Sunday, December 4, 2022

Pain Medicine For Diabetic Neuropathy

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Regular Exercise Can Help

Diabetes, Nerve Pain, and Medication

A healthy lifestyle is important in every individual, but even more so in someone with neuropathy. This means that you must maintain a healthy weight, avoid toxin exposure, getting regular physical exercise, making sure your diet is balanced and nutritious, ensuring you consume the right levels of vitamins and minerals , not smoking, and avoiding alcohol. These things all have a positive impact damaged nerves.

People with neuropathy often experience cramps, which can be reduced through exercise. It also helps to make the muscles stronger and stops them from wasting away. In terms of types of exercise, people with this condition should focus on at least walking regularly at a brisk pace. Doing so three times per week can greatly reduce the pain associated with this nerve damage. Meanwhile, sports such as tai chi, Pilates, and yoga can all be beneficial.

Studies have shown that those who get regular exercise to improve muscle strength and prevent muscular atrophy are better capable of controlling blood glucose levels. In addition, having a healthy diet to ensure that you have a good nutritional balance can help immensely.

What Causes Diabetic Neuropathy

Although the exact causes of diabetic neuropathy are unknown, several factors may contribute to the disorder, including:

  • High blood sugar . High blood glucose causes chemical changes in nerves and impairs the nerves ability to transmit signals. It can also damage blood vessels that carry oxygen and nutrients to the nerves.
  • Metabolic factors. In addition to glucose levels, high triglyceride and cholesterol levels are also associated with increased risk of neuropathy. Patients who are overweight or obese are also at increased risk of developing neuropathy.
  • Inherited factors. There are some genetic traits that may make some people more susceptible to nerve disease than others.

What Causes Diabetes And Neuropathy

People with diabetes have trouble controlling their blood glucose levels because they dont react to the hormone insulin normally. Insulin is needed to help bring glucose into cells to be used for energy so the amount that remains in the blood can be controlled.

Diabetes affects people of all ages, genders and racial/ethnic backgrounds, but its more common in people are who overweight, older and leading lifestyles that impair normal hormonal balance.

Some risk factors make people more susceptible to complications caused by diabetes, including neuropathy , include:

  • having uncontrolled blood sugar this is the biggest risk factor for all complication of diabetes
  • having diabetes for a long period of time the longer youve had it, the higher chance you have of developing nerve damage
  • being overweight or obese
  • living a sedentary lifestyle
  • smoking cigarettes
  • having high amounts of fat in the blood, high cholesterol or high blood pressure
  • having an autoimmune disease, which inflames nerves
  • having experienced any mechanical injuries to the nerves
  • certain territory factors or inherited traits that make nerve damage more likely

Diabetic Neuropathy Takeaways

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Clinical Features Of Diabetic Neuropathy

DPN may present with a wide range of clinical symptoms and signs. Some people may be entirely asymptomatic, where a foot ulcer can be the first presentation. However, other patients may experience one or a number of different symptoms such as paresthesia , numbness and neuropathic pain which can range from mildly troublesome to intractable, causing great suffering . These symptoms may be sporadic or constant, and their natural history varies among patients. Sensory symptoms may be present for only a short period of time before they disappear entirely, or they may become chronic. Sensory symptoms and clinical examination signs begin in the toes/distal foot symmetrically. On physical examination, light touch and pin-prick of the distal foot is commonly impaired first, followed by more advanced sensory and motor abnormalities. As the disease progresses, it spreads proximally up the leg before impacting the finger tips and upper limbs. The physical examination for patients with painful-DPN is generally indistinct from those without neuropathic pain. However, some patients may have a pure small fiber neuropathy which results in a loss of small fiber modalities with normal large fiber function . Additionally, a small sub-set of patients have the so called irritable nociceptor phenotype with positive sensory signs such as allodynia and hyperalgesia .

Symptoms Of Diabetic Neuropathy

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Diabetes affects the sensory, motor and autonomic nervous systems. One of the systems most damaged from diabetes is the peripheral nervous system, which is a complex web of nerves that connect the central nervous system to the rest of the body. This is the reason diabetic neuropathy can cause symptoms and complications just about anywhere on the body, from the fingers and toes to the genitals and eyes.

