Diabetic Neuropathies: The Nerve Damage of Diabetes - C...

Diabetic Neuropathies: The Nerve Damage of Diabetes

Diabetic Neuropathies: The Nerve Damage of Diabetes

diabetes.niddk.nih.gov

What are diabetic neuropathies?
Diabetic neuropathies are a family of nerve disorders caused by diabetes. People with diabetes can, over time, develop nerve damage throughout the body. Some people with nerve damage have no symptoms. Others may have symptoms such as pain, tingling, or numbness—loss of feeling—in the hands, arms, feet, and legs. Nerve problems can occur in every organ system, including the digestive tract, heart, and sex organs.

About 60 to 70 percent of people with diabetes have some form of neuropathy. People with diabetes can develop nerve problems at any time, but risk rises with age and longer duration of diabetes. The highest rates of neuropathy are among people who have had diabetes for at least 25 years. Diabetic neuropathies also appear to be more common in people who have problems controlling their blood glucose, also called blood sugar, as well as those with high levels of blood fat and blood pressure and those who are overweight.

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What causes diabetic neuropathies?
The causes are probably different for different types of diabetic neuropathy. Researchers are studying how prolonged exposure to high blood glucose causes nerve damage. Nerve damage is likely due to a combination of factors:

metabolic factors, such as high blood glucose, long duration of diabetes, abnormal blood fat levels, and possibly low levels of insulin
neurovascular factors, leading to damage to the blood vessels that carry oxygen and nutrients to nerves
autoimmune factors that cause inflammation in nerves
mechanical injury to nerves, such as carpal tunnel syndrome
inherited traits that increase susceptibility to nerve disease
lifestyle factors, such as smoking or alcohol use
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What are the symptoms of diabetic neuropathies?
Symptoms depend on the type of neuropathy and which nerves are affected. Some people with nerve damage have no symptoms at all. For others, the first symptom is often numbness, tingling, or pain in the feet. Symptoms are often minor at first, and because most nerve damage occurs over several years, mild cases may go unnoticed for a long time. Symptoms can involve the sensory, motor, and autonomic—or involuntary—nervous systems. In some people, mainly those with focal neuropathy, the onset of pain may be sudden and severe.

Symptoms of nerve damage may include

numbness, tingling, or pain in the toes, feet, legs, hands, arms, and fingers
wasting of the muscles of the feet or hands
indigestion, nausea, or vomiting
diarrhea or constipation
dizziness or faintness due to a drop in blood pressure after standing or sitting up
problems with urination
erectile dysfunction in men or vaginal dryness in women
weakness
Symptoms that are not due to neuropathy, but often accompany it, include weight loss and depression.

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What are the types of diabetic neuropathy?
Diabetic neuropathy can be classified as peripheral, autonomic, proximal, or focal. Each affects different parts of the body in various ways.

Peripheral neuropathy, the most common type of diabetic neuropathy, causes pain or loss of feeling in the toes, feet, legs, hands, and arms.
Autonomic neuropathy causes changes in digestion, bowel and bladder function, sexual response, and perspiration. It can also affect the nerves that serve the heart and control blood pressure, as well as nerves in the lungs and eyes. Autonomic neuropathy can also cause hypoglycemia unawareness, a condition in which people no longer experience the warning symptoms of low blood glucose levels.
Proximal neuropathy causes pain in the thighs, hips, or buttocks and leads to weakness in the legs.
Focal neuropathy results in the sudden weakness of one nerve or a group of nerves, causing muscle weakness or pain. Any nerve in the body can be affected.
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Neuropathy Affects Nerves Throughout the Body
Peripheral neuropathy affects

toes
feet
legs
hands
arms
Autonomic neuropathy affects

heart and blood vessels
digestive system
urinary tract
sex organs
sweat glands
eyes
lungs
Proximal neuropathy affects

thighs
hips
buttocks
legs
Focal neuropathy affects

eyes
facial muscles
ears
pelvis and lower back
chest
abdomen
thighs
legs
feet

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What is peripheral neuropathy?
Peripheral neuropathy, also called distal symmetric neuropathy or sensorimotor neuropathy, is nerve damage in the arms and legs. Your feet and legs are likely to be affected before your hands and arms. Many people with diabetes have signs of neuropathy that a doctor could note but feel no symptoms themselves. Symptoms of peripheral neuropathy may include

numbness or insensitivity to pain or temperature
a tingling, burning, or prickling sensation
sharp pains or cramps
extreme sensitivity to touch, even light touch
loss of balance and coordination
These symptoms are often worse at night.


