Diabetic Foot Pain – OUCH!

What is diabetic nerve pain?

from American Academy of Neurology

“Diabetic nerve pain is a condition that can develop in people who have diabetes. Diabetes leads to high blood sugar levels. This can lead to nerve damage in about 50 percent of people with diabetes. The damage occurs in the nerve endings in the feet and legs and sometimes in the hands and arms. Blood vessels that carry oxygen to the nerves also can become damaged. This damage can slow down nerve signals to the muscles. It also can cause the nerves to send signals at the wrong times, which can result in pain. Sometimes the nerves stop communicating completely. This can lead to numbness in the feet and hands.

People with diabetic nerve pain can develop many symptoms. Some people will have symptoms soon after starting treatment. However, symptoms tend to develop slowly over many years. They often are noticeable several years after diagnosis. These symptoms can disrupt sleep, which can lead to mood changes and lower quality of
life. The main symptoms are painful tingling, burning, and numbness. As the condition worsens, weakness can occur in the legs. This may be experienced as feeling “unsteady.” Symptoms often start in the feet and, later, progress to the hands and arms. Other body parts also can be affected. These include the organs that control automatic body processes. Some people develop digestive problems such as nausea (upset stomach), vomiting, constipation, or diarrhea. Other problems include difficulty with bladder control or sexual function. Dizziness can happen when changing positions quickly.

About 25 percent of people with diabetes will have pain and numbness from nerve damage. Controlling blood sugar levels can help prevent diabetic nerve pain.

I have diabetic nerve pain. My doctor said there are many drugs that treat it. How do I know which are most helpful?

Many drugs are available to treat diabetic nerve pain.
The evidence for how well they work varies. The evidence is best for drugs that treat seizures and depression and for some painkillers.

Seizure Drugs

Several seizure drugs can help treat diabetic nerve pain. Strong evidence shows the seizure drug pregabalin is helpful. To a small degree, it also can improve sleep and quality of life. There is moderate evidence that the seizure drug gabapentin can help treat diabetic nerve pain. Weak evidence shows that gabapentin may work better if taken with the antidepressant venlafaxine. There is moderate evidence that the seizure drug valproate is a helpful therapy. However, women who are pregnant or who plan to be pregnant should be aware that this drug can cause serious birth defects. People who take valproate also can experience weight gain and trouble controlling blood sugar levels.

For these reasons, it may not be a good choice for treating diabetic nerve pain.

In contrast, other seizure drugs might not be helpful therapies for diabetic nerve pain. There is moderate evidence that the drugs oxcarbazepine, lamotrigine, and lacosamide likely do not help treat this condition. There is not enough evidence to show if the drug topiramate is helpful.

Antidepressants

Several antidepressants also can help treat diabetic nerve pain. There is moderate evidence that the drugs amitriptyline, venlafaxine, and duloxetine can be helpful. However, not enough evidence is available to show if any one drug is
more helpful than another.

There is not enough evidence to show if the drugs desipramine, imipramine, or fluoxetine are helpful therapies. There also is not enough evidence to show if combining
the drug nortriptyline with fluphenazine is helpful.

Opioids

Opioids are a type of painkiller. Although powerful at first, opioids can have less of an effect over time. There is moderate evidence that the opioids dextromethorphan, morphine sulphate, tramadol, and oxycodone controlled- release can help treat diabetic nerve pain. There is not enough evidence to show if any one drug is more helpful than another.

It is important to be aware that opioids can have serious side effects. For example, dextromethorphan and tramadol can cause sleepiness. This may be dangerous for certain common tasks such as driving. Tramadol also can cause upset stomach and constipation. What’s more, opioids can lead to new pain problems such as rebound headaches. These are headaches that set in between drug doses. Over time, a person taking opioids can become dependent on them.

Other Drugs

Several other drugs are available for treating diabetic nerve pain. These include topical drugs, which are applied directly to the skin. There is moderate evidence that capsaicin cream and isosorbide dinitrate spray can be helpful. Some people who have used capsaicin cream described having burning pain in hot weather or when the skin comes in contact with warm or hot water. There is weak evidence that the lidocaine patch may help treat diabetic nerve pain.

