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Diabetic Neuropathy

Definition


Disease: Diabetic Neuropathy Diabetic Neuropathy
Category: Neurological diseases

Disease Definition:

Some form of nerve damage eventually occurs in many people with diabetes. It is a condition known as diabetic neuropathy. Although high blood sugar damages the nerves in the legs and feet most often, but it can also injure nerve fibers throughout the body.

 

The symptoms of diabetic neuropathy range from pain and numbness in the extremities to problems with the digestive system, heart, urinary tract and blood vessels, depending on the nerves that are affected. For some people, the symptoms of diabetic neuropathy may be painful, disabling and even fatal, while in other people they may be mild.

 

The most common serious complication of diabetes is diabetic neuropathy. However, a healthy lifestyle and tight blood sugar control can slow the progress of diabetic neuropathy or even prevent it.
 

Work Group:


Symptoms, Causes

Symptoms:

Diabetic neuropathy has four major types. A person may experience the symptoms of several types or just one type. Most of these symptoms develop gradually, so that until considerable damage has occurred, the patient won’t notice them. In some cases, the symptoms of diabetic neuropathy may develop before the diagnosis of diabetes. Depending on the type of neuropathy and which nerves are affected, the signs and symptoms of diabetic neuropathy vary:

 

Peripheral neuropathy:

The most common form of diabetic neuropathy is peripheral neuropathy, which damages most commonly the nerves in the legs and feet, but could also damage those in the arms and hands. Some of the symptoms that peripheral neuropathy may cause include:

 

  • Sharp, jabbing or electric shock-like pain that becomes worse at night.
  • Numbness or a reduced ability to feel pain or changes in temperature, particularly in the feet
  • Difficulty walking and muscle weakness
  • Serious foot problems, such as infections, bone and joint pain, deformities and ulcers.
  • A tingling, burning or prickling sensation that starts in the toes or the balls of the feet and spreads upward in a gradual way.
  • Loss of coordination and balance
  • Extreme sensitivity to the lightest touch. For instance, the weight of a sheet can be agonizing for some people.

 

Focal neuropathy:

Focal neuropathy usually involves a single nerve and comes on suddenly. This condition can cause severe pain; however, in a few weeks or months, this pain usually goes away on its own. Older adults are affected by focal neuropathy more commonly. Some of the signs and symptoms that this condition may cause include:

 

  • Bell’s palsy, which is the paralysis of one side of the face.
  • Pain in the shin or foot
  • Double vision, aching behind one eye or difficulty focusing the eyes.

 

A nerve compression may sometimes cause focal neuropathy. The most common type of compression neuropathy in people with diabetes is carpal tunnel syndrome. some of the signs and symptoms that carpal tunnel syndrome may cause include:

 

  • Pain that radiates or extends from the wrist up the arm to the shoulder or down into the palm or fingers, particularly after repetitive or forceful use.
  • A sense of weakness in the hands and a tendency to drop objects
  • Numbness, swelling or tingling in the fingers when holding a newspaper or driving a car.

 

Autonomic neuropathy:

The heart, lungs, eyes, stomach, sex organs, intestines and bladder is controlled by the autonomic nervous system. The nerves in any of the areas mentioned above may be affected by diabetes, causing:

 

  • Uncontrolled diarrhea, constipation or a combination of the two
  • Erectile dysfunction. More than half the men with diabetes who are age 60 or older are affected by this condition.
  • Bladder problems, including urinary incontinence or frequent urinary tract infections.
  • Sexual difficulties in women, such as vaginal dryness
  • Abdominal pain, bloating and belching, or other digestive problems
  • Inability of the body to adjust blood pressure and heart rate, which may lead to orthostatic hypotension, a condition in which there’s a sharp drop in the blood pressure after standing or sitting.
  • Changes in the way the eyes adjust from light to dark
  • Problems regulating the body temperature
  • Gastroparesis, which is the slow stomach emptying, leading to loss of appetite, nausea and vomiting.
  • Increased or decreased sweating

 

People who have had poorly-controlled diabetes for many years are more likely to experience autonomic neuropathy.

 

Proximal neuropathy:

Severe pain in the hip and thigh or buttocks, usually beginning on one side of the body, is the characteristic of proximal neuropathy, which is also called diabetic amyotrophy or femoral neuropathy. The patient’s thigh muscles will become weak and atrophied eventually, making it difficult to rise from a sitting position. Severe weight loss is also experienced by many people. Older adults and people who have type 2 diabetes are most commonly affected by proximal neuropathy. Severe pain in the trunk of the body is caused by another form of this condition.
 

