Diabetic Neuropathy

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What is diabetic neuropathy?

Diabetic neuropathy is a nerve disorder commonly caused by diabetes. Over time, high blood sugar levels from diabetes can damage nerves throughout your body.

There are several types of diabetic neuropathy.

• Peripheral neuropathy is from damage to the peripheral nervous system. It reduces your ability to sense pain, touch, temperature, and vibration in certain parts of the body and may sometimes affect movement and muscle strength. It most often affects the feet and lower legs and may contribute to serious foot problems, such as ulcers, infection, and bone and joint deformities. It is the most common form of diabetic neuropathy.
• Autonomic neuropathy is from damage to the autonomic nervous system. These nerves control the involuntary functions of your body, such as heartbeat, blood pressure, sweating, digestion, urination, and some aspects of sexual function. This is also a common form of diabetic neuropathy.
• Focal neuropathy affects a single nerve, most often in the wrist, thigh, or foot. It may also affect the nerves of the back and chest and those that control the eye muscles. Focal neuropathy usually develops suddenly.

What causes diabetic neuropathy?

Over time, high blood sugar levels from diabetes can damage nerves throughout your body. The higher your blood sugar levels, the greater your risk of getting neuropathy. The risk of nerve damage also increases as you age and the longer you have diabetes. Excessive use of alcohol may further increase the risk. Around 50% of people who have diabetes will eventually get diabetic neuropathy.¹

What are the symptoms?

Symptoms vary according to which nerves are injured. Diabetic neuropathy can interrupt the normal flow of nerve signals through the legs, arms, and other parts of the body. This may limit your ability to feel pain, which is one way the body protects itself against injury. The sensation of pain tells your brain to pull your hand off a hot stove or to remove the rock from your shoe.

When the internal organs and body systems are affected by neuropathy, it can cause:

• Digestive system problems, such as frequent bloating, belching, constipation, nausea and vomiting, diarrhea, and abdominal pain.
• Temperature regulation problems, such as profuse sweating of the torso, face, or neck at night or while eating certain foods, such as spicy foods and cheese. Alternatively, some people may have reduced sweating, especially in their feet and legs.
• Urinary system problems, such as difficulty sensing when the bladder is full or difficulty emptying the bladder completely.
• Sexual problems, such as erection problems in men and vaginal dryness in women.
• Heart and blood vessel problems, leading to poor circulation or low blood pressure. This may cause dizziness, weakness, or fainting when you stand or sit up from a reclining position.
• Difficulty sensing when your blood sugar is low.

How is diabetic neuropathy diagnosed?

A diagnosis of diabetic neuropathy is based largely on your symptoms, your medical history, and a neurologic examination. This means your doctor will check how well you feel touch and temperature. Your doctor will also test your strength and your reflexes. Tests such as electromyogram (EMG) and nerve conduction studies may be done to confirm the diagnosis. Additional tests may be needed to identify which type of neuropathy you have and the organ or system affected, and to help guide treatment.

How is it treated?

There is no cure for diabetic neuropathy. Treatment focuses on slowing the progression of the disease by consistently keeping your blood sugar levels within a narrow and tightly controlled target range and taking proper care of your feet to keep them free from sores and infections. Tight blood sugar control means a hemoglobin A1C (HbA1C) level near normal. Your doctor will be able to tell you what normal is.

Treatment will be tailored to your symptoms.

• Medicines may be used to relieve pain associated with peripheral neuropathy.
• Medicines for digestive system problems or blood vessel problems, elastic stockings, and devices to improve erections or lubricating creams for vaginal dryness may be prescribed for autonomic neuropathy.
• Treatment for focal neuropathy may include a splint or brace for a compressed nerve.

Can diabetic neuropathy be prevented?

Keeping your blood sugar levels near normal may help prevent neuropathy from ever developing. The best way to do this is by getting to and staying at a healthy weight. Exercising and eating healthy foods are the best things you can do to prevent complications from diabetes. If you have diabetic neuropathy, it is important to take care of your feet and keep your blood sugar levels within a narrow target range. By taking care of yourself, you may prevent neuropathy from becoming worse. For more information on prevention, see the topics Type 1 Diabetes: Living With the Disease or Type 2 Diabetes: Living With the Disease.