Peripheral neuropathy affects the nerves in your toes, feet, legs, hands, and arms.
Peripheral neuropathy may also cause muscle weakness and loss of reflexes, especially at the ankle, leading to changes in the way a person walks. Foot deformities, such as hammertoes and the collapse of the midfoot, may occur. Blisters and sores may appear on numb areas of the foot because pressure or injury goes unnoticed. If foot injuries are not treated promptly, the infection may spread to the bone, and the foot may then have to be amputated. Some experts estimate that half of all such amputations are preventable if minor problems are caught and treated in time.

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What is autonomic neuropathy?
Autonomic neuropathy affects the nerves that control the heart, regulate blood pressure, and control blood glucose levels. Autonomic neuropathy also affects other internal organs, causing problems with digestion, respiratory function, urination, sexual response, and vision. In addition, the system that restores blood glucose levels to normal after a hypoglycemic episode may be affected, resulting in loss of the warning symptoms of hypoglycemia.


Autonomic neuropathy affects the nerves in your heart, stomach, intestines, bladder, sex organs, sweat glands, eyes, and lungs.
Hypoglycemia Unawareness
Normally, symptoms such as shakiness, sweating, and palpitations occur when blood glucose levels drop below 70 mg/dL. In people with autonomic neuropathy, symptoms may not occur, making hypoglycemia difficult to recognize. Problems other than neuropathy can also cause hypoglycemia unawareness. For more information about hypoglycemia, see the fact sheet Hypoglycemia at www.diabetes.niddk.nih.gov/dm/pubs/hypoglycemia.

Heart and Blood Vessels
The heart and blood vessels are part of the cardiovascular system, which controls blood circulation. Damage to nerves in the cardiovascular system interferes with the body’s ability to adjust blood pressure and heart rate. As a result, blood pressure may drop sharply after sitting or standing, causing a person to feel light-headed or even to faint. Damage to the nerves that control heart rate can mean that your heart rate stays high, instead of rising and falling in response to normal body functions and physical activity.

Digestive System
Nerve damage to the digestive system most commonly causes constipation. Damage can also cause the stomach to empty too slowly, a condition called gastroparesis. Severe gastroparesis can lead to persistent nausea and vomiting, bloating, and loss of appetite. Gastroparesis can also make blood glucose levels fluctuate widely, due to abnormal food digestion. For more information, see the fact sheet Gastroparesis at www.digestive.niddk.nih.gov/ddiseases/pubs/gastroparesis.

Nerve damage to the esophagus may make swallowing difficult, while nerve damage to the bowels can cause constipation alternating with frequent, uncontrolled diarrhea, especially at night. Problems with the digestive system can lead to weight loss.

Urinary Tract and Sex Organs
Autonomic neuropathy often affects the organs that control urination and sexual function. Nerve damage can prevent the bladder from emptying completely, allowing bacteria to grow in the bladder and kidneys and causing urinary tract infections. When the nerves of the bladder are damaged, urinary incontinence may result because a person may not be able to sense when the bladder is full or control the muscles that release urine.

Autonomic neuropathy can also gradually decrease sexual response in men and women, although the sex drive may be unchanged. A man may be unable to have erections or may reach sexual climax without ejaculating normally. A woman may have difficulty with arousal, lubrication, or orgasm.

For more information, see the fact sheets Nerve Disease and Bladder Control and Sexual and Urologic Problems of Diabetes at www.kidney.niddk.nih.gov.

