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Home , Diabetic neuropathy

Diabetic Neuropathies: The Damage of

National Diabetes Information Clearinghouse

What are diabetic • neurovascular factors, leading to dam­ age to the blood vessels that carry neuropathies? oxygen and nutrients to Diabetic neuropathies are a family of nerve • autoimmune factors that cause inflam­ disorders caused by diabetes. People with U.S. Department mation in nerves of Health and diabetes can, over time, develop nerve dam­ Human Services age throughout the body. Some people with • mechanical injury to nerves, such as nerve damage have no symptoms. Others NATIONAL may have symptoms such as , tingling, INSTITUTES • inherited traits that increase susceptibil­ OF HEALTH or numbness—loss of feeling—in the hands, ity to nerve arms, feet, and legs. Nerve problems can • lifestyle factors, such as smoking or occur in every organ system, including the alcohol use digestive tract, , and sex organs. About 60 to 70 percent of people with diabe­ What are the symptoms of tes have some form of neuropathy. People with diabetes can develop nerve problems at diabetic neuropathies? any time, but risk rises with age and longer Symptoms depend on the type of neuropathy duration of diabetes. The highest rates of and which nerves are affected. Some people neuropathy are among people who have with nerve damage have no symptoms at all. had diabetes for at least 25 years. Diabetic For others, the first symptom is often numb­ neuropathies also appear to be more com­ ness, tingling, or pain in the feet. Symptoms mon in people who have problems control­ are often minor at first, and because most ling their blood , also called blood nerve damage occurs over several years, sugar, as well as those with high levels of mild cases may go unnoticed for a long time. blood fat and blood pressure and those who Symptoms can involve the sensory, motor, are overweight. and autonomic—or involuntary—nervous systems. In some people, mainly those with focal neuropathy, the onset of pain may be What causes diabetic sudden and severe. neuropathies? Symptoms of nerve damage may include The causes are probably different for differ­ ent types of diabetic neuropathy. Research­ • numbness, tingling, or pain in the toes, ers are studying how prolonged exposure to feet, legs, hands, arms, and fingers high blood glucose causes nerve damage. • wasting of the muscles of the feet or Nerve damage is likely due to a combination hands of factors: • indigestion, , or vomiting • metabolic factors, such as high blood • or constipation glucose, long duration of diabetes, abnormal blood fat levels, and possibly • dizziness or faintness due to a drop in low levels of blood pressure after standing or sitting up • problems with urination • in men or vaginal Neuropathy Affects Nerves dryness in women Throughout the Body • weakness affects Symptoms that are not due to neuropathy, • toes but often accompany it, include weight loss • feet and depression. • legs What are the types of • hands diabetic neuropathy? • arms affects Diabetic neuropathy can be classified as peripheral, autonomic, proximal, or focal. • heart and blood vessels Each affects different parts of the body in • digestive system various ways. • urinary tract • Peripheral neuropathy, the most • sex organs common type of diabetic neuropathy, • sweat glands causes pain or loss of feeling in the toes, feet, legs, hands, and arms. • eyes • Autonomic neuropathy causes changes • in digestion, bowel and bladder func­ Proximal neuropathy affects tion, sexual response, and perspiration. • thighs It can also affect the nerves that serve the heart and control blood pressure, • hips as well as nerves in the lungs and eyes. • buttocks Autonomic neuropathy can also cause • legs unawareness, a condition Focal neuropathy affects in which people no longer experience the warning symptoms of low blood • eyes glucose levels. • facial muscles • Proximal neuropathy causes pain in the • ears thighs, hips, or buttocks and leads to • pelvis and lower back weakness in the legs. • chest • Focal neuropathy results in the sud­ den weakness of one nerve or a group • abdomen of nerves, causing or • thighs pain. Any nerve in the body can be • legs affected. • feet

2 Diabetic Neuropathies: The Nerve Damage of Diabetes What is peripheral neuropathy? Peripheral neuropathy, also called distal symmetric neuropathy or sensorimotor neuropathy, is nerve damage in the arms and legs. Feet and legs are likely to be affected before hands and arms. Many people with diabetes have signs of neuropathy that a doc­ tor could note but feel no symptoms them­ selves. Symptoms of peripheral neuropathy may include • numbness or insensitivity to pain or temperature • a tingling, burning, or prickling sensation • sharp or • extreme sensitivity to touch, even light touch • loss of balance and coordination These symptoms are often worse at night.