Frequently Asked Questions

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	Foot care for people with diabetes

Diabetic neuropathy—especially peripheral neuropathy—initially may not cause any noticeable symptoms. If you have diabetes, it is important to have regular medical checkups to check for signs of neuropathy and treat problems before they become serious.

Symptoms of diabetic neuropathy may vary depending on the type of neuropathy you have.

Symptoms of peripheral neuropathy

Peripheral neuropathy tends to develop slowly over months or years. Symptoms may get worse during pregnancy. Generally, symptoms may include:

• Tingling, numbness, tightness, or burning, shooting, or stabbing pain in the feet, hands, or other parts of the body. Bone and joint deformities can develop, especially of the feet (such as Charcot foot). See an illustration of Charcot foot .
• Reduced feeling or numbness, most often in the feet. Check your feet every day for skin problems (chapped, broken skin or excessive dryness) or minor injuries (blisters, calluses, or ingrown toenails). People who have had diabetes 10 or more years, have poor blood sugar control, or have blood vessel, kidney, or eye complications are at increased risk for foot and leg sores and possible amputation.
• Greatly reduced or greatly increased sensitivity to light touch or temperature.
• Weakness and loss of balance and coordination.

Symptoms of autonomic neuropathy

Autonomic neuropathy may affect digestion, the body's ability to regulate temperature, urination, sexual function, and heart and blood vessel function, including blood pressure. Symptoms may get worse during pregnancy. Symptoms generally may include:

• Frequent bloating, belching, constipation, heartburn, nausea and vomiting, diarrhea, and abdominal pain. These symptoms may indicate gastroparesis, a condition that causes the stomach to empty much slower than normal.
• Profuse sweating of the torso, face, or neck at night or while eating certain foods, such as spicy foods and cheese. Alternatively, some people may have reduced sweating, especially in their feet and legs.
• Difficulty sensing when the bladder is full or difficulty emptying the bladder completely.
• Sexual problems, such as erection problems in men and vaginal dryness in women.
• Dizziness, weakness, or fainting when you stand or sit up from a reclining position (orthostatic hypotension).
• Difficulty knowing when your blood sugar is low (hypoglycemia unawareness).

Symptoms of focal neuropathy

Symptoms of focal neuropathy usually appear suddenly. They may include:

• Pain, weakness, and motor problems in a single area of the body, such as a wrist, thigh, or foot. In cases of a compressed or pinched nerve, soreness and pain may develop more gradually over several weeks or months.
• Pain in and around one of your eyes, difficulty moving the eyes, and double vision. Focal neuropathy may sometimes affect the nerves that control your eye muscles.

Symptoms of focal neuropathy usually get better over time. But focal neuropathy may be permanent.

A diagnosis of diabetic neuropathy is based largely on your symptoms, medical history, and neurologic examination. During a neurologic exam, your doctor will check how well you feel touch and temperature. Your doctor will also check your strength and reflexes. Electromyogram (EMG) and nerve conduction studies may be done to confirm a diagnosis. These tests measure how well and how quickly the nerves and muscles conduct electrical impulses. When nerve damage is present, the speed of nerve function slows.

Problems associated with autonomic neuropathy—which affects the nerves that control internal functions—can be difficult to diagnose. When new symptoms develop, further testing may be needed to diagnose the problem, identify the cause, and guide treatment. For example, a study that measures how fast your stomach empties may be done if symptoms like bloating, indigestion, or vomiting suggest gastroparesis, a condition that causes the stomach to take too long to empty.

Nerve problems in people with diabetes may be caused by other conditions, such as kidney disease, alcohol dependence, or a vitamin B₁₂ deficiency. A variety of laboratory tests (such as a complete blood count) may be used to screen for conditions other than diabetes that could be causing symptoms. Your symptoms and medical history will determine which tests are needed.