Causes:

Running through the body, a complex system of nerves connect the brain to the muscles, skin and other organs. The brain senses pain and temperature through these nerves, and performs automatic tasks such as digestion and controls the muscles.

 

DAMAGE TO NERVES AND BLOOD VESSELS:

Diabetic neuropathy results when prolonged exposure to high blood sugar damages the delicate nerve fibers. However, the exact cause of this is still not known. The complex interaction between nerves and blood vessels as well as a combination of other factors play a role. The ability of the nerves to transmit signals is impaired by high blood pressure. The walls of the small blood vessels called capillaries that supply the nerves with oxygen and nutrients may also become weakened due to high blood pressure.

 

OTHER FACTORS:

Some of the other factors that may contribute to diabetic neuropathy are:

 

Protein glycation:

When the sugars in a person’s body react with proteins and alter the nature of those proteins, this condition occurs. Aging and complications of diabetes, such as diabetic neuropathy, have been linked to glycated proteins.

 

Inflammation in the nerves caused by an autoimmune response:

When a person’s immune system mistakenly attacks part of the body as if it were a foreign organism, this condition occurs.

 

Smoking and alcohol abuse:

A person’s risk of infections will be significantly increased in case he/she smokes or abuses alcohol because both of these things damage the nerves as well as the blood vessels.

 

Genetic factors:

Some people may be more susceptible to nerve damage due to genetic factors that are not related to diabetes.
 

Complications

Complications:

Some of the serious complications that diabetic neuropathy may cause include:

 

Loss of a limb:

A lack of feeling in the feet may be caused by nerve damage. Because of this, cuts and sores may go unnoticed and eventually become severely infected or ulcerated, which is the condition where the skin and soft tissues break down. Diabetes reduces blood flow to the feet, making the risk of infection higher. Amputation of a toe, foot or even the lower leg may be necessary in case infection spreads to the bone and causes tissue death, a condition known as gangrene.

 

Social isolation:

People with this condition, especially older adults, may become dependent on others, leaving them increasingly isolated and depressed, due to the pain, disability and embarrassment caused by nerve damage.

 

Charcot joints:

When a joint, usually in the foot, deteriorates because of nerve damage, this condition occurs. Loss of sensation is the characteristic of this condition, in addition to instability, swelling and sometimes deformity in the joint itself.

 

Hypotension:

The body’s ability to adjust blood pressure may be affected by damage to the nerves that control circulation. A sharp drop in pressure may result when a person stands up after sitting, a condition called orthostatic hypotension, leading to dizziness and fainting.

 

Urinary incontinence and urinary tract infections:

The bladder may be prevented from emptying completely due to damage to the nerves that control it. This will lead to urinary tract infections because it will allow bacteria to grow in the patient’s bladder and kidneys. The patient’s ability to sense when he/she needs to urinate or to control the muscles that release urine may also be affected by nerve damage.

 

Hypoglycemia unawareness:

A person will develop symptoms such as shakiness, a fast heartbeat and sweating in case his/her blood sugar drops too low (below 70 mg/dL or below 3.0 mmol/L). These are symptoms that warn the person of the problem so that he/she can take steps to raise their blood sugar quickly. A person’s ability to notice these symptoms may be affected by autonomic neuropathy. Hypoglycemia can be fatal if it is left untreated.

 

Increased or decreased sweating:

A person’s body won’t be able to regulate its temperature properly in case his/her sweat glands don’t function normally. A reduced perspiration or anhidrosis, which is a complete lack of perspiration, may be a life-threatening condition. However, autonomic neuropathy causes excessive sweating more commonly, especially at night.

 

Sexual dysfunction:

Erectile dysfunction may result in men and problems with lubrication and arousal in women in case autonomic neuropathy damages the nerves that affect the sex organs. This complication is quite common.

 

Digestive problems:

A range of problems including severe constipation or diarrhea, or alternating bouts of constipation and diarrhea, in addition to bloating, loss of appetite, nausea and vomiting may result from nerve damage to the digestive system. The condition in which the stomach empties too slowly or not at all (gastroparesis) is one of the especially serious problems of this condition. This may severely affect blood sugar levels and nutrition, cause nausea and vomiting, and interfere with digestion.
 

