Diabetic Neuropathy

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Overview

Diabetic neuropathy is nerve damage often encountered in diabetes. In time, hyperglycemia ( the elevated sugar level in the blood of patients with diabetes) can affect the nerves of the entire body. There are several types of diabetic neuropathy.
 
Peripheral neuropathy results from the damage of the peripheral nervous system. This leads to decreased pain, tactile, thermal and vibration sensitivity in certain parts of the body and can sometimes affect the ability of motion and muscle strength. It affects most commonly the feet (feet and legs) and may contribute to the appearance of serious problems such as ulcers, infections or bone and joint deformities. It is the most common form of diabetic neuropathy.
 
Autonomic neuropathy (vegetative) is the result of the damage of the autonomic nervous system. These nerves are involved in the control of involuntary body functions such as heartbeat, blood pressure, sweating, digestion, kidney function and some aspects related to the sexual function. This is a common form of diabetic neuropathy as well.
 
Focal neuropathy affects a single nerve, most commonly in the wrist, thigh or leg. It may also affect nerves in the back and chest as well as those that control eye muscles. It often occurs in compressible conditions or conditions of crushing the nerves, such as the carpal tunnel syndrome (a consequence of the compression of the median nerve in the wrists). However, the carpal tunnel syndrome commonly occurs in people with diabetes but no focal neuropathy. Focal neuropathy usually appears all of a sudden and it is the rarest form of diabetic neuropathy.
 

Article Contents:
Overview
Symptoms
Investigation
Early diagnosis
Treatment


Symptoms

Diabetic neuropathy – especially peripheral neuropathy – is initially asymptomatic. Patients with diabetes should undergo regular health checkups in time to diagnose neuropathy and treat this problem before serious complications develop.
If the nerve is already damaged and efforts are done in order to establish the level of glucose at a target value (hemoglobin A1c [HbA1c] below 7% for a period of 2 to 3 months), the initial symptoms will increase during the decrease of blood glucose . However, symptoms will improve when glycemia levels will stabilize at a lower value (minimum).
Symptoms in diabetic neuropathy may vary depending on the type of neuropathy.
 
Peripheral neuropathy
Peripheral neuropathy tends to develop slowly over time, in months or years. The symptoms may get worse during pregnancy. Generally, the symptoms are:
- Tingling, numbness, contraction or burning, stinging pain in the legs, hands, or in other parts of the body; bone and joint deformities occur mainly in the foot (e.g. such as the diabetic foot or Charcot arthropathy)
- Decrease of sensitivity or numbness in the foot are more common; self-examination of skin lesions (cracks, wounds of the skin or excessive dryness) or minor injuries (blisters, areas of friction -”corns”- or the ingrown increase of toenails a) is required every day; the evolution of diabetes for 10 years or more, poor control of blood glucose or the appearance of vascular, kidney or eye complications, all increase the risk of leg injuries and the possible evolution towards a fatal foot amputation
- Reductions or large increases in sensitivity to light touch or thermal stimulation
- Reduction or loss of balance and coordination disorders.
 
Autonomic neuropathy
Autonomic neuropathy can affect digestion, temperature control ability,the renal function, the sexual function and the activity of the heart and blood vessels, including blood pressure. Symptoms may get worse during pregnancy. Generally, the symptoms are:
- Frequent bloating, belching, constipation, retrosternal burning sensation, nausea and vomiting, diarrhea or abdominal pain; these symptoms may indicate gastroparesis, situation in which the stomach empties more slowly than normally
- Profuse sweating at the level of the torso, face, neck, at night or during the ingestion of certain foods, such as spicy foods and cheese; instead, to other patients a reduced sweating, especially in the legs, appears
- Loss of the sensation of bladder fullness or difficulty when emptying a full bladder
- Sexual dysfunction, such as problems with erection in men and vaginal dryness in women
- Dizziness, weakness, or syncope (loss of consciousness) appeared when rising suddenly from a lying to a standing position (orthostatic hypotension)
- Difficulties of adjustment when blood sugar is low (‘hypoglycemia unawareness’, that is, there are no warning or adjustement signals when producing hypoglycaemia).
 
Focal neuropathy
The symptoms of focal neuropathy can occur suddenly. These may include:
- Pain, weakness and motor impairment in one region of the body, such as the wrist, thigh or foot, if the production mechanism is the compression or crushing the nerve (e.g. carpal tunnel syndrome), the pain and the median nerve pain will develop gradually over a period of weeks or months
- Intraocular and periocular pain, difficulty when moving the eyes and double vision (diplopia) because focal neuropathy can sometimes affect the nerves that control eye muscles
- If the nerve is not compressed or squeezed, the symptoms of focal neuropathy may disappear usually for 6 to 8 weeks.


