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Peripheral diabetic neuropathy
is a common complication of Type 1 diabetes and Type 2 diabetes. Peripheral diabetic neuropathy is also referred to as painful diabetic neuropathy (PDN), painful diabetic peripheral neuropathy, or diabetic peripheral neuropathy (DPN). DPN affects up to 50% of people who have either Type 1 or Type 2 diabetes. DPN is a type of nerve damage that develops over time. It can affect the feet and legs, and sometimes the arms and hands. Understanding DPN and how to manage it can be helpful. Let’s take a look at DPN in more detail and what can be done to manage it.What is peripheral diabetic neuropathy?
Diabetic neuropathy is a complication of diabetes that is defined by nerve damage. Having high blood glucose levels over time (as well as other risk factors like high cholesterol) can cause nerve damage, although DPN can also occur in people with good blood sugar control. The symptoms depend on which type of diabetic neuropathy you have. While this article focuses on peripheral diabetic neuropathy, we will first give a quick overview of the different types of diabetic neuropathy. You may have one or more types of diabetic neuropathy.Autonomic neuropathy
Affects autonomic nerves that control internal organs. This type of neuropathy can affect blood pressure, heart rate, digestion, bladder, sex organs, sweat glands, and eyes. The nerve damage can also cause hypoglycemia unawareness.Focal neuropathy
Focal neuropathy (also called mononeuropathy) affects single nerves, usually in your hand (such as carpal tunnel syndrome), head, leg, or torso.Proximal neuropathy
A rare type of neuropathy that can be very disabling. It tends to affect a hip, buttock, or thigh, on one side.Peripheral diabetic neuropathy
A dysfunction in the peripheral nervous system—it usually affects the feet and legs, and can also affect the hands and arms. This is the most common type of diabetic neuropathy, affecting up to 50% of people with diabetes.Symptoms of diabetic peripheral neuropathy may include:
- Tingling/loss of sensation (feeling pins and needles in the feet)
- Numbness in the feet, even when blisters or injuries are present, or when walking
- Painful symptoms (you may feel burning, stabbing, shooting, or sharp pain) and sensitivity
- Feeling very hot or cold in the feet and hands
- Weak muscles in the feet and legs
- Unsteadiness when standing or walking
- Leg or foot ulcers (open sores) which take a long time to heal
How is peripheral diabetic neuropathy diagnosed?
Your doctor will perform a physical exam and review your symptoms and medical history. The physical exam will include a foot exam and a neurological exam.People with diabetes should have their feet and legs examined at every visit. The doctor will check your feet for any problems and ensure you have blood flow and feeling in the area. Your doctor may test you by:
- Using a tuning fork to see if you can feel the vibration
- Touching your feet and toes with a nylon strand (monofilament test) to see if you can feel it
- Examining your gait (how you walk)
- Testing your balance
Your doctor may also order blood work—such as thyroid tests, kidney tests, and vitamin B12 levels—to see if anything else is causing nerve damage. Sometimes, people who take metformin (a commonly prescribed diabetes drug) have low levels of B12 and will need to take a B12 supplement with their metformin.
Many people who have DPN also have nephropathy and retinopathy, so regular visits with a nephrologist and ophthalmologist are important, too.
Peripheral diabetic neuropathy treatment options
Although there is no cure for DPN, there are several ways to manage or treat the symptoms. Talk to your doctor about different ways to help your pain from DPN. Some non-pharmacological ways to treat DPN include managing your blood glucose, blood pressure, and cholesterol, losing weight if necessary, avoiding alcohol, and stopping smoking.Peripheral diabetic neuropathy treament
In terms of prescription drugs, first-line treatment includes prescription drugs such as Lyrica (pregabalin), Neurontin (gabapentin), or Cymbalta (duloxetine). Elavil (amitriptyline) is another first-line treatment but should not be used in older adults due to its side effects.If first-line treatments do not work, doctors may try an antidepressant such as Effexor (venlafaxine) or Pristiq (desvenlafaxine), or an opioid pain medication such as Ultram (tramadol).
Other measures may include topical pain-relief patches such as lidocaine, or a pain-relieving cream like capsaicin. Other options may include isosorbide dinitrate spray and transcutaneous electrical nerve stimulation (TENS).
