Diabetic Neuropathy: Treatment

Diabetic neuropathy can not be treated well. Its treatment is not satisfactory. So the main aim of treatment of diabetic neuropathy is control of blood sugar aggressively. But despite good control of blood sugar there may not be any improvement of diabetic neuropathy symptoms. Even the control of blood glucose may be problematic, as diabetic neuropathy can make a diabetic patient less aware of his/her hypoglycemia, thereby prolonging the hypoglycemic episodes and making the patient more prone to effects of hypoglycemia.

There may be loss of sensation in the feet and this can place the patient at risk of ulceration of feet and its sequalae. If patient is having some signs or symptoms of neuropathy, he should examine the feet daily and take precautions like wearing footwear regularly to prevent ulceration and calluses in the feet. Patient education for prevention of injury or ulceration of feet is of paramount importance in the management of diabetic neuropathy. If there is any foot deformity a podiatrist should be consulted.     

Risk factors of neuropathy should also be treated. Common risk factors of neuropathy are hypertension and hypertriglyceridemia. Neurotoxins like alcohol should be avoided. Stopping of smoking, supplementation of possible deficiency of vitamins like folic acid and vitamin B12 and symptomatic treatment is the mainstay of treatment of diabetic neuropathy.

Chronic and painful diabetic nephropathy is very difficult to treat, but anti depressants (selective serotonin norepinephrine reuptake inhibitors such as duloxetine or tricyclic antidepressants such as amitriptyline, desipramine, nortriptyline, imipramine) or anticonvulsants (gabapentin, pregabalin, carbamazepine, lamotrigine) may be useful. USFDA has approved duloxetine and pregabalin for treatment of pain associated with diabetic neuropathy. But due to lack of study on these drugs, it is recommended that the treatment of neuropathic pain should be started with tricyclic antidepressant and switching if there is no response or if side effects develop.

The patient of diabetic neuropathy may require to be referred to a pain management center. Pain of acute diabetic neuropathy may resolve over time as there is progressive neuronal damage from diabetes and the medications can be withdrawn.

Treatment of orthostatic hypotension secondary to autonomic neuropathy is also difficult. Many drugs like fludrocortisone, midodrine, clonidine, octreotide, and yohimbine are used with limited success and more side effects for this purpose. Nonpharmacologic maneuvers like adequate salt intake, avoidance of dehydration, avoidance of diuretics, and support to lower extremity etc. may provide some relief from pain due to diabetic neuropathy.

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