Early Detection

For some diseases, doctors can use screening tests to look for problems before you have any symptoms. But doctors cannot test for all types of autonomic or focal neuropathy. So it is important to report to your doctor any pain, weakness, or motor problems you have. Also mention any changes in digestion, urination, sexual function, sweating, or dizziness. Your doctor will also look for signs of autonomic neuropathy during your physical exams.

Screening for peripheral neuropathy can help prevent foot ulcers and amputation. The American Diabetes Association (ADA) recommends people with diabetes see a health professional to examine their feet for cracked or peeling skin, excessive or reduced sweating, blisters, calluses, ulcers, signs of infection, bone and joint abnormalities, and walking and balance during each medical visit. The ADA also recommends a complete foot exam by a health professional at least once a year.² This examination can detect a loss of sensation in your feet, which can lead to more serious foot problems.

There is currently no cure for diabetic neuropathy. When you have it, treatment is about keeping the disease from getting worse. Good control of diabetes over time is the key to treating neuropathy. Getting to and staying at a healthy weight is a good start.

To help control your diabetes, exercise and eat food that is good for you. Controlling diabetes means maintaining blood sugar levels within the target range (near normal hemoglobin A1C [HbA1C] levels). This will do more to help diabetic neuropathy than anything else.

For more information on good diabetes control, see the topics Type 1 Diabetes: Living With the Disease or Type 2 Diabetes: Living With the Disease.

Initial treatment

Treatment for diabetic neuropathy depends on your symptoms and the type of neuropathy that you have. Generally, treatment focuses on reducing current symptoms and preventing the condition from worsening by keeping your blood sugar level within a narrow target range (hemoglobin A1C [HbA1C] levels near normal). You can keep your blood sugar levels within the target range by taking your insulin or oral diabetes medicine as prescribed, checking your blood sugar level often, following your diet for diabetes, exercising, and seeing your health professional regularly. For more information, see the topics Type 1 Diabetes: Living With the Disease or Type 2 Diabetes: Living With the Disease.

In addition, it is important to properly care for your feet when you have diabetic neuropathy. This condition may cause a loss of feeling in your feet. It is possible for a sore or other foot problem to go unnoticed. Without proper foot care, an untreated foot sore can lead to a serious infection or possibly amputation.³ For more information, see:

Foot care for people with diabetes.

It is also wise to maintain healthy habits such as seeing your doctor regularly, controlling your blood pressure, eating a balanced diet, exercising regularly, not smoking, and limiting your alcohol use. Additional treatment depends on the specific type of diabetic neuropathy that you have along with your current symptoms.

Many people with peripheral neuropathy have mild to severe pain in specific parts of their bodies. Talk with your health professional about treatment that can reduce your pain and improve your physical functioning, mood, and mental well-being. These treatments may include:

• Medicines such as pain relievers or creams to relieve pain. Prescription medicines often used to reduce pain from diabetic neuropathy may include medicines that are more commonly used to treat depression, such as tricyclic antidepressants and the antidepressant duloxetine hydrochloride, and medicines that control seizures, such as pregabalin and gabapentin. These medicines may be tried to reduce your pain even though you do not have depression or seizures.
• Complementary therapies such as acupuncture. Acupuncture has not been well studied as a treatment for diabetic neuropathy. But some studies show that it may help with pain.
• Physical therapy such as exercises, stretching, and massage. If you are told to use heat or ice, be careful. Neuropathy can make it hard for you to feel changes in temperature.
• Transcutaneous electrical nerve stimulation (TENS), which is a type of therapy that attempts to reduce pain by applying brief pulses of electricity to nerve endings in the skin.

Autonomic neuropathy—which affects nerves that regulate internal functions—can affect digestion, urination, sweating, sexual function, blood pressure, and other involuntary body functions. Some symptoms of autonomic neuropathy can be hard to manage, but others respond well to treatment:

