What doctors want you to immediately know about diabetic neuropathy is that it doesn’t mean you’re going to lose your foot or your fingers. It is a manageable — and preventable — condition.
Neuropathy affects peripheral nerves in our arms and legs, said Richard Wlodarski, MD, a neurologist at Endeavor Health who specializes in neuromuscular medicine and neurophysiology, specifically peripheral nerves and muscles.
Neuropathy causes
“There could be many different causes of neuropathy, but diabetic neuropathy typically starts at the ends of the longest nerves,” he said. “It typically starts at the feet and then slowly progresses up the legs and affects the fingers.”
The specific mechanism for diabetic neuropathy is complex, but include lack of oxygen and blood flow to the nerves as well as oxidative stress.
Types of neuropathy
Small fiber neuropathy is the most common form of neuropathy, where the small diameter nerve fibers are affected, leading to painful symptoms. Those symptoms include sharp, shooting pain, burning pain and even numbness. It’s usually localized in the toes and feet.
Other patients develop large-fiber neuropathy, suffering from imbalance, difficulty sensing where their feet are in space and worsening numbness.
Type 2 diabetes
The best way to avoid neuropathy is, unsurprisingly, to avoid type 2 diabetes. However, not all diabetics will get diabetic neuropathy, and experts aren’t sure why that is. Nonetheless, maintaining good control of diabetes is key, said Dr. Wlodarski.
Now, if you are a type 2 diabetic and you’re managing it properly, don’t feel bad if you still develop neuropathy.
“In type 2 diabetics, improving the glucose doesn’t always correlate with an improvement in the neuropathy,” he said.
“It seems like only 30 to 40 percent [of type 2 diabetics] get improvement in their neuropathy even if they have tight control of their glucose, versus type 1 diabetics — the autoimmune version — which has a very clear correlation between glucose control and neuropathy, over 70 percent.”
That signals there’s something more at play in type 2 diabetics and it’s probably related to the entire metabolic syndrome those patients often possess: including high blood pressure, high triglycerides, low HDL cholesterol, abdominal obesity and elevated glucose levels.
“I tell my patients with type 2 diabetes with diabetic neuropathy, it’s not enough to just control your glucose and control your A1C, you need to improve the entire metabolic syndrome,” he said. “It requires multidisciplinary care — trying to improve their cholesterol, obesity, high glucose — it requires a coordinated effort with neurology as well as primary care and an effort on the patient’s part.”
Type 1 diabetes
Type 1 diabetes is thought to be an autoimmune attack on the pancreatic cells that produce insulin, leading to elevated blood sugar levels, which can affect nerves. Type 2 diabetics have a resistance to insulin rather than a deficiency of insulin.
“They have this insulin resistance along with those other metabolic syndrome features and I think it’s a combination of those that really contributes to their neuropathy,” he said.
He recommends patients try alpha-lipoic acid supplements to help with neuropathy symptoms. It’s available over the counter.
“Other than that, there’s no direct treatment for diabetic neuropathy,” Dr. Wlodarski said. “If someone could come up with that, they’d be a billionaire. It really comes down to symptomatic management and treating the painful symptoms that often occur.”
There are a variety of pain medications to help suppress the nerve pain, although there’s unfortunately no cure for the numbness or lack of sensation, he said.
Outlook
“Most of the time, diabetic neuropathies are not too debilitating; patients won’t progress to a wheelchair,” he said. “It might affect balance a bit, depending on how uncontrolled they’ve been and for how long. I generally try to reassure my patients it’s not going to leave them debilitated. They’re not going to need amputations because of the neuropathy.”
Another interesting thing about diabetic neuropathy is that it can worsen drastically if a patient lowers his or her A1C level too fast, he said.
“Providers will see an A1C level that’s high and be alarmed and try and treat it aggressively with insulin and other diabetes medications and in so doing, by dropping the A1C so rapidly, they can exacerbate or worsen the diabetic neuropathy. We call it treatment-induced neuropathy,” he said.
“That can lead to severe pain or lack of sensation as well as other issues. I always hope providers are aware of that and will lower the A1C gradually as opposed to very quickly over a couple of months. It should be lowered less than two A1C points per three months, is generally the recommendation. It’s a tough issue to treat and occurs because your body is used to that level of glucose for so long.”
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