Investigation

The diagnosis of peripheral neuropathy is based on symptoms, medical history and physical examination. The electromyogram (EMG) and Nerve conduction studies can be done in order to confirm the diagnosis. These tests measure as well and as fast as possible the electrical impulse is conducted to the nerves and muscles. When the nerve is affected, the nerve conduction velocity is slowed.
Disorders related to autonomic neuropathy – which affect the nerves involved in controlling the involuntary, internal functions – are difficult to diagnose. When symptoms develop, further investigations are needed in order to determine the etiology and guide the patient to a certain treatment. For example, a test that measures how quickly the stomach empties may be done in the presence of symptoms such as flatulence, indigestion or vomiting that suggest gastroparesis, a situation in which the stomach empties in a long time.
Nerve disorders and other diseases such as kidney disease, chronic consumption of alcoholism or vitamin B12 deficiency can occur in people with diabetes.
Varied laboratory tests (e.g. hemoleucogram) are necessary for screening other various causes of diabetes which produce the same type of symptoms. These analyses will be conducted according to medical history and symptoms.

Early diagnosis

There is no recommended screening protocol for autonomic or focal neuropathy, but during regular medical checkups all these aspects are tracked. Any pain, weakness or motor disorder, changes in digestion, kidney or sexual function, sweating or dizziness must be declared.
Peripheral neuropathy screening helps to prevent ulcers or amputations. American Diabetes Association (ADA) recommends that people with diabetes should be consulted by a specialist in foot examination for cracks or peeling skin, excessive or reduced sweating, blisters, corns, ulcers or signs of infection, bone deformities or joint changes, gait and balance during each consultation. ADA also recommends that this test should be done at least once a year. During these checkups the loss of sensation in the foot, leading on to the occurrence of severe complications, can be detected.