• Mild constipation. Eating small, frequent meals that are high in fiber and low in fat may help.
• Frequent diarrhea. Eating foods that are high in fiber may help. You may need medicines that slow the rate at which digested food and waste travel through the intestines or antibiotics such as tetracycline, amoxicillin, or metronidazole.
• Mild gastroparesis. This is a condition that causes the stomach to empty very slowly. It may get better if you eat small, frequent meals that are low in fiber and fat. Medicines that help the stomach empty more quickly may also be needed. Controlling blood sugar levels may reduce symptoms of gastroparesis.⁴
• Abnormal sweating. If you sweat a lot, try to avoid intense heat and humidity. If you sweat severely while eating certain foods, anticholinergic medicines may help. However, these medicines have side effects that may sometimes be more troublesome than the abnormal sweating. Botulinum toxin (Botox) injections may also help.⁵ If you don't sweat enough, you can use moisturizers to help with dry or cracked skin. Drinking more water can prevent overheating. Try to avoid places that are very hot or very cold.
• Lack of awareness of low blood sugar level. This is also called hypoglycemia unawareness. You can adjust your insulin and allow your blood sugar levels to be a little bit higher than the normal range. Normally, it is recommended that you keep your hemoglobin A1C (HbA1C) at near normal levels.
• Urinary problems.Urinary problems can be treated with antibiotics for urinary tract infections and medicines to improve bladder control.
• Sexual problems. Your doctor may suggest using medicines or devices to improve erections. Or you may need nonprescription lubricants and estrogen creams for vaginal dryness. For more information, see sexual problems.
• Blood pressure problems. Wearing elastic stockings and taking medicines can help if you have blood pressure problems.

Ongoing treatment

Ongoing treatment for diabetic neuropathy includes making sure your blood sugar levels stay tightly controlled within a narrow target range. Tight blood sugar control means a near normal level of hemoglobin A1C (HbA1C). You also need to maintain wise health habits such as seeing your doctor regularly, controlling your blood pressure, getting regular exercise, limiting alcohol use, and not smoking. Also, take good care of your feet so that foot sores and other foot problems do not develop. For more information, see:

Foot care for people with diabetes.

Other treatment is tailored to your specific symptoms and the type of diabetic neuropathy that you have.

Many people with peripheral neuropathy—which affects nerves that supply sensation and touch—have mild to severe pain in specific parts of their bodies. Treatment can reduce pain and improve physical functioning, mood, and mental well-being and may include:

• Medicines such as nonprescription pain relievers or creams to relieve pain. The most common medicines used to treat symptoms of diabetic neuropathy include anticonvulsant drugs such as pregabalin and gabapentin, tricyclic antidepressants, and the antidepressant duloxetine hydrochloride.
• Complementary therapies such as acupuncture. Acupuncture has not been well studied as a treatment for diabetic neuropathy. But some studies show that it may help with pain.
• Physical therapy such as exercises, stretching, and massage. If you are told to use heat or ice, be careful. Neuropathy makes it hard for you to feel changes in temperature.
• Transcutaneous electrical nerve stimulation (TENS), which is a type of therapy that attempts to reduce pain by applying brief pulses of electricity to nerve endings in the skin.

Autonomic neuropathy—which affects nerves that regulate internal functions—can cause problems with digestion, urination, sweating, sexual function, blood pressure, and other involuntary body functions. Some symptoms of autonomic neuropathy can be hard to manage, but others respond well to treatment:

• Mild constipation. Eating small, frequent meals that are high in fiber and low in fat may help.
• Frequent diarrhea. Eating foods that are high in fiber may help. You may need medicines that slow the rate at which digested food and waste travel through the intestines or antibiotics such as tetracycline, amoxicillin, or metronidazole.
• Mild gastroparesis. This is a condition that causes the stomach to empty very slowly. It may get better if you eat small, frequent meals that are low in fiber and fat. Medicines that help the stomach empty more quickly may also be needed. Controlling blood sugar levels may reduce symptoms of gastroparesis.⁴
• Abnormal sweating. If you sweat a lot, try to avoid intense heat and humidity. If you sweat severely while eating certain foods, anticholinergic medicines may help. However, these medicines have side effects that may sometimes be more troublesome than the abnormal sweating. Botulinum toxin (Botox) injections may also help.⁵ If you don't sweat enough, you can use moisturizers to help with dry or cracked skin. Drinking more water can prevent overheating. Try to avoid places that are very hot or very cold.
• Lack of awareness of low blood sugar level. This is also called hypoglycemia unawareness. You can adjust your insulin and allow your blood sugar levels to be a little bit higher than the normal range. Normally, it is recommended that you keep your hemoglobin A1C (HbA1C) near normal.
• Urinary problems.Urinary problems can be treated with antibiotics for urinary tract infections and medicines to improve bladder control.
• Sexual problems. Your doctor may suggest using medicines or devices to improve erections. Or you may need nonprescription lubricants and estrogen creams for vaginal dryness. For more information, see sexual problems.
• Blood pressure problems. Wearing elastic stockings and taking medicines can help if you have blood pressure problems.

