27, 2012

Date of last modification: October 23, 2015

 

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Its mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides Academic quality information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

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