Peripheral neuropathy may also cause mus­ Peripheral neuropathy affects the nerves in the toes, cle weakness and loss of reflexes, especially feet, legs, hands, and arms. 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 an occurs and is not treated promptly, the infection may spread to the , and the foot may then have to be amputated. Many amputa­ tions are preventable if minor problems are caught and treated in time.

3 Diabetic Neuropathies: The Nerve Damage of Diabetes What is autonomic Hypoglycemia Unawareness neuropathy? Normally, symptoms such as shakiness, sweating, and palpitations occur when blood Autonomic neuropathy affects the nerves glucose levels drop below 70 mg/dL. In that control the heart, regulate blood pres­ people with autonomic neuropathy, symp­ sure, and control blood glucose levels. toms may not occur, making hypoglycemia Autonomic neuropathy also affects other difficult to recognize. Problems other than internal organs, causing problems with neuropathy can also cause hypoglycemia digestion, respiratory function, urination, unawareness. sexual response, and vision. In addition, the system that restores blood glucose levels to Heart and Blood Vessels normal after a hypoglycemic episode may The heart and blood vessels are part of the be affected, resulting in loss of the warning cardiovascular system, which controls blood symptoms of hypoglycemia. circulation. Damage to nerves in the car­ diovascular 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 the 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 . Severe gastroparesis can lead to persistent nausea and vomiting, , and loss of appetite. Gastroparesis can also make blood glucose levels fluctuate widely due to abnormal food digestion. Nerve damage to the esophagus may make swallowing difficult, while nerve damage to the bowels can cause constipation alternat­ ing with frequent, uncontrolled diarrhea, especially at night. Problems with the diges­ Autonomic neuropathy affects the nerves in the tive system can lead to weight loss. heart, stomach, intestines, bladder, sex organs, sweat glands, eyes, and lungs.

4 Diabetic Neuropathies: The Nerve Damage of Diabetes Urinary Tract and Sex Organs What is proximal Autonomic neuropathy often affects the neuropathy? organs that control urination and sexual Proximal neuropathy, sometimes called lum­ function. Nerve damage can prevent the bosacral plexus neuropathy, femoral neurop­ bladder from emptying completely, allowing athy, or diabetic amyotrophy, starts with pain to grow in the bladder and kidneys in the thighs, hips, buttocks, or legs, usually and causing urinary tract . When on one side of the body. This type of neu­ the nerves of the bladder are damaged, ropathy is more common in those with type 2 may result because a diabetes and in older adults with diabetes. person may not be able to sense when the Proximal neuropathy causes weakness in the bladder is full or control the muscles that legs and the inability to go from a sitting to release urine. a standing position without help. Treatment Autonomic neuropathy can also gradu­ for weakness or pain is usually needed. The ally decrease sexual response in men and length of the recovery period varies, depend­ women, although the sex drive may be ing on the type of nerve damage. unchanged. A man may be unable to have erections or may reach sexual climax with­ What is focal neuropathy? out ejaculating normally. A woman may have difficulty with arousal, lubrication, or Focal neuropathy appears suddenly and orgasm. affects specific nerves, most often in the head, torso, or leg. Focal neuropathy may Sweat Glands cause Autonomic neuropathy can affect the nerves • inability to focus the eye that control sweating. When nerve dam­ • double vision age prevents the sweat glands from work­ ing properly, the body cannot regulate its • aching behind one eye temperature as it should. Nerve damage can • paralysis on one side of the face, called also cause profuse sweating at night or while Bell’s palsy eating. • severe pain in the lower back or pelvis Eyes • pain in the front of a thigh Finally, autonomic neuropathy can affect the • pain in the chest, stomach, or side of the eyes, making them less respon­ • pain on the outside of the shin or inside sive to changes in light. As a result, a person of the foot may not be able to see well when a light is turned on in a dark room or may have • chest or abdominal pain that is some­ trouble driving at night. times mistaken for heart disease, a heart attack, or Focal neuropathy is painful and unpredict­ able 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.