Treatment if the condition gets worse

If diabetic neuropathy gets worse, you may have serious problems such as severe gastroparesis, bladder infections, or foot problems. In addition to striving for tightly controlled target range blood sugar levels (hemoglobin A1C [HbA1C] near normal) and taking good care of your feet, you may need further treatment if diabetic neuropathy progresses.

Diabetic neuropathy is a major risk factor for foot infections or foot ulcers leading to amputation.³ It is possible to have permanent disfigurement in one or both of your feet—Charcot foot—from diabetic neuropathy. Surgery is sometimes needed to correct deformed joints that can result from Charcot foot. See an illustration of Charcot foot .

Severe gastroparesis may require other treatment, such as medicines that empty the stomach more quickly or the insertion of a feeding tube into the stomach.⁴

Severe bladder infections or other bladder problems, such as loss of control, may require further diagnostic testing and treatments such as medicines or surgery to improve bladder function.

In addition, it is common to experience symptoms of depression with any chronic disease, such as diabetes or diabetic neuropathy. Seeking help for depression may improve your overall well-being and aid in the treatment of your condition.

What To Think About

No matter what you or your doctor try, you may not be pain-free. Be clear with your doctor about what is helping and what is not. You and your doctor can work together to find the right combination of medicine and other treatments to help you the most.

FDA Advisory. The U.S. Food and Drug Administration (FDA) has issued an advisory on antidepressant medicines and the risk of suicide. The FDA does not recommend that people stop using these medicines. Instead, a person taking antidepressants should be watched for warning signs of suicide. This is especially important at the beginning of treatment or when doses are changed.

The FDA also advises that patients be observed for increases in anxiety, panic attacks, agitation, irritability, insomnia, impulsivity, hostility, and mania.

In addition to having regular medical checkups, the best way to avoid the progression of diabetic neuropathy is to control your blood sugar, take good care of your feet, and practice wise health habits.

Control your blood sugar level

The single most important step you can take to prevent the development and progression of diabetic neuropathy is to keep your blood sugar level consistently within a tightly controlled and narrow target range. Tight blood sugar control means a near normal level of hemoglobin A1C (HbA1C).

Keeping your blood sugar level within the target range also helps decrease your chances of getting other complications from diabetes, such as eye disease and kidney problems. For more information, see the topic Type 1 Diabetes: Living With the Disease or Type 2 Diabetes: Living With the Disease.

Take care of your feet

Diabetic neuropathy affects the feet more often than any other part of the body. Diabetes interferes with your body's ability to fight infection, so that even a minor foot injury, such as a blister or scratch, or athlete's foot can lead to serious infections or amputation. However, serious foot problems are the most preventable complications of diabetes.

Because the nerve damage caused by diabetic neuropathy may make you less likely to notice minor problems with your feet, it is wise to inspect your feet every day. Protect them from injury by wearing properly fitted shoes and socks at all times. If vision problems from diabetic retinopathy or another eye disease make it difficult for you to examine your feet, have someone assist you. Ask your doctor to check your feet at each visit, and have a thorough medical examination of your feet at least once a year. For more information, see

Foot care for people with diabetes.

If you have severe numbness, a history of skin sores, or bone and joint deformities (such as Charcot foot), you may benefit from custom-fitted shoes. Medicare and some health insurance plans will pay for these shoes if they are needed.

