Diabetes mellitus is a common disease with multiple complications. The most common neurologic symptom among patients with diabetes is a distal (hands and feet, or farthest from the heart), symmetric polyneuropathy, or peripheral neuropathy. This complication is estimated to affect between 10 and 50 percent of patients with diabetes. A minority of patients with neuropathy will be symptomatic and will have either positive symptoms (burning, tingling) or negative symptoms (numbness, weakness). The human body has three types of nerve systems – sensory (controls the ability to feel and sense things like cold or heat), motor (controls movement), and autonomic (controls automatic functions like digestion, respiration, etc.). Of the three, diabetes most commonly affects the sensory nerves causing burning, numbness, or tingling of the feet or hands. But it can attack the motor nerves causing weakness or paralysis or the autonomic nerves, most commonly causing a condition called gastroparesis, which negatively affects digestion and the passage of food through the gut.
Primary care practitioners can easily screen patients for diabetic neuropathy. The key elements of screening include the patient’s history, physical examination, and sensory assessment. Sensory screening can include whether the patient can feel a pinprick or sense vibration using a tuning fork. Lab testing can be used to identify other causes of neuropathy. For example, a low Vitamin B12 level may cause neuropathy and should be suspected in someone taking metformin and in someone who has had bariatric surgery or has a malabsorption syndrome. Multiple myeloma, a disease of the bone marrow, may often initially present with symptoms of a peripheral neuropathy, and may be diagnosed with a blood test.
Treatment of diabetic neuropathy is usually guided by other diseases or conditions the patient may have. For example, amitriptyline, used to treat severe depression and other psychiatric illnesses, may be very helpful but may not be tolerated by elderly patients, those with electrical heart conduction disorders, or at higher doses. Anticonvulsants like gabapentin and pregabilin may also help and can improve nighttime sleep but may cause daytime drowsiness. SSRIs (Prozac, Zoloft, Effexor) may help but may cause unpleasant side effects.
The biggest problem with diabetic neuropathy besides its symptoms is the development of diabetic foot ulcers, which have a lifetime incidence of 25 percent. Because their feet are numb, diabetics with neuropathy may not feel or detect the presence of a foot ulcer until it is fairly advanced. Advanced foot ulcers often result in bone infections and amputations. Neuropathy may also cause foot deformities like Charcot foot, which make walking painful and difficult. It is for these reasons that those with diabetes should see not only their primary care doctor but also a podiatrist at regular intervals.
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