5 Diabetic Neuropathies: The Nerve Damage of Diabetes People with diabetes also tend to develop A comprehensive foot exam assesses the nerve compressions, also called entrapment skin, muscles, , circulation, and sen­ syndromes. One of the most common is sation of the feet. The doctor may assess carpal tunnel syndrome, which causes numb­ protective sensation or feeling in the feet by ness and tingling of the hand and sometimes touching them with a nylon monofilament— muscle weakness or pain. Other nerves similar to a bristle on a hairbrush—attached susceptible to entrapment may cause pain on to a wand or by pricking them with a pin. the outside of the shin or the inside of the People who cannot sense pressure from a foot. pinprick or monofilament have lost protec­ tive sensation and are at risk for developing foot sores that may not heal properly. The Can diabetic neuropathies doctor may also check temperature percep­ be prevented? tion or use a tuning fork, which is more sen­ The best way to prevent neuropathy is to sitive than touch pressure, to assess vibration keep blood glucose levels as close to the perception. normal range as possible. Maintaining safe blood glucose levels protects nerves through­ Other Tests out the body. The doctor may perform other tests as part of the diagnosis. How are diabetic • Nerve conduction studies or electro­ neuropathies diagnosed? myography are sometimes used to help determine the type and extent of nerve Doctors diagnose neuropathy on the basis of damage. Nerve conduction studies symptoms and a physical exam. During the check the transmission of electrical cur­ exam, the doctor may check blood pressure, rent through a nerve. Electromyogra­ heart rate, muscle strength, reflexes, and phy shows how well muscles respond to sensitivity to position changes, vibration, electrical signals transmitted by nearby temperature, or light touch. nerves. These tests are rarely needed to Foot Exams diagnose neuropathy. • A check of shows Experts recommend that people with dia­ how the heart responds to deep breath­ betes have a comprehensive foot exam each ing and to changes in blood pressure year to check for peripheral neuropathy. and posture. People diagnosed with peripheral neuropa­ thy need more frequent foot exams. • Ultrasound uses sound waves to pro­ duce an image of internal organs. An ultrasound of the bladder and other parts of the urinary tract, for example, can be used to assess the structure of these organs and show whether the bladder empties completely after urination.