Sweat Glands
Autonomic neuropathy can affect the nerves that control sweating. When nerve damage prevents the sweat glands from working properly, the body cannot regulate its temperature as it should. Nerve damage can also cause profuse sweating at night or while eating.

Eyes
Finally, autonomic neuropathy can affect the pupils of the eyes, making them less responsive to changes in light. As a result, a person may not be able to see well when a light is turned on in a dark room or may have trouble driving at night.

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What is proximal neuropathy?
Proximal neuropathy, sometimes called lumbosacral plexus neuropathy, femoral neuropathy, or diabetic amyotrophy, starts with pain in the thighs, hips, buttocks, or legs, usually on one side of the body. This type of neuropathy is more common in those with type 2 diabetes and in older adults with diabetes. Proximal neuropathy causes weakness in the legs and the inability to go from a sitting to a standing position without help. Treatment for weakness or pain is usually needed. The length of the recovery period varies, depending on the type of nerve damage.

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What is focal neuropathy?
Focal neuropathy appears suddenly and affects specific nerves, most often in the head, torso, or leg. Focal neuropathy may cause

inability to focus the eye
double vision
aching behind one eye
paralysis on one side of the face, called Bell’s palsy
severe pain in the lower back or pelvis
pain in the front of a thigh
pain in the chest, stomach, or side
pain on the outside of the shin or inside of the foot
chest or abdominal pain that is sometimes mistaken for heart disease, a heart attack, or appendicitis
Focal neuropathy is painful and unpredictable and occurs most often in older adults with diabetes. However, it tends to improve by itself over weeks or months and does not cause long-term damage.

People with diabetes also tend to develop nerve compressions, also called entrapment syndromes. One of the most common is carpal tunnel syndrome, which causes numbness and tingling of the hand and sometimes muscle weakness or pain. Other nerves susceptible to entrapment may cause pain on the outside of the shin or the inside of the foot.

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How can I prevent diabetic neuropathies?
The best way to prevent neuropathy is to keep your blood glucose levels as close to the normal range as possible. Maintaining safe blood glucose levels protects nerves throughout your body.

For additional information about preventing diabetes complications, including neuropathy, see the Prevent Diabetes Problems Series at www.diabetes.niddk.nih.gov/dm/pubs/complications.

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How are diabetic neuropathies diagnosed?
Doctors diagnose neuropathy on the basis of symptoms and a physical exam. During the exam, your doctor may check blood pressure, heart rate, muscle strength, reflexes, and sensitivity to position changes, vibration, temperature, or light touch.

Foot Exams
Experts recommend that people with diabetes have a comprehensive foot exam each year to check for peripheral neuropathy. People diagnosed with peripheral neuropathy need more frequent foot exams. A comprehensive foot exam assesses the skin, muscles, bones, circulation, and sensation of the feet. Your doctor may assess protective sensation or feeling in your feet by touching your foot with a nylon monofilament—similar to a bristle on a hairbrush—attached to a wand or by pricking your foot with a pin. People who cannot sense pressure from a pinprick or monofilament have lost protective sensation and are at risk for developing foot sores that may not heal properly. The doctor may also check temperature perception or use a tuning fork, which is more sensitive than touch pressure, to assess vibration perception.

Other Tests
The doctor may perform other tests as part of your diagnosis.

Nerve conduction studies or electromyography are sometimes used to help determine the type and extent of nerve damage. Nerve conduction studies check the transmission of electrical current through a nerve. Electromyography shows how well muscles respond to electrical signals transmitted by nearby nerves. These tests are rarely needed to diagnose neuropathy.
A check of heart rate variability shows how the heart responds to deep breathing and to changes in blood pressure and posture.
Ultrasound uses sound waves to produce an image of internal organs. An ultrasound of the bladder and other parts of the urinary tract, for example, can show how these organs preserve a normal structure and whether the bladder empties completely after urination.
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How are diabetic neuropathies treated?
The first treatment step is to bring blood glucose levels within the normal range to help prevent further nerve damage. Blood glucose monitoring, meal planning, physical activity, and diabetes medicines or insulin will help control blood glucose levels. Symptoms may get worse when blood glucose is first brought under control, but over time, maintaining lower blood glucose levels helps lessen symptoms. Good blood glucose control may also help prevent or delay the onset of further problems. As scientists learn more about the underlying causes of neuropathy, new treatments may become available to help slow, prevent, or even reverse nerve damage.

