Treatment of Neuropathy   (October 17, 2013)

I recently received the following question:

I was wondering what your thoughts on diabetic neuropathy are. I am solely relying on my various doctor’s opinions (symptoms and prick test) who say I have small fiber neuropathy. I have been on an insulin pump for about 9 months now, but to be honest, the first decade as a type 1 diabetic, I lacked funds to have my own health insurance and proper doctor care. I finally ended up on Medicare, but by that time, the damage of high blood sugars and sometimes guessing on my own insulin needs had already been done. I guess my question is, what role should endocrinologists play in the neuropathy arena, if any? I am wondering if this is something my pain management doctor will have to treat inevitably.

My reply:

I sense two different questions here: how to treat your neuropathy, and who should treat it.

Let’s tackle the question of treatment first. There are different kinds of neuropathy, a few of which have specific treatments. For example if you had autonomic neuropathy causing gastroparesis, treatment would include dietary changes, specific medications, and even surgery and nerve stimulators might be recommended. For this form of neuropathy, a referral to a gastroenterologist for evaluation and testing would be appropriate.

You don’t mention what your symptoms are, hence it’s difficult to guess if your diagnosis of “small fiber neuropathy” is the typical situation in people with diabetes, which presents with numbness, dysesthesias, and/or pain in the feet. This form of neuropathy is frequently called peripheral neuropathy (or more precisely, distal symmetric sensory polyneuropathy). It is common in people with diabetes, and is usually attributed to long-term poor diabetes control – but it may also have additional causative factors including (among others) alcohol abuse, neurotoxic medications, and vitamin B12 deficiency. These should be investigated, and if present, treated. If no other factors are found, then the standard treatments for peripheral neuropathy should be tried: tighten up the control of diabetes, topical creams such as capsaicin, and oral medications including antidepressants, anticonvulsants and opiods. Some newer drugs are specifically approved for treatment of diabetic nerve pain, including Cymbalta (duloxetine), Lyrica (pregabalin), and Nucynta ER (tapentadol).

What type of medical specialist should be involved with the care of diabetic neuropathy? I think that any physician interested in chronic pain could coordinate figuring out the diagnosis and treatment.  A knowledgeable general physician such as a Family Practice or Internal Medicine specialist might be a good choice. As diabetes specialists frequently see patients with diabetic nerve pain, they too are usually up-to-date on what to do. But, please note, some endocrinologists don’t deal with diabetes much, and would be little better than asking your next-door neighbor for advice.

Should you be referred to a “pain specialist”? Depends. Medically-trained physicians specializing in neurologic disorders (called neurologists) would certainly be a good choice. If there’s a vascular component to your difficulties (due to narrowing of blood vessels in the legs), then a vascular surgeon should definitely be consulted. But seeing an anesthesiologist who wants to earn extra bucks on the side by injecting pain patients with nerve blocks, trigger point injections, and epidural steroids should, IMHO, be avoided like the plague. These folks just don’t have the patience to act comprehensively, working over the long term to control your diabetes, look for other risk factors, and try a second (or third or fourth) treatment modality when an earlier trial doesn’t work out.

As I hint above, it might well be necessary to try different medications to figure out how to best control the pain. And controlling the diabetes as best you can is definitely in order.

Hope this helps!