6 Diabetic Neuropathies: The Nerve Damage of Diabetes How are diabetic • , such as (Lyrica), (Gabarone, Neu­ neuropathies treated? rontin), , and lamotrig­ The first treatment step is to bring blood ine (Lamictal) glucose levels within the normal range to • and opioidlike drugs, such as help prevent further nerve damage. Blood controlled-release , an opi­ glucose monitoring, meal planning, physical oid; and (Ultram), an activity, and diabetes medicines or insulin that also acts as an will help control blood glucose levels. Symp­ toms may get worse when blood glucose is and pregabalin are approved by first brought under control, but over time, the U.S. Food and Drug Administration spe­ maintaining lower blood glucose levels helps cifically for treating painful diabetic periph­ lessen symptoms. Good blood glucose con­ eral neuropathy. trol may also help prevent or delay the onset People do not have to be depressed for an of further problems. As scientists learn antidepressant to help relieve their nerve more about the underlying causes of neurop­ pain. All have side effects, and athy, new treatments may become available some are not recommended for use in older to help slow, prevent, or even reverse nerve adults or those with heart disease. Because damage. over-the-counter pain medicines such as As described in the following sections, acetaminophen and ibuprofen may not work additional treatment depends on the type of well for treating most nerve pain and can nerve problem and symptom. have serious side effects, some experts rec­ ommend avoiding these medications. Pain Relief Treatments that are applied to the skin— Doctors usually treat painful diabetic neu­ typically to the feet—include ropathy with oral medications, although cream and patches (Lidoderm, other types of treatments may help some Lidopain). Studies suggest that nitrate people. People with severe nerve pain may sprays or patches for the feet may relieve benefit from a combination of medications pain. Studies of alpha-, an or treatments and should consider talking antioxidant, and evening primrose oil with a health care provider about treatment suggest they may help relieve symptoms and options. improve nerve function in some patients. Medications used to help relieve diabetic A device called a bed cradle can keep sheets nerve pain include and blankets from touching sensitive feet • tricyclic , such as ami­ and legs. Acupuncture, biofeedback, or triptyline, , and may help relieve pain in (Norpramin, Pertofrane) some people. Treatments that involve elec­ trical nerve stimulation, magnetic therapy, • other types of antidepressants, such as and laser or light therapy may be helpful but duloxetine (Cymbalta), , need further study. Researchers are also (Wellbutrin), studying several new therapies in clinical (Paxil), and citalopram (Celexa) trials.

7 Diabetic Neuropathies: The Nerve Damage of Diabetes Gastrointestinal Problems To treat erectile dysfunction in men, the doc­ To relieve mild symptoms of gastroparesis— tor will first do tests to rule out a hormonal indigestion, belching, nausea, or vomiting— cause. Several methods are available to treat doctors suggest eating small, frequent erectile dysfunction caused by neuropathy. meals; avoiding fats; and eating less fiber. Medicines are available to help men have When symptoms are severe, doctors may and maintain erections by increasing blood prescribe erythromycin to speed digestion, flow to the penis. Some are oral medica­ metoclopramide to speed digestion and help tions and others are injected into the penis relieve nausea, or other medications to help or inserted into the urethra at the tip of the regulate digestion or reduce stomach acid penis. Mechanical vacuum devices can also secretion. increase blood flow to the penis. Another option is to surgically implant an inflatable To relieve diarrhea or other bowel prob­ or semirigid device in the penis. lems, doctors may prescribe an antibiotic such as tetracycline, or other medications as Vaginal lubricants may be useful for women appropriate. when neuropathy causes vaginal dry­ ness. To treat problems with arousal and Dizziness and Weakness orgasm, the doctor may refer women to a gynecologist. Sitting or standing up slowly may help prevent the light-headedness, dizziness, or Foot Care fainting associated with blood pressure and circulation problems. Raising the head of People with neuropathy need to take special the bed or wearing elastic stockings may also care of their feet. The nerves to the feet help. Some people benefit from increased are the longest in the body and are the ones salt in the diet and treatment with salt- most often affected by neuropathy. Loss retaining hormones. Others benefit from of sensation in the feet means that sores or high blood pressure medications. Physical injuries may not be noticed and may become therapy can help when muscle weakness or ulcerated or infected. Circulation problems loss of coordination is a problem. also increase the risk of foot ulcers. Smok­ ing increases the risk of foot problems and Urinary and Sexual Problems . A health care provider may be able to provide help with quitting smoking. To clear up a , the doctor will probably prescribe an antibiotic. More than 60 percent of all nontraumatic Drinking plenty of fluids will help prevent lower-limb in the United States another infection. People who have incon­ occur in people with diabetes. Nontraumatic tinence should try to urinate at regular amputations are those not caused by trauma intervals—every 3 hours, for example— such as severe injuries from an accident. because they may not be able to tell when In 2004, about 71,000 nontraumatic amputa­ the bladder is full. tions were performed in people with diabe­ tes. Comprehensive foot care programs can reduce amputation rates by 45 to 85 percent.