Studies have found that diabetics with neuropathy usually report having a significantly poorer quality of life compared with those without neuropathy, especially if the nerve damage causes pain.

High blood sugar over long periods of time affects blood pressure/blood flow and the arteries, which impacts how nerves communicate and send signals to one another throughout the body. Sometimes nerve damages can progress the point that it causes permanent loss of sensation, heart damage, skin sores/ulcers, loss of vision and even the need for lower-limb amputations.

While peripheral neuropathy is the most common type of diabetic neuropathy, other types can also develop, including:

Common signs and neuropathy symptoms include:

  • cramps, pain, tingling and numbness in the toes, hands, feet, legs or elsewhere
  • hypoglycemia symptoms, including shakiness, sweating and a fast heartbeat
  • damage to the nerves in the bladder and urinary tract, which cause frequent urination

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The Classification And Definition Of Diabetic Neuropathies

Diabetic neuropathies are heterogenous in their clinical presentation, risk factors and pathophysiology. The neuropathic syndromes may be classified according to the nerve type affected , site of nerve injury , and disease time course . The neuropathic syndromes may broadly be divided into typical DPN and atypical diabetic neuropathies, the latter of which are outside the scope of this review . The American Diabetes Association has recently developed a simplified classification schema for diabetic neuropathies, reproduced in Table 1 . Typical DPN is by far the most prevalent form of neuropathy in diabetes and characteristically affects both sensory and motor nerves in a peripheral distribution . However, the relative impact on small and large sensory fibers, and motor fibers varies among individuals. The Toronto Diabetic Neuropathy Expert Group defined DPN as a symmetrical, length dependent sensorimotor polyneuropathy attributable to metabolic and microvessel alterations as a result of chronic hyperglycemia exposure and cardiovascular risk covariates .

Table 1. Classification for diabetic neuropathies.

Importance Of Living A Healthy Lifestyle

When people experience pain, it means that their tissue is injured or inflamed, and/or that they are ill. Often, pain starts suddenly and it is common for it to get worse under emotional distress. This means that mental health must also be considered in the diagnosis and treatment of pain. This is particularly true in people who suffer from chronic pain, such as neuropathy, as they must be able to accept a continuous reduced quality of life.

Often, chronic pain is a symptom of an underlying disease. For instance, neuropathy is commonly associated with diabetes. However, many people who suffer from this condition find themselves trapped in a vicious cycle. They experience pain, which causes emotional distress, which makes the pain worse. The knowledge that this medical condition is hard to treat makes this even worse.

What this demonstrates is just how important it is that people focus not just on medical treatments and medication, but that they also focus on themselves. They must identify the root cause of the pain they experience and treat it appropriately. Someone who does not lead a healthy lifestyle, in other words, will experience the symptoms in a far stronger degree.

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Hacks And Remedies That Can Help Too

Some podiatrists recommend alternative paths to treatment as well.

Dr. Brittany A. Portonova, a podiatrist who practices in Hazle Township, Pennsylvania, tells DiabetesMine, For pain control, mild cases of diabetic neuropathy pain can be managed well with a complex mix of vitamins, most notably Vitamin B6 and B12, in addition to alpha-lipoic acid. Some vitamin stores or pharmacies will offer complex/combined vitamins that are geared specifically toward diabetic neuropathy. Moderate to severe neuropathy pain is usually well managed by a combination of over-the-counter or prescription topical pain creams and oral prescription medications with much success.

She continues, Secondarily to pain management, we look to supplement with proper supportive shoes, orthotics, and diabetic shoes. Its important in the presence of neuropathy to be fitted for these devices by either a podiatrist or credentialed pedorthist to make sure that you are getting a quality product that will not cause any unwanted blisters, sores, or infections in the setting of neuropathy. Lastly, therapy and exercise regimens are highly recommended to help with chronic pain, weakness, and gait disturbances that can affect those with neuropathy.

Some people with T1D have opted for homeopathic remedies to manage their neuropathy pain.

In terms of what triggers the pain for McCollister, wearing certain kinds of shoes , or even getting a pedicure or stubbing a toe can cause inflammation.

