Diabetic Neuropathy

Diabetic neuropathy is the most common cause of nerve pain in this region. It is also the one where treating the cause, not just the pain, truly changes what happens to you.

What is diabetic neuropathy?

Blood sugar that stays high or swings up and down damages the peripheral nerves. The longest ones go first. That is why it reaches the feet before the hands. It is also why it climbs up both legs evenly, like a stocking, instead of hitting one limb.

It starts in prediabetes, before blood sugar reaches the diabetic range. That is why so many patients are told their sugar is fine while their feet burn. See prediabetes and nerve damage.

What are the symptoms of diabetic neuropathy?

• Burning, tingling or electric pain in the feet, usually worse at night and at rest.
• A sensation of walking on gravel, or of wearing socks that are not there.
• Numbness. Patients often call it a relief. In fact it means the damage is spreading.
• Loss of balance, especially in the dark or on uneven ground.
• Less protective feeling. That is what lets a foot injury you never noticed turn into an ulcer.

The order these show up in matters. It is laid out in the stages of diabetic neuropathy.

What is the best treatment for diabetic neuropathy?

Treatment runs on three tracks at once. Most patients come in having been offered only the second.

1. Treating the cause

Glucose stability, not the glucose average, is what tracks with how the nerves do. It is the only track that changes where this is headed, not just the symptom. A continuous glucose monitor shows the spikes after meals that an A1c averages away. We look for other causes we can correct at the same time. B12, thyroid, alcohol and several medicines all damage small fibers on their own, apart from the diabetes. Finding one changes the outlook. See metabolic care and metformin and B12 deficiency.

2. Treating the pain

Nerve pain does not respond to ordinary painkillers. The medicines that do work — gabapentin, pregabalin, duloxetine, the tricyclics — each have real trade-offs. Picking between them depends on sleep, kidney function, mood and what else you take. All of it is laid out under medications for diabetic nerve pain.

3. Neuromodulation, where medication has failed

When nerve-pain medicine has not worked or you cannot take it, a temporary percutaneous nerve stimulation system is available here. Fine electrodes go under the skin. They stay in about twenty days, then they come out — with no permanent implant left behind. Non-invasive vagus nerve stimulation is also used in selected patients. Neither is a first step. Neither replaces the first track.

Assessment

EMG and nerve conduction study grades damage to the large fibers in an objective way. Know what it does not do. It does not measure small fibers. So a normal study in a patient with burning feet is a common and misleading result. See small fiber neuropathy.

To be seen, call or text us. We are at 12174 Natural Bridge Rd, Suite 110, St. Louis, MO 63044.

What usually gets missed

Glycemic variability. A fine A1c can hide daily spikes to 250 and back. The average looks good. The nerves are being injured on the way up and down.

The foot examination. Loss of protective feeling takes seconds to test with a monofilament (a thin nylon thread pressed on the skin). It is the single best predictor of an ulcer — and it is routinely skipped.

The autonomic side. Dizziness when you stand, feeling full too early at meals, sweating for no reason and not sensing low blood sugar are all the same disease. They are almost never linked to it. See autonomic neuropathy.

Circulation. Artery disease and neuropathy often show up together. The two together are more dangerous than either one alone. Telling them apart matters.

Can diabetic neuropathy be reversed?

Tight glucose control slows neuropathy by a wide margin in type 1 diabetes. In type 2 the effect is smaller. That surprises people. It is worth being honest about instead of overselling.

Large-fiber loss that is already set does not reverse. Early small-fiber damage can improve once your metabolism is truly stable. That is the whole case for continuous monitoring instead of a snapshot every three months. The honest, fiber-by-fiber answer is under can diabetic neuropathy be reversed.

The full guide

Can diabetic neuropathy be reversed?
Which fibers recover, which do not, and how to tell which you have.

The stages of diabetic neuropathy
Why less burning can mean fiber loss, not healing.

Burning feet at night
Nerve or circulation, and why heating pads are dangerous here.

Small fiber neuropathy
Why the nerve conduction study came back normal.

Medications for diabetic nerve pain
Gabapentin, pregabalin, duloxetine, tricyclics — and the trade-offs.

Metformin and B12 deficiency
A cause we can correct that gets missed for years.

Prediabetes and nerve damage
Damage starts before you meet the criteria for diabetes.

Neuropathy or a circulation problem?
The one question that separates them.

Diabetic foot care
How numbness becomes an ulcer, and how to stop it.

Autonomic neuropathy
Heart rate, digestion, sweating and bladder — the same disease.

Diabetes damages nerves, blood vessels and the inner ear. Each one adds to the risk of falling on its own. Balance and fall-risk assessment measures all three instead of guessing the risk from the feet alone.

Sources

• Elafros MA et al. Towards prevention of diabetic peripheral neuropathy: clinical presentation, pathogenesis, and new treatments. The Lancet. Neurology, 2022. PubMed 36115364
• Zhu J et al. Diabetic peripheral neuropathy: pathogenetic mechanisms and treatment. Frontiers in endocrinology, 2023. PubMed 38264279
• Jang HN et al. Pharmacological and Nonpharmacological Treatments for Painful Diabetic Peripheral Neuropathy. Diabetes & metabolism journal, 2023. PubMed 37670573
• Ziegler D. Pathogenetic treatments for diabetic peripheral neuropathy. Diabetes research and clinical practice, 2023. PubMed 38245327