Treatment

There is no cure for diabetic neuropathy. Once installed, the treatment focuses on the secondary prevention (removal of aggravating factors) which consists in maintaining blood glucose levels to a target value. A tight glucose control consists of maintaining an average of the hemoglobin A1c [HbA1c] below 7% for a period of 2 to 3 months.
 Initial treatment
The treatment of diabetic neuropathy depends on the nature and the type of neuropathy symptoms. Generally, treatment aims at reducing symptoms and preventing complications by maintaining glucose level as close to the values of the target value as possible (hemoglobin A1c [HbA1c] below 7% for a period of 2 to 3 months). This value can be achieved by treatment with insulin or oral antidiabetic drugs as it was prescribed by your doctor, periodical checking of blood sugar through a diabetic diet, regular exercise and regular checkups.
Moreover, if diabetic neuropathy already exists, a careful self-examination of the legs is important because wounds or other severe injuries may pass unnoticed at this level by the loss of sensation. Without a careful tracking or not treating these problems in time, can cause severe infections or amputations.
It is also important to maintain a healthy lifestyle such as regular exercise, controlling blood pressure, diet, stopping smoking and limiting alcohol intake. Additional treatment may be set depending on the type of diabetic neuropathy.
 Peripheral neuropathy
Many patients with peripheral neuropathy have mild to severe pain in specific areas of the body. When consulting a doctor it must be brought into question the treatment that can reduce pain and improve the physical and mental condition of the patient. These treatments may include medications or ointments that reduce pain and may include medicines used to treat depression such as tricyclic antidepressants, antidepressants such as duloxetine hydrochloride, antiepileptic drugs (AEDs) as gabapentin. This medication has an analgesic effect (reduces pain) even if there are no associated illnesses such as depression or epilepsy. The complementary therapies are acupuncuture, massage and biofeedback. Physiotherapy with heat or ice and exercises can improve muscle strength. Transcutaneous electrical nerve stimulation (TENS) is a type of therapy that tries to reduce pain by applying short pulses to the nerve endings in the skin.
 Focal neuropathy
In case of compression, crushing or pluck, as in the case of focal neuropathy, fixing, anchoring the affected limb (e.g. wearing wrist cuffs can reduce the numbness and discomfort in the carpal tunnel syndrome) can sometimes reduce the pressure nerve. Surgery is indicated if symptoms become persistent.
 Autonomic neuropathy
Autonomic neuropathy – damage of the nerves involved in controlling involuntary functions – can affect digestion, kidney and sexual function, sweating, blood pressure and other involuntary controlled functions. Some symptoms of this type of neuropathy are difficult to master and some respond very well to treatment:
- Moderate constipation is treated with frequent meals in small quantities, high in fiber and low in fat
- Frequent diarrhea is treated with antibiotics such as tetracycline, amoxicillin, metronidazole or medicines that slow the intestinal transit
- Moderate gastroparesis (disorder in which the stomach empties slowly) includes frequent meals in small amounts, low in fiber and fat, and medicines to stimulate the motor activity of the stomach in order to make it empty faster; blood glucose control can reduce the symptoms of gastroparesis
- intense sweating includes avoiding heat and humidity; fluid intake also prevents the overheat of the body; if sweating occurs when consuming certain foods, drugs with anticholinergic effects can be helpful, but these drugs have more side effects which may be much more irritating than the excessive sweating
- Lack of regulation in situations when blood sugar is low (hypoglicemia unawareness) is controlled by adjusting insulin doses and accepting a blood glucose level above the accepted target; normally the values of glycosylated hemoglobin A1c [HbA1c] should be kept below 7%
- Kidney impairment needs antibiotics for the urinary infection and medication to functionally control the urinary bladder
- Impairment of the sexual function benefits from drugs or devices to improve erection and estrogen creams and lubricants for vaginal dryness
- Blood pressure disorders: medical elastic stockings and the administration of antihypertensive drugs.
 Maintenance treatment
The chronic treatment for diabetic neuropathy includes glycemic control at a value close to the target value. This involves maintaining an average of the glycated hemoglobin A1c [HbA1c] below 7% for a period of 2 to 3 months. It is also important to maintain a healthy lifestyle such as regular exercise, controlling blood pressure, diet, stopping smoking, limiting alcohol intake and closely watching the foot to prevent injuries or severe complications at this this level. Treatment is also based on symptoms and the type of neuropathy.
 Treatment if the diseases worsens
If the neuropathy develops, serious complications such as gastroparesis, urinary infections or complications in the foot may occur. Additional measures to maintain target blood glucose levels and careful self-examination are necessary if the diabetic neuropathy progresses. The diabetic neuropathy is a major risk factor for the occurrence of infections or foot ulcers that may lead to amputation. The occurrence of permanent deformation in one or both feet is possible, the Charcot foot, in which case, surgery is necessary in order to correct these deformities.
Severe gastroparesis requires other treatment, such as drugs that accelerate gastric emptying or artificial feeding by gastrostomy ( a tube which allows feeding) in severe cases. Severe bladder infections or other problems at this level (such as the loss of bladder control), require additional diagnostic tests and medication or surgery in order to improve the bladder function.
Additionally, depression can occur in the context of chronic disease such as diabetes or diabetic neuropathy, and a professional consultation and an appropriate treatment can improve the health of the patient.
 Outpatient treatment (at home)
In addition to the regular checkups in order to prevent the progression of diabetic neuropathy, it is necessary to control blood sugar, to carefully examine the feet and establish a healthy lifestyle.
 The control of glycemia
The most important step to be followed in order to prevent diabetic neuropathy is to keep blood sugar constant, at a value close to the target value. The tight glucose control consists of maintaining an average of the glycated hemoglobin A1c [HbA1c] below 7% for a period of 2 to 3 months. However, lowering blood glucose at the target value may increase symptoms for a short period of time. Keeping this value is necessary in order to prevent diabetic complications such as that of the eye and the kidney.
 Careful foot care
Diabetic neuropathy affects the feet more often than other body parts. In diabetes there is a weak decrease of the ability of defence against infection, and even a minor leg injury, such as a blister or a scratch, which can lead to serious infections and even amputation.
Yet foot complications in diabetes are the most preventable complications of any other complications.
Because of nerve damage, in diabetic neuropathy,minor injuries may pass unnoticed because of the loss of sensation, so a regular inspection of the leg is necessary. Foot protection can be provided by wearing socks most of the time and proper shoes . If there are already ocular complications such as diabetic retinopathy or other eye disease, this inspection becomes difficult and it is necessary the help of another person. During the periodical medical examination your foot will be carefully examined, and that examinationl is necessary at least once a year. If there is severe numbness and skin sores, joint or bone deformities (e.g. Charcot foot), the patient should have appropriate shoes for this kind of problems.
 Establishing and maintaining a healthy lifestyle
Reducing the risk of developing diabetic neuropathy can be achieved by:
- Blood pressure control: neuropathy progresses more likely in people with high blood pressure; it is not clear yet the direct mechanism between high blood pressure and the progression of neuropathy, but usually the maintenance of blood pressure as close to the normal as possible reduces the risk of complications from diabetes
- Regular exercise and maintaining an appropriate body weight: exercise and weight control helps the body to use insulin properly, this leading to the maintenance of blood glucose levels close to the target value and prevention of the development and progression of nerve damage; a medical specialist checkup and a thorough examination of the foot is needed before starting doing exercises. Complications of the foot, blood pressure and other problems associated with diabetic neuropathy may raise some concerns related to the safety of physical exercises: repetitive exercises and weight lifting should be avoided.
- Stopping smoking: Smoking increases the risk of neuropathy in people with diabetes ; it can also increase blood pressure and worsen other problems in diabetes
- Limiting alcohol intake: alcohol consumption (more than 4 days per week) can worsen neuropathy and its symptoms
- Diet: the consumption of vitamins each day will ensure the nutritional needs and a balanced diet ensures the maintenance of a proper weight; if gastroparesis exists, it is necessary the consumption of meals in small quantities besides the 3 main meals.

 

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