8 Diabetic Neuropathies: The Nerve Damage of Diabetes Careful foot care involves • cleaning the feet daily using warm— Points to Remember not hot—water and a mild soap. Soak­ • Diabetic neuropathies are nerve ing the feet should be avoided. A soft disorders caused by many of the towel can be used to dry the feet and abnormalities common to diabetes, between the toes. such as high blood glucose. • inspecting the feet and toes every day • Neuropathy can affect nerves for cuts, blisters, redness, swelling, throughout the body, causing calluses, or other problems. Using a numbness and sometimes pain in mirror—handheld or placed on the the hands, arms, feet, or legs, and floor—may be helpful in checking the problems with the digestive tract, bottoms of the feet, or another person heart, sex organs, and other body can help check the feet. A health care systems. provider should be notified of any • Treatment first involves bringing problems. blood glucose levels within the • using lotion to moisturize the feet. normal range. Good blood glucose Getting lotion between the toes should control may help prevent or delay be avoided. the onset of further problems. • filing corns and calluses gently with a • Foot care is an important part of pumice stone after a bath or shower. treatment. People with neuropathy • cutting toenails to the shape of the need to inspect their feet daily for toes and filing the edges with an emery any injuries. Untreated injuries board each week or when needed. increase the risk of infected foot sores and amputation. • always wearing shoes or slippers to pro­

tect feet from injuries. Wearing thick, • Treatment also includes pain relief soft, seamless socks can prevent skin and other medications as needed, irritation. depending on the type of nerve damage. • wearing shoes that fit well and allow the

toes to move. New shoes can be broken • Smoking increases the risk of foot in gradually by first wearing them for problems and amputation. A only an hour at a time. health care provider may be able to provide help with quitting. • looking shoes over carefully before put­ ting them on and feeling the insides to make sure the shoes are free of tears, sharp edges, or objects that might injure Hope through Research the feet. The National Institute of Diabetes and Diges­ People who need help taking care of their tive and (NIDDK) conducts feet should consider making an appointment and supports research to help people with to see a foot doctor, also called a podiatrist. diabetes. Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available, and help others by contribut­ ing to medical research. For information about current studies, visit www.ClinicalTrials.gov. 9 Diabetic Neuropathies: The Nerve Damage of Diabetes For More Information For more information, contact the following organizations: See the following publications from the NIDDK for more information about topics American Diabetes Association related to diabetic neuropathies: 1701 North Beauregard Street Alexandria, VA 22311 • Gastroparesis—stomach nerve dam- Phone: 1–800–DIABETES (342–2383) age—available online at www.diges- Email: [email protected] tive.niddk.nih.gov/ddiseases/pubs/ Internet: www.diabetes.org gastroparesis • Hypoglycemia—available online at American Podiatric Medical Association www.diabetes.niddk.nih.gov/dm/pubs/ 9312 Old Georgetown Road hypoglycemia Bethesda, MD 20814–1621 Phone: 1–800–FOOTCARE (366–8227) • Nerve Disease and Bladder Control— or 301–581–9200 available online at www.kidney.niddk. Fax: 301–530–2752 nih.gov/kudiseases/pubs/nervedisease Email: [email protected] • Prevent diabetes problems: Keep your Internet: www.apma.org feet and skin healthy and Prevent diabe- tes problems: Keep your American Urological Association healthy, two publications in the Prevent Foundation Diabetes Problems Series—available 1000 Corporate Boulevard online at www.diabetes.niddk.nih.gov/ Linthicum, MD 21090 dm/pubs/complications Phone: 1–800–828–7866 or 410–689–3700 • Sexual and Urologic Problems of Fax: 410–689–3998 Diabetes—available online at www. Email: [email protected] diabetes.niddk.nih.gov/dm/pubs/sup Internet: www.UrologyHealth.org • Take Care of Your Feet for a Lifetime, Centers for Disease Control and Prevention available from the National Diabe- National Center for Chronic Disease Pre- tes Education Program by calling vention and Health Promotion 1–888–693–NDEP (6337) or visiting Division of Diabetes Translation www.ndep.nih.gov/campaigns/Feet/ 4770 Buford Highway NE, Mail Stop K–10 Feet_overview.htm Atlanta, GA 30341–3717 These publications are also available by call- Phone: 1–800–CDC–INFO (232–4636) ing 1–800–860–8747. or 770–488–5000 Email: [email protected] Internet: www.cdc.gov/diabetes

