Painful diabetic neuropathy   (June 14, 2009)

Diabetic nerve damage to the feet, sometimes called diabetic neuropathy, or more correctly, diabetic distal symmetric sensory polyneuropathy, frequently causes people with diabetes to lose sensation in their feet, which is usually describe as "numbness." Sadly, there's really not much available to help this loss of sensation.

However, diabetic neuropathy occasionally creates a severe burning pain in the feet, or other very unpleasant sensations, that can be extremely frustrating. The following treatment program is suggested for painful diabetic neuropathy.

First of all . . .

Get your diabetes straightened out as best you can! Aim to keep your blood sugar tests normal as often as possible, and to get your A1C value into the normal range. The blood sugar should ideally be about 100 before meals, and 140 or 150 as the highest blood sugar that is ever seen. This extremely tight control may require shots of insulin several times daily, very careful attention to meal planning and frequent monitoring of your blood sugar level, under the care of a knowledgeable physician specializing in diabetes, working together with a nurse who is a Certified Diabetes Educator. This seems to be the best way to help to treat the painful feet.

Protecting your feet

Whether or not you have diabetic neuropathy, there is a list of things to do to protect your feet:

* Be careful to protect your feet from injury. Any minor injury may allow infection to set in, which could lead to gangrene and amputation. This means wearing shoes at all times.
* Look at your feet (with your eyes, or someone else can look if it's difficult for you to do): every day! If new problems are seen, such as a blister or red spot, telephone your doctor's office promptly for advice; stay off your feet until you get other advice.
* Break in new shoes slowly, so that they don't accidentally cause blisters.
* Keep several pairs of shoes at work, or in the car, so you can rotate among them if your feet feel tired.
* Every patient with neuropathy resulting in anesthesia should be under the care of a podiatrist for routine foot care, such as trimming nails and calluses.
* And be sure the diagnosis is correct! (There are other conditions that can also cause neuropathy). You should have an EMG/NCV study done, and some blood tests. Ask your diabetes specialist or neurologist if your personal physician isn't sure what to do.)

What about pain medications?

Pain control with standard pain-relief medications such as aspirin, ibuprofen, and acetaminophen may be helpful in some cases. You should be on a regularly scheduled program of one of these, taking the medication several times every day. Since these medications do have side effects, discuss which one to use with your personal physician.

Unfortunately, these medications probably will not provide adequate relief, and some patients have had narcotics prescribed for pain relief. Diabetic experts do not recommend the use of narcotics to treat diabetic neuropathy under any circumstances: diabetes control and "pain-blockers" can often control the pain.

"Pain-blockers"

Medications that block pain can be very useful in the treatment of diabetic neuropathy. These medications are not painkillers. They were originally developed for the treatment of other conditions, and have been found to work occasionally to relieve diabetic neuropathy. It will be necessary to try a medication program with one of these "pain-blockers" for several months to find out if it might be helpful for your pain.

Needless to say, these medications have a risk of side-effects, which should be discussed thoroughly with your physician before starting a trial. There is no guarantee that any of the "pain-blockers" will work, and they must be tried, and then decide whether it helped enough to keep it going, or whether a second (or third) program might be tried. Pain-blocking medications include:

* antidepressant medications, such as Elavil (amitriptyline), Prozac (fluoxetine), and others;
* anti-seizure medications, such as Dilantin (phenytoin), Tegretol (carbamazepine), and Neurontin (gabapentin).

New medications

Newer prescription medications that treat diabetic peripheral neuropathic pain are also available.

* Cymbalta (duloxetine) is approved for use for the management of diabetic peripheral neuropathic pain, as well as fibromyalgia, depression, and generalized anxiety.
* Lyrica (pregabalin) is approved for use in the management of neuropathic pain associated with diabetic peripheral neuropathy and other conditions including postherpetic neuralgia (nerve pain after shingles) and fibromyalgia.

Skin Creams

A non-prescription pepper cream (capsaicin) for application onto painful skin is available. This medication has been shown to give relief for painful diabetic neuropathy in some cases. If capsaicin is stopped, the pain will return. It does have side effects of a transient severe burning for a week or so before numbing sets in. Advice when using capsaicin include

* Wear gloves when applying capsaicin cream.
* Do not apply it immediately after a hot bath or shower or use it with a heating pad.
* Avoid getting capsaicin cream in eyes and other mucus membranes or broken skin.

Summary

If you have painful burning sensations in your feet, ask your physician about whether you might benefit from one or another of these medications.