In contrast, some drugs used for diabetic nerve pain have not been shown to be helpful. These include clonidine, pentoxifylline, and mexiletine, which mainly are used for heart or circulation problems. Moderate evidence shows that these three drugs likely are not helpful. There is not enough evidence to show if vitamins or alpha-lipoic acid are helpful therapies.

Are there any therapies other than drugs that help treat diabetic nerve pain?

Several nondrug therapies are available to treat diabetic nerve pain. One therapy is transcutaneous electric nerve stimulation, or TENS. A TENS unit is a portable device that sends an electrical current through wires to electrodes attached to the skin. There is moderate evidence that TENS can be helpful.

On the other hand, other nondrug therapies have not been shown to help diabetic nerve pain. There is moderate evidence that magnetic shoe insoles, laser therapy, and Reiki therapy (a form of alternative medicine) likely are not helpful. Not enough evidence is available to show if electrotherapy combined with the antidepressant amitriptyline is helpful.

I have diabetic nerve pain. Will any of these therapies improve my quality of life or daily functioning?

Overall, the studies examined in this guideline found that some therapies help treat diabetic nerve pain. Some studies looked just at the drugs’ effects on pain and not on other problems such as lowered quality of life or ability to function. Other studies looked at the effects on these problems but found little or no evidence. It is clear that more research is needed to understand how well these therapies can help with problems other than pain.

Nerve pain is a chronic problem for many people with diabetes. More research is needed to know how well the therapies discussed here work over time. When choosing
a therapy, be sure to learn about potential side effects. Remember to tell your doctor about any other health problems you may have. Finally, keep in mind that it takes time for a drug to take full effect. Depending on the person, a drug dose may need to be adjusted.

Note: This statement is provided as an educational service of the American Academy of Neurology. It is based on an assessment of current scientific and clinical information. It is not intended to include all possible proper methods of care for a particular neurologic problem or all legitimate criteria for choosing to use a specific procedure. Neither is it intended to exclude any reasonable alternative methodologies. The AAN recognizes that specific patient care decisions are the prerogative of the patient and the physician caring for the patient, based on all of the circumstances involved.

 

Australian information can be found in a very good article  Drug treatment of neuropathic pain

If you have any questions, or would like to share any comments on your experiences with diabetic foot pain (neuropathy) and its management, please contribute below.

7 Comments

  1. helwild on March 1, 2014 at 8:26 pm

    Thanks so much David. There is much here of interest. It is such a comprehensive coverage, I will come back and read this again. I have had Type 2 diabetes for 13 years now, & am just starting to experience nerve pain in a wide range of places, including behind the ears.. My doctor said it is probably neuralgia. I also suffer from cramp. Over the past 3 or 4 years this has changed, & whilst the thigh cramps I used to experience nightly have settled with magnesium & dietary changes, the cramps in my feet are very new, and can strike at any time, not just at night. They can also occur many times overnight. I have to stand up to alleviate the worst of the cramp, and cannot sleep on my side with feet placed on top of each other.
    regards
    Helen

  2. helwild on March 1, 2014 at 8:28 pm

    ps I have been told by others with t2d that statins (commonly prescribed for cholesterol) can cause or contribute to cramps. Have you heard this?

    • Imagine_David on March 14, 2015 at 8:52 pm

      Helen, Yes, this can be a pain ….. IM not sure about actual cramps though.

      i.e. statins can cause muscle pain: like any other medication, if there are any side effects or perceived side effects, then the doctor should be consulted re cause.

  3. Imagine_David on March 2, 2014 at 10:45 pm

    Helen, thanks for your replies.

    Yes, as you know from first hand experience, this pain of nerve damage can have a significant effect on sleep which in turn can have a huge negative effect on the quality of life. It is true that some cholesterol medication can cause muscle pains – its always a good idea to have your pharmacist on your Team: checking any medication risks, side effects etc. So many people today see a different GP each visit.