10 Diabetic Neuropathies: The Nerve Damage of Diabetes Juvenile Diabetes Research Foundation National Institute of Neurological Disorders International and Stroke 26 Broadway, 14th Floor P.O. Box 5801 New York, NY 10004 Bethesda, MD 20824 Phone: 1–800–533–CURE (2873) Phone: 1–800–352–9424 Fax: 212–785–9595 or 301–496–5751 Email: [email protected] Internet: www.ninds.nih.gov Internet: www.jdrf.org National Kidney and Urologic Diseases Lower Extremity Amputation Prevention Information Clearinghouse Program 3 Information Way Health Resources and Services Bethesda, MD 20892–3580 Administration Phone: 1–800–891–5390 5600 Fishers Lane TTY: 1–866–569–1162 Rockville, MD 20857 Fax: 703–738–4929 Phone: 1–888–ASK–HRSA (275–4772) Email: [email protected] Internet: www.hrsa.gov/leap Internet: www.kidney.niddk.nih.gov National Diabetes Education Program Pedorthic Footwear Association 1 Diabetes Way 2025 M Street NW, Suite 800 Bethesda, MD 20814–9692 Washington, DC 20036 Phone: 1–888–693–NDEP (6337) Phone: 1–800–673–8447 TTY: 1–866–569–1162 or 202–367–1145 Fax: 703–738–4929 Fax: 202–367–2145 Email: [email protected] Email: [email protected] Internet: www.ndep.nih.gov Internet: www.pedorthics.org National Digestive Diseases Information Clearinghouse 2 Information Way Bethesda, MD 20892–3570 Phone: 1–800–891–5389 TTY: 1–866–569–1162 Fax: 703–738–4929 Email: [email protected] Internet: www.digestive.niddk.nih.gov National Heart, , and Blood Institute Information Center P.O. Box 30105 Bethesda, MD 20824–0105 Phone: 301–592–8573 Fax: 240–629–3246 Email: [email protected] Internet: www.nhlbi.nih.gov

11 Diabetic Neuropathies: The Nerve Damage of Diabetes You may also find additional information about this National Diabetes topic by visiting MedlinePlus at www.medlineplus.gov. Information Clearinghouse This publication may contain information about med- ications. When prepared, this publication included 1 Information Way the most current information available. For updates Bethesda, MD 20892–3560 or for questions about any medications, contact Phone: 1–800–860–8747 the U.S. Food and Drug Administration toll-free at 1–888–INFO–FDA (463–6332) or visit www.fda.gov. TTY: 1–866–569–1162 Consult your doctor for more information. Fax: 703–738–4929 Email: [email protected] Internet: www.diabetes.niddk.nih.gov

The U.S. Government does not endorse or favor any The National Diabetes Information specific commercial product or company. Trade, Clearinghouse (NDIC) is a service of the proprietary, or company names appearing in this National Institute of Diabetes and Digestive document are used only because they are considered and Kidney Diseases (NIDDK). The NIDDK necessary in the context of the information provided. If a product is not mentioned, the omission does not is part of the National Institutes of Health of mean or imply that the product is unsatisfactory. 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. Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. 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 fact sheet to duplicate and distribute as many copies as desired. This fact sheet is also available at www.diabetes.niddk.nih.gov.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health

NIH Publication No. 09–3185 February 2009