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DIABETIC NEUROPATHY SYMPTOMS
Diabetic neuropathy affects all
peripheral nerves: pain fibers, motor
neurons, autonomic nerves. It therefore
necessarily can affect all organs and
systems since all are innervated. There
are several distinct syndromes based on
the organ systems and members affected,
but these are by no means exclusive. A
patient can have sensorimotor and
autonomic neuropathy or any other
combination. Symptoms vary depending on
the nerve(s) affected and may include
symptoms other than those listed.
Symptoms usually develop gradually over
years.
Symptoms may include:
Numbness and tingling of extremities
Dysesthesia (decreased or loss of
sensation to a body part)
Diarrhea
Erectile dysfunction
Urinary
incontinence (loss of bladder control)
Impotence
Facial, mouth and eyelid
drooping
Vision changes
Dizziness
Muscle weakness
Difficulty swallowing
Speech impairment
Fasciculation
(muscle contractions)
Anorgasmia
Burning or electric pain
TREATMENT
Despite advances
in the understanding of the metabolic
causes of neuropathy, treatments aimed
at interrupting these pathological
processes have been limited. Thus, with
the exception of tight glucose control,
treatments are for reducing pain and
other symptoms.
Options for pain
control include tricyclic
antidepressants (TCAs), serotonin
reuptake inhibitors (SSRIs) and
antiepileptic drugs (AEDs). A systematic
review concluded that "tricyclic
antidepressants and traditional
anticonvulsants are better for short
term pain relief than newer generation
anticonvulsants."[2] A combination of
these medication (gabapentin +
nortriptyline) may also be superior to a
single agent.[3]
The only two
drugs approved by the FDA for diabetic
peripheral neuropathy are the
antidepressant duloxetine and the
anticonvulsant pregabalin. Before trying
a systemic medication, people with
localized diabetic periperal neuropathy
might relieve their symptoms with
lidocaine patches.[1]
In addition
to pharmacological treatment there are
several other modalities that help some
cases. These have shown to reduce pain
and improve patient quality of life
particularly for chronic neuropathic
pain: Interferential Stimulation;
Acupuncture; Meditation; Cognitive
Therapy; and prescribed exercise.
Tricyclic antidepressants
TCAs include imipramine, amitriptyline,
desipramine and nortriptyline. These
drugs are effective at decreasing
painful symptoms but suffer from
multiple side effects that are dosage
dependent. One notable side effect is
cardiac toxicity, which can lead to
fatal arrhythmias. At low dosages used
for neuropathy, toxicity is rare, but if
symptoms warrant higher doses,
complications are more common. Among the
TCAs, amitriptyline is most widely used
for this condition, but desipramine and
nortriptyline have fewer side effects.
Serotonin reuptake inhibitor
SSRIs include fluoxetine, paroxetine,
sertraline and citalopram. These agents
have not been FDA approved to treat
painful neuropathy because they have
been found to be no more efficacious
than placebo in several controlled
trials. Side effects are rarely serious,
and do not cause any permanent
disabilities. They cause sedation and
weight gain, which can worsen a
diabetic's glycemic control. They can be
used at dosages that also relieve the
symptoms of depression, a common
concommitent of diabetic neuropathy.
The SSNRI duloxetine (Cymbalta) is
approved for diabetic neuropathy. By
targeting both serotonin and
norepinephrine, it targets the painful
symptoms of diabetic neuropathy, and
also treats depression if it exists.
Typical dosages are between 60 mg and
120 mg.
Antiepileptic
drugs
AEDs, especially
gabapentin and the related pregabalin,
are emerging as first line treatment for
painful neuropathy. Gabapentin compares
favorably with amitriptyline in terms of
efficacy, and is clearly safer. Its main
side effect is sedation, which does not
diminish over time and may in fact
worsen. It needs to be taken three times
a day, and it sometimes causes weight
gain, which can worsen glycemic control
in diabetics. Carbamazepine (Tegretol)
is effective but not necessarily safe
for diabetic neuropathy. Its first
metabolite, oxcarbazepine, is both safe
and effective in other neuropathic
disorders, but has not been studied in
diabetic neuropathy. Topiramate has not
been studied in diabetic neuropathy, but
has the beneficial side effect of
causing mild anorexia and weight loss,
and is anecdotally beneficial.
Other treatments
α-lipoic
acid, an anti-oxidant that is a
non-prescription dietary supplement has
shown benefit in a randomized controlled
trial that compared once-daily oral
doses of 600 mg to 1800 mg compared to
placebo, although nausea occurred in the
higher doses.
Though not yet
commercially available, C-peptide has
shown promising results in treatment of
diabetic complications, including
neuropathies. Once thought to be a
useless by-product of insulin
production, it helps to ameliorate and
reverse the major symptoms of diabetes.
In more recent years, Photo Energy
Therapy devices are becoming more widely
used to treat neuropathic symptoms.
Photo Energy Therapy devices emit near
infrared light (NIR Therapy) typically
at a wavelength of 880 nm. This
wavelength is believed to stimulate the
release of Nitric Oxide, an
Endothelium-derived relaxing factor into
the bloodstream, thus vasodilating the
capilaries and venuoles in the
microcirculatory system. This increase
in circulation has been shown effective
in various clinical studies to decrease
pain in diabetic and non-diabetic
patients. Photo Energy Therapy devices
seem to address the underlying problem
of neuropathies, poor microcirculation,
which leads to pain and numbness in the
extremities
Tight glucose
control
Treatment of early
manifestations of sensorimotor
polyneuropathy involves improving
glycemic control. Tight control of blood
glucose can reverse the changes of
diabetic neuropathy, but only if the
neuropathy and diabetes is recent in
onset. Conversely, painful symptoms of
neuropathy in uncontrolled diabetics
tend to subside as the disease and
numbness progress.
The mechanisms
of diabetic neuropathy are poorly
understood. At present, treatment
alleviates pain and can control some
associated symptoms, but the process is
generally progressive.
As a
complication, there is an increased risk
of injury to the feet because of loss of
sensation (see diabetic foot). Small
infections can progress to ulceration
and this may require amputation.
Metanx
Metanx®
is a prescription medical food for the
dietary management of endothelial
dysfunction in patients with diabetic
peripheral neuropathy.
How is
Metanx® different than over-the-counter
vitamins?
Traditional
over-the-counter vitamins are synthetic
forms of the nutrients found in nature.
This is the case for common B-vitamins
such as folic acid, vitamin B6 and
vitamin B12. Each of these must be
converted into their natural, active
forms before they can actually be used
by the body's cells for such vital
functions as DNA production, cell
reproduction and homocysteine
metabolism.
B Vitamin Active Form
Folic acid L-methylfolate
Vitamin B6 Pyridoxal 5'-phosphate
Vitamin B12 Methylcobalamin
Metanx® is a prescription medical food
and has a unique formulation providing
the active forms of folate, vitamin B6
and vitamin B12 to manage the distinct
nutritional requirements of diabetic
neuropathy patients who often experience
numbness, tingling, and burning
sensations in their feet.
Each
Metanx® tablet contains:
L-methylfolate
3mg
Pyridoxal 5'-phosphate 35mg
Methylcobalamin 2mg
The
bioefficacy of one Metanx® tablet can be
compared to taking 19 folic acid tablets
(1mg each) 2 B12 tablets (1mg each), and
2 B6 tablets (25mg each).
Metanx®
is available to nutritionally manage
endothelial dysfunction associated with
numbness, tingling, and burning
sensations in diabetic neuropathy
patients.
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