    To have the pharmacist on your team can avoid the lesser quality prescription combinations that sometimes happen; or other medications that could be better suited to the person with diabetes than what has actually been prescribed.

    Another tactic could be to ask the doctor prescribing the medication: “this is what I am using already, is this new medication safe t mix with these others?”

    Safe journey,
    David

  4. helwild on March 6, 2015 at 12:55 pm

    Leg pain and cramps as a result of diabetic neuropathy are usually a common side effect of long term diabetes and nerve damage. There are a couple of supplements that may help, with a doctor’s approval. The whole vitamin B group, especially B12, and the mineral magnesium may help. Fish oil, commonly used in arthritis and rheumatism, may help. Your GP can order a test for the Vitamin B deficiency, and also for anaemia, and order a supplement which may need to be an injection, as the body can find oral vitamin B hard to process. Here is a link about Vitamin B12 deficiency. http://www.bupa.com.au/health-and-wellness/health-information/az-health-information/vitamin-b12-deficiency-anaemia
    Cramps commonly occur as a result of sweating, which can lead to a deficiency of potassium, which is excreted in sweat. However, potassium cannot be taken as a supplement, it is dangerous to do so, but must be taken in common foods, such as bananas, peaches, and many others. The Magnesium and zinc needed to metabolise potassium may be lacking in the diet, and Mg & Zn are safe to take as supplements. Magnesium supports muscle. Some heart specialists prescribe it for heart patients and some sporting coaches recommend magnesium supplements for the whole team. I personally take a magnesium tablet at night for night time leg and foot cramps, and a multivitamin for women or a Berocca tablet in the morning, as these are both high in Vitamin B and also have some zinc. Fish oil is safe to take, but again, best to inform the GP or endo if it is being taken in high doses.

    There are some practical home treatments which help some people with diabetic leg pain.
    1.Avoiding dehydration. As well as protecting the kidneys, drinking water throughout the day helps to avoid leg cramps, flushes out toxins, and helps to flush excess blood glucose from the system.
    2. Manage bgl as closely as possible to avoid further nerve damage.
    3. Walking. Although walking may be painful, it actually increases circulation in the legs. If walking on land is too painful to bear, walking in water may be less painful There are shallower public swimming pools which are ideal for this, and all public pools set aside one or two lanes for non swimmers. There are indoor pools at gyms, which often offer exercise classes, or periods in the day when people can free walk or exercise. In summer, walking in the ocean may be of benefit.
    4.Less alcohol. Alcohol kills nerves. The recommendation is no more than 4 alcoholic drinks per week.
    5.Warm baths- these increase the flow of blood to the skin and nerves, as well as helping with relaxation. They do help some people.
    6.Foot health: with leg pain, and diabetic neuropathy, foot care becomes even more important. Visual inspection daily and immediate treatment of any foot injury are crucial in maintaining mobility. Untreated foot injury is the single most common cause of amputation in diabetes.
    7.Capsaicin cream applied 3-4 times daily may help. Derived from chilis. Obviously cleaning the hands afterwards is very important.
    8. Mental health and well being management. Pain is real. It can be overwhelming at times. Some doctors will prescribe pain killers. Some work on the physical level. The addictive ones that are derived from the opiates can be counter productive, as they can make the mind confused. There are some mindfulness and wellbeing practices which can help in tolerating and working through episodes or ongoing pain. I can provide further information on practices such as cognitive behaviour therapy, narrative therapy, relaxation, control of the breath, muscle relaxation, if you think any of these might help.
    Helen Wilde
    Senior Counsellor

  5. Zac Greensmith on March 11, 2015 at 6:35 pm

    Hi Helen I am very interested in your post above especially ” There are some mindfulness and wellbeing practices which can help in tolerating and working through episodes or ongoing pain. I can provide further information on practices such as cognitive behaviour therapy, narrative therapy, relaxation, control of the breath, muscle relaxation, if you think any of these might help.” I am interested in reading all of the above Thanks Zac

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