Practice wise health habits

Many health professionals believe that you can further reduce your risk of getting severe neuropathy if you:

• See your doctor regularly. Your doctor will be able to note any changes in your health more easily when you plan regular visits. It will be easier for you and your doctor to find problems early and to take care of them right away.
• Control your blood pressure. Neuropathy may be more likely to progress in people who have high blood pressure. It is not clear whether treating high blood pressure can directly affect the progression of neuropathy, but in general, keeping blood pressure as close to normal as possible may reduce the risk of the complications from diabetes. For more information, see the topic High Blood Pressure.
• Exercise regularly and maintain a healthy weight. Exercise and weight control can help your body use insulin better. This helps keep your blood sugar level within a tightly controlled and narrow target range, which may help prevent the development and progression of nerve damage. Talk to your doctor and have a thorough exam of your feet before beginning an exercise program. Foot problems, blood pressure problems, or certain other problems associated with neuropathy may raise unique concerns about exercising safely, such as whether you should avoid repetitive, weight-bearing exercises.
• Limit your alcohol intake. Having four or more drinks per week may make neuropathy and its symptoms worse.
• Eat a balanced diet. Consider taking a daily multivitamin to ensure that you are meeting your nutritional needs. A balanced diet can also help you maintain a healthy weight. If you have gastroparesis, eat several small meals a day instead of three regular meals.

Organizations

• Abdominal Pain, Age 12 and Older
• Chronic Pain
• Constipation, Age 12 and Older
• Diabetic Nephropathy
• Diabetic Retinopathy
• Diarrhea, Age 12 and Older
• Erection Problems (Erectile Dysfunction)
• High Blood Pressure (Hypertension)
• Type 1 Diabetes
• Type 1 Diabetes: Living With Complications
• Type 1 Diabetes: Living With the Disease
• Type 1 Diabetes: Recently Diagnosed
• Type 2 Diabetes
• Type 2 Diabetes: Living With Complications
• Type 2 Diabetes: Living With the Disease
• Type 2 Diabetes: Recently Diagnosed

Citations

1. Feldman EL, et al. (2003). Somatosensory neuropathy. In D Porte Jr et al., eds., Ellenberg and Rifkin's Diabetes Mellitus, 6th ed., pp. 771–788. New York: McGraw-Hill.

2. American Diabetes Association (2004). Preventive foot care in diabetes. Clinical Practice Recommendations 2004. Diabetes Care, 27(Suppl 1): S63–S64.

3. Jeffcoate WJ, Harding KG (2003). Diabetic foot ulcers. Lancet, 361(9368): 1545–1551.

4. Vinik AI, et al. (2003). Diabetic autonomic neuropathy. In D Porte Jr et al., eds. Ellenberg and Rifkin's Diabetes Mellitus, 6th ed., pp. 789–804. New York: McGraw-Hill.

5. Restivo DA, et al. (2002). Improvement of diabetic autonomic gustatory sweating by botulinum toxin type A. Neurology, 59(12): 1971-1973.

Other Works Consulted

• American Diabetes Association (2004). Physical activity/exercise and diabetes. Clinical Practice Recommendations 2004. Diabetes Care, 27(Suppl 1): S58–S62.

• Boulton AJM, et al. (2005). Diabetic neuropathies: A statement by the American Diabetes Association. Diabetes Care, 28(4): 956–962.

• Frykberg RG, et al. (2000). Diabetic foot disorders: A clinical practice guideline. Journal of Foot and Ankle Surgery, 39(Suppl 5): S1–S60. Also available online: http://www.acfas.org/pubresearch/cpg/diabetic-cpg.htm.

• Ganchi PA, Eriksson E (2005). Diabetes mellitus and wound healing. In CR Kahn et al., eds., Joslin's Diabetes Mellitus, 14th ed., pp. 1133–1144. Boston: Joslin Diabetes Center.

• Ganguli SC, Tougas GN (2001). Diabetes and the gastrointestinal tract. In HC Gerstein, RB Haynes, eds., Evidence-Based Diabetes Care, pp. 545–567. Hamilton, ON: BC Decker.

Author:	Monica Rhodes	Last Updated July 27, 2006
Medical Review:	Caroline S. Rhoads, MD - Internal Medicine Barrie J. Hurwitz, MD - Neurology
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