Those of you who read these monthly articles know that we have written about neuropathy before. You also know that I was given this diagnosis and treated with one of the medications we will mention in this article, to no avail. I finally saw a neurologist who diagnosed me with a degenerative spinal problem. A decompression operation later and I am running, lifting weights, and wonder of wonders, feeling just great. We add this so that you will make sure that you have differential diagnosis if you do not improve or you are not sure. Another fact to keep in mind is that as we age, we can have two medical problems, i.e. neuropathy and slipped discs. One doctor who sees lots of one diagnosis may tend to see many of the same. This month we will retell the story of this complication of diabetes.
There are three types of neuropathy: sensory, autonomic and motor. You might ask why talk about neuropathy again, and why how to treat it now? One of us is dealing with painful legs, and feet and has been diagnosed with the condition. If we need to know more, we presume that many of you do too. Lest you think you are exempt from the possibility of this complication, it is estimated that 60%-70% of we who have diabetes will have mild to severe forms of neuropathy.
Of these, sensory neuropathy is the most common, affecting our experience of temperature, touch, and pain. Autonomic neuropathy affects nerves involved in involuntary actions in the body such as emptying of the stomach, intestines and bladder. Motor neuropathy affects the nerves in movement, a condition that is rare in diabetes.
Please look back at articles on retinopathy, nephropathy, cardiovascular complications, gastroparesis, and hypertension. All of these complications have warranted their own articles in this What's Hot section of our monthly magazine... Distal neuropathy affects the hands and feet and is the most common form of diabetic neuropathy. It usually is bi-lateral, that is it affects both sides of the body, but it can affect only one side.
Diabetic amyotrophy affects the nerves in the thighs and may affect both legs. Charcot joint may occur if the bones in the feet develop fractures and the foot becomes misaligned. Because of neuropathy, you may not feel the pain of the fracture. The foot can then lose muscle support and may eventually become deformed.
Foot drop can be caused by neuropathy, or a slipped disc. It was one symptom of my classic L5 disc when my daughter was a baby and I had my first decompression. A foot drop is just that. You have difficulty lifting your foot or as with me, I could not lift my toes. It makes for tripping and is no fun.
Now, on to the treatment. Much of this information is gleamed from medical articles from journals, drug trial papers, and medical organizations like the ADA. and the AMA. Before I begin this section, it is important to know that there are many web sites that promise a "miracle" cure for tingling feet, numbness, and shooting pain of neuropathy with their rather expensive cures. The other day a very famous cancer physician was on the air and she said, if they (a site) are asking for your money or credit card, close it. She went on to say that pain can make us look for any way out, but that pain management is available and that we should look to science for answers, not to charlatans. This is not to say that just medication can be used to help. Massage, water therapy, and acupuncture have been used for pain relief, as have self hypnosis, relaxation techniques and TENS (See the first article on neuropathy). When you visit your physician, you will rate the pain from 1 to 10 with 10 being the worst. You can discuss all of your options from creams, to medications, to physical therapy. Get all the information available; make a Plan A, and a Plan B for the case that Plan A doesn't help.
When you make a plan with your physician, you will most likely be in the "control pain" mode. Some people have described neuropathy of the lower extremities as like pins and needles and numbness which can change to the shooting pain of icicles through your feet or legs. As the condition worsens, you may lose your ability to feel pain even when the neurologist pricks you with a pin during his medical examination. As with many complications of diabetes, people with symptoms of less than 6 months duration, which are associated with alterations in glycemic control, have a better prognosis when compared to people with chronic conditions lasting more than 6 months.
When I was first diagnosed with neuropathy the first drug of choice was Gabapentin, which is an anticonvulsant. I found more than a few research papers that show the benefit of using these medications. I found out that I had spinal deterioration when I went to join a research project for another anticonvulsant that is currently becoming popular. You will start low on these medications and build up to a therapeutic level for you, which will range form 900 to 3,600 mg per day for the Gabapentin. There are side effects to any medication so make sure you ask. In research it was found to be efficacious for the treatment of pain and sleep interference associated with diabetic peripheral neuropathy. It also exhibited a positive effect on mood and quality of life.
One of the most popular families of medications for neuropathy is tricyclic antidepressants, which have been studied over the years. They have been found to be reliable for relieving pain in people with and without depression. Arranged in order from the most potent anticholinergic effects, the most common medications are amitriptyline, imipramine, nortriptyline, and desipramine. This is good to know because if you have side effects on one tricyclic, you can try another. They are usually given at night starting low and building to a therapeutic dose. There is some research that serotonin reuptake inhibitors (SRI's) may benefit those with neuropathy. There is research on the efficacy of using fluoxetine.
Narcotic analgesics are often used to control the breakthrough of refractory pain. They are more controversial for the treatment of chronic pain because habituation usually occurs. They are sometimes used at night for sleep, but all patients should be warned not to raise the dose.
Non-steroidal anti-inflammatory drugs have been shown to be effective in controlling neuropathy in a number of studies. Ibuprofen and sulindac have been studied and have demonstrated their effectiveness in controlling pain. However, caution should be exercised when diabetics take these medications because of the risk of nephrotoxity, although in the studies of these anti-inflammatory medications none was noted.
Not all agents for pain control come in pill form. Topical capsaicin cream stimulates the release and subsequent depletion of substance P from sensory fibers. Studies on whether this cream works vary, with some positive results, and some showing no benefit from its use. Weighing the results of research, capsaicin cream appears to be effective for many people. Poor compliance is common with its use because it needs to be applied often, and frequently burns, causing initial exacerbation of symptoms and redness at the site of application.
According to the ADA, non-steroidal anti-inflammatory drugs offer pain relief. Tricyclic antidepressants remain a commonly used medication. After six weeks of treatment, many patients report significant relief independent of mood but correlating to increasing medication dosage. Topical creams can then be added if neuropathy pain persists. Anticonvulsants are also a first line medication with very good results. Now for the most important fact we can bring to you: If you do not improve, ask for a consultation with a specialist. I thank my lucky stars that I went to a neurologist for a second opinion because I had gotten to the point of being unable to stand, sit, walk, you name it. The pain continued to get worse and my ability to live any kind of life was greatly impaired. Taking Neurontin did not help, nor did the anti-inflammatory that I popped regularly. All they did was to allow me to nap and then the pain rebounded and I was worse off than before. Waking up from surgery and being able to walk, pain free was better than just about any thing I can think of, so do ask for the referral if you do not receive relief from medications and other interventions you and your physician decide on.
BSP