Treatments:

There’s no cure for diabetic neuropathy. Treatment will focus on managing complications, slowing the progression of the disease, restoring function and relieving pain.

 

SLOWING THE PROGRESSION OF THE DISEASE:

To help delay the progression of peripheral neuropathy and maybe even cause an improvement in the symptoms, consistently keeping blood sugar within a narrow target range is very important. In some cases, the overall risk of diabetic neuropathy may be reduced by more than 60% by an intense glucose control. The goals of treatment with an intense blood sugar control will be:

 

  • Less than 180 mg/dL (10 mmol/L) blood sugar level two hours after meals
  • 90 to 130 mg/dL (5 to 7 mmol/L) blood sugar level before meals
  • Less than 7% hemoglobin A1C, which is an indicator of a person’s blood sugar control for the past few months.

 

The substance that carries oxygen inside red blood cells is called hemoglobin. A1C is the amount of sugar that has bound to hemoglobin in the blood. The higher the patient’s average blood sugar level for the past two or three months, the higher his/her A1C number will be. People who don’t have diabetes have an A1C between 4% and 6%. In order to slow down a person’s nerve damage he/she should:

  • Stop smoking
  • Get plenty of physical activity
  • Follow the doctor’s recommendations for good foot care
  • Avoid alcohol entirely. However, if drinking is allowed, a woman shouldn’t drink more than one drink a day and a man shouldn’t drink more than two.
  • Keep their blood pressure under control
  • Maintain a healthy weight
  • Follow a healthy eating plan

 

RELIEVING PAIN:

One of the most difficult things in managing diabetic neuropathy is providing effective pain relief. Nerve pain can be relieved by several medications, but not all of them work on everyone and most of them have side effects that should be weighed against their benefits. These are some of the medications that could be used for relieving pain:

 

Anti-seizure medications:

These medications could be prescribed for nerve pain despite the fact that they were developed to treat seizure disorders (epilepsy). Drowsiness and dizziness are some of their side effects. Some examples of these medications are carbamazepine, gabapentin and pregabalin.

 

Tricyclic antidepressants:

By interfering with chemical processes in the brain that cause a person to feel pain, these medications may provide relief for mild to moderate symptoms. However, these medications also have side effects. Some examples are desipramine, imipramine and amitriptyline nortriptyline. SSRIs (selective serotonin reuptake inhibitors) have fewer side effects but work less for pain; two examples are fluoxetine hydrochiloride and paroxetine. SNRIs (serotonin and norepinephrine reuptake inhibitors) are a newer class of antidepressants that relieve pain with only few side effects and so are usually a better choice.

 

Lidocaine patch:

The topical anesthetic lidocaine is contained in this patch. It should be applied to the area where the pain is most severe. Even though this patch may cause a rash in some people, but it usually has no side effects.

 

Capsaicin:

In some people, the sensations of pain may be reduced when capsaicin creams are applied. Capsaicin is the same chemical that gives hot peppers their bite.

 

Other medications:

The pain caused by diabetic neuropathy may be relieved by opioid analgesics. However, these medications can’t be used as a long-term treatment because they have some serious side effects, such as addiction. Examples of opioid analgesics are oxycodone and codeine.

 

MANAGING COMPLICATIONS:

Many of the complications of neuropathy can be treated with specific treatments:

 

Urinary tract problems:

Loss of bladder control can be treated with antispasmodic medications (anticholinergics), behavioral techniques such as timed urination, and devices such as rings inserted into the vagina to prevent urine leakage called pessaries. Usually, the most effective treatment is a combination of therapies.

 

Digestive problems:

Eating soups and pureed foods, eating smaller but more frequent meals and reducing fiber and fat in the diet usually helps with gastroparesis. Additionally, dietary changes and medications can help with constipation, diarrhea and nausea.

 

Orthostatic hypertension:

Simple lifestyle measures such as drinking plenty of water, avoiding alcohol and standing up slowly usually helps with low blood pressure on standing (orthostatic hypotension). This condition may also be treated with several medications, either alone or together. For instance, fludrocortisone is a drug that raises blood pressure by helping boost the blood volume.

 

Sexual dysfunction:

Vaginal lubricants and estrogen creams may help women with sexual dysfunction. Although not safe or effective for everyone, but vardenafil, sildenafil and tadalafil can improve sexual function in some men. Vacuum devices or penile implants may also be used in case medications fail.
 

Prognosis:

Not available

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