Over The Counter Nerve Pain Medications

Diabetic Peripheral Neuropathy Treatment 2021[Diabetic Nerve Pain]

The first step should always be to try over-the-counter medication. These include OTC drugs such as ibuprofen, acetaminophen, and naproxen, one of the best over the counter pain relievers for nerve pain. You should consult your doctor before taking these as some may have adverse affects on the colon or liver if taken in large dosages or longer than recommended. When this is no longer effective, or not effective enough, a number of other treatment options are available.

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New Perspective In Diabetic Neuropathy: From The Periphery To The Brain A Call For Early Detection And Precision Medicine

  • 1Endocrinology Department, Renmin Hospital of Wuhan University, Wuhan, China
  • 2Diabetes Research Unit, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Sheffield, United Kingdom

Diabetic peripheral neuropathy is a common chronic complication of diabetes mellitus. It leads to distressing and expensive clinical sequelae such as foot ulceration, leg amputation, and neuropathic pain . Unfortunately, DPN is often diagnosed late when irreversible nerve injury has occurred and its first presentation may be with a diabetic foot ulcer. Several novel diagnostic techniques are available which may supplement clinical assessment and aid the early detection of DPN. Moreover, treatments for DPN and painful-DPN are limited. Only tight glucose control in type 1 diabetes has robust evidence in reducing the risk of developing DPN. However, neither glucose control nor pathogenetic treatments are effective in painful-DPN and symptomatic treatments are often inadequate. It has recently been hypothesized that using various patient characteristics it may be possible to stratify individuals and assign them targeted therapies to produce better pain relief. We review the diagnostic techniques which may aid the early detection of DPN in the clinical and research environment, and recent advances in precision medicine techniques for the treatment of painful-DPN.

How Is Diabetic Neuropathy Diagnosed

Early diagnosis of diabetic neuropathy gives patients the best chance of effective treatment. But since not all foot or limb pain means diabetic neuropathy, accurate diagnosis is important to ensure appropriate treatment.

Diagnosis of diabetic neuropathies is based on history, clinical examination and supporting laboratory tests. Your doctor may:

  • Check muscle strength and reflexes.
  • Check muscle sensitivity to position, vibration, temperature and light touch.
  • Request additional tests, such as:
    • Ultrasound to determine how parts of the urinary tract are functioning.
    • Electromyography to determine how muscles respond to electrical impulses.
    • Nerve conduction studies to check flow of electrical current through a nerve.
    • Skin biopsies to evaluate cutaneous nerve innervation.
    • Nerve and muscle biopsies for histopathological evaluation.

A comprehensive evaluation including a review of blood pressure, cholesterol and blood glucose screenings combined with more advanced screening, helps the doctor rule out other causes and identify the core problem.

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Clinical Context Summary For All Evidence

It is notable that the placebo effect varied from 0% to 50% pain reduction in these studies.

Adjuvant analgesic agents are drugs primarily developed for an indication other than treatment of PDN that have been found to lessen pain when given to patients with PDN. Their use in the treatment of PDN is common.e33 The panel recognizes that PDN is a chronic disease and that there are no data on the efficacy of the chronic use of any treatment, as most trials have durations of 220 weeks. It is important to note that the evidence is limited, the degree of effectiveness can be minor, the side effects can be intolerable, the impact on improving physical function is limited, and the cost is high, particularly for novel agents.

A summary of Level A and B recommendations for the treatment of PDN is provided in

Summary of recommendations

Determine What Contributed To Your Condition

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If you have been diagnosed with peripheral neuropathy, diabetic neuropathy, or any other form of nerve damage, you must start by determining what has contributed to this condition. For instance, compression, autoimmune disorders, hormonal deficiencies, vitamin deficiencies, medication-related toxicity, toxin exposure, and infections can all lead to this deterioration of the nerves.

Either way, when nerve damage occurs, the nerves axons can regenerate over time, so long as the cell of the nerve itself hasn’t died. Hence, it is possible to experience recovery if treated in the right way, at the right time. In other words, this is a symptom and not a disease itself, and it is vital that the disease is identified and treated to protect the nerves.