Peripheral diabetic neuropathy medications
Anticonvulsants
Anticonvulsants such as Lyrica (pregabalin) or Neurontin (gabapentin) may be helpful in treating nerve pain from DPN. Common side effects include dizziness, drowsiness, and weight gain. Lyrica is specifically indicated to treat pain from DPN.Serotonin-norepinephrine reuptake inhibitors (SNRIs)
SNRIs are antidepressants used to treat major depressive disorder, or depression. They work by increasing levels of serotonin and norepinephrine. SNRIs include Cymbalta (duloxetine), Effexor (venlafaxine), and Pristiq (desvenlafaxine). Cymbalta is the only SNRI that is specifically indicated for DPN. Side effects commonly include dizziness and drowsiness, as well as stomach problems like indigestion, constipation, and nausea.Tricyclic antidepressants (TCA)
Elavil (amitriptyline) is the only TCA that is recommended to treat pain from DPN. Common side effects include dry mouth, trouble sleeping, dizziness, fatigue, and headache. Elavil should generally be avoided in older adults because it can cause side effects like extreme fatigue and orthostatic hypotension, which is when you get dizzy when going from a sitting down or lying down position to standing up.Opioid pain medications
Ultram (tramadol) and Nucynta ER (tapentadol extended-release) are sometimes used to treat DPN. Nucynta ER is indicated to treat peripheral diabetic neuropathy. Common side effects include nausea, drowsiness, and constipation.Lidocaine patches
Lidocaine patches, available in various prescription and over-the-counter (OTC) formulations, can be worn for up to 12 hours and should be removed for 12 hours. They may help the pain from DPN and have few side effects.Capsaicin
Topical capsaicin cream, available in several OTC products, can help reduce pain. However, some people cannot tolerate the burning side effects. Qutenza is a prescription capsaicin patch that is approved to treat DPN.Other medications
While the medications listed above are preferred treatments for DPN, sometimes they are not effective or cannot be tolerated. Other options that are considered third-line treatments include selective serotonin reuptake inhibitors (SSRIs) such as Celexa (citalopram), Paxil (paroxetine), or Lexapro (escitalopram), or other opioids (besides Ultram or Nucynta).What is the best medication for peripheral diabetic neuropathy?
The best medication for peripheral diabetic neuropathy depends on your symptoms, medical conditions, medical history, and other medications you take that could interact with peripheral diabetic neuropathy medication. Your doctor can take this information into consideration and decide which treatment is most appropriate for you. Below is information about some of the most commonly prescribed medications for DPN.| Best medications for peripheral diabetic neuropathy | ||||
|---|---|---|---|---|
| Drug Name | Drug Class | Administration Route | Standard Dosage | Common Side Effects |
| Cymbalta (duloxetine) | Serotonin-norepinephrine reuptake inhibitor (SNRI) | Oral | 30 mg twice daily or 60 mg once daily | Nausea, dry mouth, drowsiness |
| Effexor, Effexor XR (venlafaxine) | SNRI | Oral | 150 mg daily | Nausea, dry mouth, drowsiness |
| Elavil (amitriptyline) | Tricyclic antidepressant (TCA) | Oral | 10 mg daily at bedtime, to start, slowly increasing dose as directed by doctor | Drowsiness, dizziness, dry mouth |
| Lyrica (pregabalin) | Anticonvulsant | Oral | 150 mg twice daily | Drowsiness, dizziness, dry mouth |
| Neurontin (gabapentin) | Anticonvulsant | Oral | 400 mg 3 times daily | Drowsiness, dizziness, impaired coordination |
| Nucynta ER (tapentadol ER) | Opioid pain medication | Oral | 100 mg twice daily | Nausea, constipation, dizziness |
| Pristiq (desvenlafaxine) | SNRI | Oral | 200 mg daily | Nausea, dizziness, trouble sleeping |
| Ultram (tramadol) | Opioid pain medication | Oral | 50 mg every 4 to 6 hours | Nausea, constipation, dizziness |
What are the common side effects of peripheral diabetic neuropathy medication?
Some of the most common side effects of neuropathy medication include:- Dizziness
- Drowsiness
- Nausea
- Constipation
- Impaired coordination
- Dry mouth
Serious allergic reactions are rare. If you have symptoms of a serious allergic reaction such as hives, difficulty breathing, or swelling around the face, lips, tongue, or throat, get emergency medical help right away.