As described in the following sections, additional treatment depends on the type of nerve problem and symptom. If you have problems with your feet, your doctor may refer you to a foot care specialist.

Pain Relief
Doctors usually treat painful diabetic neuropathy with oral medications, although other types of treatments may help some people. People with severe nerve pain may benefit from a combination of medications or treatments. Talk with your health care provider about options for treating your neuropathy.

Medications used to help relieve diabetic nerve pain include

tricyclic antidepressants, such as amitriptyline, imipramine, and desipramine (Norpramin, Pertofrane)
other types of antidepressants, such as duloxetine (Cymbalta), venlafaxine, bupropion (Wellbutrin), paroxetine (Paxil), and citalopram (Celexa)
anticonvulsants, such as pregabalin (Lyrica), gabapentin (Gabarone, Neurontin), carbamazepine, and lamotrigine (Lamictal)
opioids and opioid-like drugs, such as controlled-release oxycodone, an opioid; and tramadol (Ultram), an opioid that also acts as an antidepressant
Duloxetine and pregabalin are approved by the U.S. Food and Drug Administration specifically for treating painful diabetic peripheral neuropathy.

You do not have to be depressed for an antidepressant to help relieve your nerve pain. All medications have side effects, and some are not recommended for use in older adults or those with heart disease. Because over-the-counter pain medicines such as acetaminophen and ibuprofen may not work well for treating most nerve pain and can have serious side effects, some experts recommend avoiding these medications.

Treatments that are applied to the skin—typically to the feet—include capsaicin cream and lidocaine patches (Lidoderm, Lidopain). Studies suggest that nitrate sprays or patches for the feet may relieve pain. Studies of alpha-lipoic acid, an antioxidant, and evening primrose oil have shown that they can help relieve symptoms and may improve nerve function.

A device called a bed cradle can keep sheets and blankets from touching sensitive feet and legs. Acupuncture, biofeedback, or physical therapy may help relieve pain in some people. Treatments that involve electrical nerve stimulation, magnetic therapy, and laser or light therapy may be helpful but need further study. Researchers are also studying several new therapies in clinical trials.

Gastrointestinal Problems
To relieve mild symptoms of gastroparesis—indigestion, belching, nausea, or vomiting—doctors suggest eating small, frequent meals; avoiding fats; and eating less fiber. When symptoms are severe, doctors may prescribe erythromycin to speed digestion, metoclopramide to speed digestion and help relieve nausea, or other medications to help regulate digestion or reduce stomach acid secretion.

To relieve diarrhea or other bowel problems, doctors may prescribe an antibiotic such as tetracycline, or other medications as appropriate.

Dizziness and Weakness
Sitting or standing slowly may help prevent the light-headedness, dizziness, or fainting associated with blood pressure and circulation problems. Raising the head of the bed or wearing elastic stockings may also help. Some people benefit from increased salt in the diet and treatment with salt-retaining hormones. Others benefit from high blood pressure medications. Physical therapy can help when muscle weakness or loss of coordination is a problem.

Urinary and Sexual Problems
To clear up a urinary tract infection, the doctor will probably prescribe an antibiotic. Drinking plenty of fluids will help prevent another infection. People who have incontinence should try to urinate at regular intervals—every 3 hours, for example—since they may not be able to tell when the bladder is full.

To treat erectile dysfunction in men, the doctor will first do tests to rule out a hormonal cause. Several methods are available to treat erectile dysfunction caused by neuropathy. Medicines are available to help men have and maintain erections by increasing blood flow to the penis. Some are oral medications and others are injected into the penis or inserted into the urethra at the tip of the penis. Mechanical vacuum devices can also increase blood flow to the penis. Another option is to surgically implant an inflatable or semirigid device in the penis.