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Topical Creams And Ointments

Many are uncomfortable with ingesting drugs of any kind. For these people, the use of topical medication treatments for relief from nerve pain like creams, gels, and ointments can be very beneficial. Painkilling gels and patches can be applied directly to the region of the skin where the feeling of discomfort is prevalent and they come with minimal side effects. For most people, aside from localized spots of irritation there is little to worry about.

Commonly, physicians will prescribe capsaicin, which changes the pain receptors in the peripheral nerves and is derived from hot peppers or lidocaine, which is an anesthetic. Generally, topical medication is only offered if the pain is chronic and localized, which is often seen in people who have herpes zoster neuralgia pain.

Researchers Compare Four Treatments For Neuropathy

Researchers publishing in JAMA Neurology describe the results of a unique trial in which 402 people with idiopathic sensory polyneuropathy were randomly assigned to one of four medications: duloxetine, mexiletine, nortriptyline, or pregabalin. After 12 weeks, each person rated their neuropathy symptoms on a scale from 1 to 10, noted any side effects, and reported whether they had quit taking the medication due to side effects, cost, or some other reason.

Though the trial is important and much needed, the results were disappointing.

  • No medication was a clear winner or highly effective. For this study, a key measure was whether a medication reduced discomfort by 50%. The most effective treatment was nortriptyline. Of the study subjects taking this medication, 25% reported their discomfort improved by at least 50%. The least effective treatment was pregabalin: only 15% of study subjects reported that much improvement.
  • Side effects were common with all of the treatments. Nortriptyline had the highest rate of side effects, at 56%. Mexiletine had the fewest at 39%. Fortunately, none of the side effects were considered serious.
  • People frequently quit taking the assigned medication. Duloxetine had the fewest discontinuations . The highest quit rate was for mexiletine . Reasons given for stopping included side effects and cost.

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Diabetic Neuropathic Pain Management

Many medications are available for the treatment of diabetic neuropathic pain. Oral agents include antidepressants and anticonvulsant drugs. According to the 2011 guideline issued by the American Academy of Neurology , American Academy of Physical Medicine and Rehabilitation and the American Academy of Physical Medicine and Rehabilitation guideline for the treatment of painful diabetic neuropathy , pregabalin is recommended for treatment of diabetic neuropathic pain. The drug has been proven effective and can improve quality of life. However, physicians should determine if the drug is clinically appropriate for their patients on a case-by-case basis. Gabapentin and sodium valproate should also be considered for diabetic neuropathy pain management.

According to a Cochrane review evaluating gabapentin for chronic neuropathic pain and fibromyalgia, gabapentin leads to significant pain relief in patients with chronic neuropathic pain when compared with a placebo. Although patients frequently experience adverse side effects, these are usually tolerable, and serious side effects were not increased when compared with side effects associated with the placebo.

According to the 2011 AAN/AANEM/AAPMR guideline, dextromethorphan, morphine sulfate, tramadol, and oxycodone should be considered for PDN treatment. No one opioid is recommended over another.

Corneal And Retinal Innervation

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A number of different ophthalmic measures of neuronal integrity have been proposed as surrogate measures of DPN and other neurological diseases, including corneal confocal microscopy , retinal nerve fiber layer thickness, and pupil responsiveness . CCM is a rapid and non-invasive modality for the study of corneal innervation and has emerged as a technique for diagnosing DPN . It has a high sensitivity and a specificity of 4064% to diagnose DPN . Furthermore, CCM measures correlate with IENFD on skin biopsy . Pritchard et al. demonstrated that a reduced corneal nerve fiber length was predictive of incident DPN . Moreover, Dehghani et al. found that corneal nerve parameters rapidly declined prior to the development of foot complications .

Optical coherence tomography has been used to identify the loss of retinal nerve fibers in a number of neurological disease, including DPN . Retinal nerve fiber layer loss is observed in patients with diabetes and correlates with the stage of diabetic retinopathy . However, reports have shown that RNFL loss in patients with diabetes without diabetic retinopathy . Indeed, two recent studies have found that measures of RNFL loss are associated with DPN . OCT and CCM measures hold promise as a reliable and repeatable non-invasive measure which may be used to detect early DPN in the clinical and research setting. However, they are not currently widely available as they require specialist expertise and expensive equipment to perform .

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