Stop the Pain of Diabetic Neuropathy
Pain from Diabetic Peripheral Neuropathy
An estimated 60-70 percent of people with diabetes have some form of neuropathy, making it one of the most common complications of diabetes. The symptoms of diabetic peripheral neuropathy (DPN) are most often felt in the toes, feet, and hands of people who have this nerve disorder, which can affect almost every system in the body.
Common descriptions of the feelings or sensations for DPN are:
Every person with DPN experiences it in different ways. For example, a person with diabetic neuropathy can lose feeling without pain or have pain without numbness. And there are people with peripheral neuropathy who have no pain at all. The most common symptom, however, is experiencing both burning and numbness, which can be key to diagnosing this nerve disorder.
"It's usually a loss of feeling, and then a burning sensation where that feeling's been lost," says Robert Gerwin, M.D., pain management specialist and practitioner and associate professor of neurology at Johns Hopkins University School of Medicine in Baltimore, Maryland. "It's not the dull, sore muscle and joint aches and pains that you may feel from aging," he says. And when these symptoms aren't given the attention they deserve, they're likely to progress.
As you click through this slideshow, you'll see why pain occurs, along with descriptions of commonly prescribed medications; topical analgesics such as capsaicin and lidocaine; and complementary pain treatments such as acupuncture and transcutaneous electrical nerve stimulation (TENS).
Talk with your doctor about the following options and decide together what methods of pain relief will ensure you have a more comfortable tomorrow.
Why You Feel Pain with Diabetic Peripheral Neuropathy
"I think in this day and age, people with diabetic neuropathy should not be suffering from pain," says pain management specialist Robert Gerwin, M.D. Good control of blood glucose levels is an important prevention step -- and crucial even if you already have pain. If you don't address your pain with your doctor in its early stages, it may become more unbearable.
A process called central sensitization occurs when the nerves throughout your body -- commonly starting at your toes and feet -- begin to transmit pain. When they continue to do so for a prolonged period of time, that pain moves at a higher frequency and the sensation feels stronger. This causes the nerve cells to become permanently damaged and eventually die, leading to genetic changes in the cells. Your nervous system may lose the ability to control the sense of pain, says Ed Ross, M.D., director of the Pain Management Center at Brigham and Women's Hospital in Boston.
The portion of the nerve that is most affected is farthest from the nerve cell in your spinal cord, where nutrition and chemical elements that are important to the nerves originate, Gerwin says. So the leg's long nerves and nerve endings in the toes are affected first. He says that if neuropathy goes untreated long enough, pain can progress to the fingers and throughout the body.
Prescription Pain Relief for Diabetic Neuropathy Symptoms
"Diabetic neuropathy is an ongoing chronic problem," says Robert Gerwin, M.D. "But I think we, as pain specialists, are seeing fewer cases than we did before because it's being handled more by the primary physicians, which is a good thing." He says that this is primarily because the medications are now commonly used by endocrinologists and internists, not just pain specialists.
Medications can be your first resort or your last. "In general, the recommendation is to increase medications stepwise, starting with the mildest drug that is effective," Gerwin says. "When someone has very mild pain, anti-inflammatory drugs like ibuprofen and acetaminophen (Tylenol) work fine."
Problems with this method arise when a person is experiencing severe pain -- then, Gerwin says, it makes no sense to start with a low-level pain medication. By the time a visit to the pain clinic is necessary, patients usually have been through the mill with what their primary care physician has prescribed and the pain is out of control.
The following slides discuss the three main medications that are generally prescribed to treat diabetic peripheral neuropathy.
Anticonvulsants pregabalin (Lyrica) and gabapentin (Neurontin) were designed to help people who have epilepsy. But the nerve-calming qualities of many of these drugs can also help quiet the burning, stabbing, or shooting pain often caused by nerve damage. These medications can decrease nerve transmissions, slowing their electrical and painful impulses. "Gabapentin is a very common first step in terms of prescription medications to treat neuropathy," says Sara Healy, Pharm. D., a retail pharmacist in Minneapolis, Minnesota.
"If you're treating someone who depression along with their diabetes, you'd start them with an antidepressant," says Robert Gerwin, M.D. These medications are sometimes known as seratonin and norepinephrine reuptake inhibitors, or SNRIs. "The SNRIs boost seratonin in the brain, which will decrease pain transmission," says Kent Holtorf, M.D., endocrinologist and medical director of the Holtorf Medical Group in Torrance, California. "And norepinephrine will give superior pain control." Two SNRIs recently became available after approval by the U.S. Food and Drug Administration: duloxetine (Cymbalta) and milnacipran (Savella).
Both anticonvulsants and antidepressants may increase blood glucose, so make sure to monitor your levels carefully and tell your health care provider about any abnormal changes.
Some primary care physicians skip antidepressants and anticonvulsants as options for pain relief and prescribe opioids such as hydrocodone with acetaminophen (Vicodin) and oxycodone with acetaminophen (Percocet), says Ed Ross, M.D.
Opioids may not be the best front-line or single-treatment option for people who have neuropathy pain because such medications don't have much effect on chronic pain within the nervous system. "Drugs like these are fine when you seriously injure yourself," says Kent Holtorf, M.D. "Or they can often be added to a primary treatment option to help in some patients. But they really don't cut out the pain entirely." Addiction can also be an issue with this type of medication.