Vaginal lubricants may be useful for women when neuropathy causes vaginal dryness. To treat problems with arousal and orgasm, the doctor may refer women to a gynecologist.

Foot Care
People with neuropathy need to take special care of their feet. The nerves to the feet are the longest in the body and are the ones most often affected by neuropathy. Loss of sensation in the feet means that sores or injuries may not be noticed and may become ulcerated or infected. Circulation problems also increase the risk of foot ulcers.

More than half of all lower-limb amputations in the United States occur in people with diabetes—86,000 amputations per year. Doctors estimate that nearly half of the amputations caused by neuropathy and poor circulation could have been prevented by careful foot care.

Follow these steps to take care of your feet:

Clean your feet daily, using warm—not hot—water and a mild soap. Avoid soaking your feet. Dry them with a soft towel and dry carefully between your toes.
Inspect your feet and toes every day for cuts, blisters, redness, swelling, calluses, or other problems. Use a mirror—laying a mirror on the floor works well—or get help from someone else if you cannot see the bottoms of your feet. Notify your health care provider of any problems.
Moisturize your feet with lotion, but avoid getting the lotion between your toes.
After a bath or shower, file corns and calluses gently with a pumice stone.
Each week or when needed, cut your toenails to the shape of your toes and file the edges with an emery board.
Always wear shoes or slippers to protect your feet from injuries. Prevent skin irritation by wearing thick, soft, seamless socks.
Wear shoes that fit well and allow your toes to move. Break in new shoes gradually by first wearing them for only an hour at a time.
Before putting your shoes on, look them over carefully and feel the insides with your hand to make sure they have no tears, sharp edges, or objects in them that might injure your feet.
If you need help taking care of your feet, make an appointment to see a foot doctor, also called a podiatrist.
For additional information about foot care, contact the National Diabetes Information Clearinghouse at 1–800–860–8747 . See the publication Prevent diabetes problems: Keep your feet and skin healthy at www.diabetes.niddk.nih.gov/dm/pubs/complications_feet. Materials are also available from the National Diabetes Education Program, including the fact sheet Take Care of Your Feet for a Lifetime at www.ndep.nih.gov/campaigns/Feet/Feet_overview.htm.

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Points to Remember
Diabetic neuropathies are nerve disorders caused by many of the abnormalities common to diabetes, such as high blood glucose.
Neuropathy can affect nerves throughout the body, causing numbness and sometimes pain in the hands, arms, feet, or legs, and problems with the digestive tract, heart, sex organs, and other body systems.
Treatment first involves bringing blood glucose levels within the normal range. Good blood glucose control may help prevent or delay the onset of further problems.
Foot care is an important part of treatment. People with neuropathy need to inspect their feet daily for any injuries. Untreated injuries increase the risk of infected foot sores and amputation.
Treatment also includes pain relief and other medications as needed, depending on the type of nerve damage.
Smoking significantly increases the risk of foot problems and amputation. If you smoke, ask your health care provider for help with quitting.
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Hope through Research
The National Institute of Diabetes and Digestive and Kidney Diseases conducts and supports research to help people with diabetes. A complete listing of clinical research studies, including those related to diabetic neuropathies, can be found at www.ClinicalTrials.gov.

The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this document are used only because they are considered necessary in the context of the information provided. If a product is not mentioned, the omission does not mean or imply that the product is unsatisfactory.