Antidepressants (such as Cymbalta, Effexor, Elavil, or Pristiq) or anticonvulsants (such as Lyrica or Neurontin) can increase the risk of suicidal thoughts and behaviors. Notify your doctor of any changes in mood or behavior.
In some cases, antidepressants or anticonvulsants can cause a life-threatening skin reaction. If you have skin problems, such as red/purple rashes or blistering, get emergency medical help right away.
Pain medications such as Ultram or Nucynta ER are both controlled substances and have a high risk of abuse or dependence.
Avoid alcohol when taking DPN medications. Also, avoid driving or operating machinery until you know how the medication affects you. Keep your DPN medication securely out of the reach of children and pets, as an overdose can be fatal.
This is a general list of side effects of DPN medications. This is not a full list of side effects, and other side effects may occur. Talk to your doctor about the potential side effects for the specific medication(s) you take, and how to address them.
What is the best home remedy for peripheral diabetic neuropathy?
Other measures you can take to treat the symptoms of DPN:
Frequently asked questions about peripheral diabetic neuropathy
What is the difference between diabetic neuropathy and peripheral neuropathy?
Diabetic neuropathy is when you have nerve damage caused by diabetes. There are several types of diabetic neuropathy. Peripheral neuropathy is the most common type of diabetic neuropathy, and involves the legs and feet, and sometimes the hands and arms.What test can detect diabetic peripheral neuropathy?
A healthcare professional will examine you, and review your symptoms and history. The doctor will examine your feet and legs, looking for any problems with blood flow and sensations.Your doctor will perform a physical exam and review your symptoms and medical history. The physical exam will include a foot exam and a neurological exam.
What is the best medicine for diabetic peripheral neuropathy?
There are a variety of treatments for diabetic peripheral neuropathy. The best treatment is different for each person. Your doctor can assess your symptoms and medical history/conditions to find the best treatment for you. DPN is often treated with antidepressants or anticonvulsants. There is no cure for DPN but the medications can help with pain and improve your quality of life.How does diabetic peripheral neuropathy affect the body?
Diabetic peripheral neuropathy can cause symptoms such as pain, tingling, numbness, and muscle weakness. Pain is often worse at night. Eventually, the pain may stop but the numbness and cold feeling may remain. In rare cases, patients may have foot complications such as ulcers, Charcot neuroarthropathy, or need an amputation. However, these complications can often be preventable with diabetes care, including good blood glucose control and regular diabetic foot care/foot exams, as well as medication. Other types of diabetic neuropathy affect other parts of the body, including the bladder, sexual organs, and eyes, among others.What is the latest treatment for diabetic neuropathy?
In July 2021, the FDA approved a spinal cord stimulation system called the Sensa Omnia SCS. It works by delivering mild electrical pulses to help with pain. There are also clinical trials to study new treatments, which you can find out here.What is the fastest way to cure diabetic peripheral neuropathy?
There is no cure for diabetic peripheral neuropathy. Keeping your blood sugar tightly controlled and avoiding high blood sugar may help the symptoms, or stop symptoms from worsening. Talk to your doctor to come up with a treatment plan that may include both medication and non-medicinal treatments to help your pain—for example, taking prescription medication for DPN along with other measures such as keeping blood sugar levels tightly controlled and checking your feet every day to catch any problems before they get worse.Related resources for peripheral diabetic neuropathy
- Diabetes and dietary supplements, National Center for Complementary and Integrative Health
- Diabetes and foot problems, National Institute of Diabetes and Digestive and Kidney Diseases
- Diabetes and nerve damage, U.S. National Library of Medicine, Medline Plus
- Diabetic neuropathy, Medscape
- Diabetic neuropathy, National Institute of Diabetes and Digestive and Kidney Diseases
- Diabetic neuropathy, Nature Reviews Disease Primers
- Diabetic peripheral neuropathy, American College of Foot and Ankle Surgeons
- Management of diabetic peripheral neuropathy, American Diabetes Association Clinical Diabetes
- Peripheral diabetic neuropathy, StatPearls
- Peripheral neuropathy, American Diabetes Association
- Peripheral neuropathy fact sheet, National Institute of Neurological Disorders and Stroke
- What is peripheral neuropathy?, Foundation for Peripheral Neuropathy