Topical Analgesics to Ease Peripheral Neuropathy Pain
Before starting medications, or if the medications prescribed to you aren't enough, over-the-counter and prescription off-label (non-FDA-approved) topical analgesics in cream, gel, and oral forms may ease the tingling, numbness, or dull pain you feel in your extremities.
The following slides discuss the three common types of topical treatments available to ease the pain of diabetic peripheral neuropathy.
Ed Ross, M.D., a pain management specialist, says there is some evidence to support that capsaicin (DiabetAid Pain and Tingling Relief; Zostrix), which is extracted from chile peppers, relieves the pain of diabetic neuropathy. "However, many of the patients I see can't tolerate it," he says. This over-the-counter topical agent, which is available in creams and other forms, irritates the nerves and keeps them firing until then they fatigue, allowing the pain to reduce.
"Capsaicin works, but it is very hard for people with a burning pain from neuropathy because it really stings and burns. It just magnifies the pain," says Robert Gerwin, M.D. The burning will settle after your body builds a tolerance, because it works by eliminating one of the chemicals that initiates pain, but it takes about a week to 10 days, with three to five applications per day. If you stop using it, even for a day, the benefit is gone and the burning sensation returns.
Unlike capsaicin, lidocaine (Lidoderm) -- an anesthetic commonly applied to the skin through a pliable patch but is also available in gel form -- should not irritate your skin. In fact, if you feel any sort of burning or pain, you should remove it immediately.
You can apply up to three patches every 12 hours to relieve pain in the most affected areas of your body. "The problem with the patch is that you have to cut it down to the right size," says endocrinologist Kent Holtorf, M.D.
If you use this product, remember to wash your hands after placing it on your skin, unless you're applying it to relieve hand pain. If used for hand pain, rinse it off after 30 minutes. When disposing of the patch, fold it over onto itself and put it in a waste container that is not accessible to children or pets.
Combination Topical Creams
Custom pain gels that combine medications such as ketoprofen, gabapentin, ketamine, and lidocaine can be prescribed by your physician and made by a compounding pharmacist. Topical delivery of these medications allows for more direct treatment to the affected area without the side effects of oral medications because very little gets into the blood.
Though topical treatments as a stand-alone pain therapy are poorly evaluated, both Ed Ross, M.D., and Kent Holtorf, M.D., recommend using them in combination with other pain-treatment therapies, both medications and complementary options, to help diminish mild pain.
Complementary Treatment Options for Diabetic Neuropathy
Pain relief doesn't always come in the form of a pill. There are several complementary options to relieve the early phases of neuropathic pain. Acupuncture and transcutaneous (through the skin) electrical nerve stimulation (TENS) are two that seem to have stronger medical support than others such as massage, relaxation therapy, and meditation.
Acupuncture can help relieve discomfort throughout the body by painlessly inserting thin needles, usually made of stainless steel, into different points along the body's energy flow, or qi (pronounced "chi"). Practitioners believe obstructions in this pathway are the source of pain you feel and are usually caused by an illness like diabetic neuropathy. The needles clear the energy flow and relieve pain.
"Acupuncture is very difficult to study and get good research to support because it's very operator dependent," says Kent Holtorf, M.D. "Unfortunately, some acupuncturists will have a great result while others will not." He says that this ancient Chinese medicine has been shown to lower stress hormones, which leads to less inflammation throughout the body and can, in turn, reduce pain transmission.
TENS is a noninvasive approach to treating neuropathic pain. Electrode patches are attached to your skin from a TENS unit, which is a portable device that you can wear around your waist. "The patches send an electrical current that will fatigue the nerves," Holtorf says. "Then they become too tired to process the pain." TENS is commonly prescribed for very mild pain.
Neuropathy Pain Prevention
It's easier -- and less expensive -- to prevent pain than to treat it. In addition to tight blood glucose control, Ed Ross, M.D., suggests three ways to prevent the onset of neuropathic pain.
Exercise. Regular physical activity can help you lose weight, which can help slow the progression of pain by reducing inflammation throughout the body. But if you already feel minor symptoms of neuropathy, don't stop moving. Find low-intensity workouts such as swimming or cycling to get in your minutes of activity throughout the day. Talk with your physician about pain-free exercises that will suit you and your schedule.
See your health-care provider regularly. The American Diabetes Association recommends you see your physician at least once a year. "Make sure that your health care provider checks you for numbness," Ross says. If the physician finds anything unusual, Ross says you are more likely to receive extra precautions to prevent future injury.
Treat pain aggressively. Be honest with your doctor about what you're feeling. "If you have any feeling of pain -- or a tingling or numbness sensation that might lead to pain -- and it's not well controlled, the prognosis for further pain is much higher," Ross says.
Where Does It Hurt?
It's difficult to remember all the things you're concerned about during your 10 or so minutes with a doctor -- but once you lie down in bed and put your feet under the covers, it's hard to forget the tingling pain in your toes. Print this Where It Hurts Worksheet to write down when and where you feel any sort of numbness, pain, tingling, or burning. Bring the sheet to your next checkup to discuss with your health care provider.