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For More Information
For more information, contact the following organizations:

American Diabetes Association
1701 North Beauregard Street
Alexandria, VA 22311
Phone: 1–800–DIABETES (342–2383)
Email: AskADA@diabetes.org
Internet: www.diabetes.org

American Urological Association Foundation
1000 Corporate Boulevard
Linthicum, MD 21090
Phone: 1–866–RING–AUA (746–4282)
or 410–689–3700
Fax: 410–689–3800
Email: patienteducation@auafoundation.org
Internet: www.auafoundation.org
www.UrologyHealth.org

American Podiatric Medical Association
9312 Old Georgetown Road
Bethesda, MD 20814–1621
Phone: 1–800–FOOTCARE (366–8227)
or 301–581–9200
Fax: 301–530–2752
Email: askapma@apma.org
Internet: www.apma.org

Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
Division of Diabetes Translation
4770 Buford Highway NE, Mail Stop K–10
Atlanta, GA 30341–3717
Phone: 1–800–CDC–INFO (232–4636) or 770–488–5000
Email: cdcinfo@cdc.gov
Internet: www.cdc.gov/diabetes

Juvenile Diabetes Research Foundation International
120 Wall Street
New York, NY 10005–4001
Phone: 1–800–533–CURE (2873)
Fax: 212–785–9595
Email: info@jdrf.org
Internet: www.jdrf.org

Lower Extremity Amputation Prevention Program
Health Resources and Services Administration
5600 Fishers Lane
Rockville, MD 20857
Phone: 1–888–ASK–HRSA (275–4772)
Internet: www.hrsa.gov/leap

National Diabetes Education Program
1 Diabetes Way
Bethesda, MD 20892–3560
Phone: 1–800–438–5383
Fax: 703–738–4929
Email: ndep@mail.nih.gov
Internet: www.ndep.nih.gov

National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD 20892–3570
Phone: 1–800–891–5389
Fax: 703–738–4929
Email: nddic@info.niddk.nih.gov
Internet: www.digestive.niddk.nih.gov

National Heart, Lung, and Blood Institute Information Center
P.O. Box 30105
Bethesda, MD 20824–0105
Phone: 301–592–8573
Fax: 240–629–3246
Email: nhlbiinfo@nhlbi.nih.gov
Internet: www.nhlbi.nih.gov

National Institute of Neurological Disorders and Stroke
P.O. Box 5801
Bethesda, MD 20824
Phone: 1–800–352–9424 or 301–496–5751
Internet: www.ninds.nih.gov

National Kidney and Urologic Diseases Information Clearinghouse
3 Information Way
Bethesda, MD 20892–3580
Phone: 1–800–891–5390
Fax: 703–738–4929
Email: nkudic@info.niddk.nih.gov
Internet: www.kidney.niddk.nih.gov

Pedorthic Footwear Association
2025 M Street NW, Suite 800
Washington, DC 20036
Phone: 1–800–673–8447 or 202–367–1145
Fax: 202–367–2145
Email: info@pedorthics.org
Internet: www.pedorthics.org

The National Diabetes Information Clearinghouse collects resource information about diabetes for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Reference Collection. This database provides titles, abstracts, and availability information for health information and health education resources. The NIDDK Reference Collection is a service of the National Institutes of Health.

You may view the results of the automatic search on diabetic neuropathy.

If you wish to perform your own search of the database, you may access and search the NIDDK Reference Collection database online.

National Diabetes Information Clearinghouse
1 Information Way
Bethesda, MD 20892–3560
Phone: 1–800–860–8747
TTY: 1–866–569–1162
Fax: 703–738–4929
Email: ndic@info.niddk.nih.gov
Internet: www.diabetes.niddk.nih.gov

The National Diabetes Information Clearinghouse (NDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1978, the Clearinghouse provides information about diabetes to people with diabetes and to their families, health care professionals, and the public. The NDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about diabetes.

This publication was originally reviewed by Peter J. Dyck, M.D., Peripheral Neuropathy Research Laboratory, Mayo Clinic Rochester, Rochester, MN; Eva L. Feldman, M.D., Ph.D., Department of Neurology, University of Michigan, Ann Arbor, MI; and Aaron I. Vinik, M.D., Ph.D., Strelitz Diabetes Research Institute, Eastern Virginia Medical School, Norfolk, VA. Dr. Feldman also reviewed the updated version of the publication.

This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.

NIH Publication No. 08–3185
February 2008