Blended Medical Approach to the Treatment of Diabetic Peripheral Polyneuropathy

 

 

Blended Medical Approach to the Treatment of Diabetic Peripheral Polyneuropathy

Of the many dangerous and unpleasant sequelae of diabetes, the complaint of burning foot pain is probably the most common.  As many as 60 to 70 percent of diabetics have some form of neuropathy, with risk rising with age of the patient and with duration of the illness. Diabetic neuropathy tends to be more prevalent in patients with poor blood sugar control and elevated triglycerides, high cholesterol, elevated blood pressure and obesity.

Diabetic neuropathy is metabolic in nature.  Entrapment or occlusive neuropathy is structural in nature. 

Symptoms

Symptoms of diabetic nerve damage may include:

1. numbness, tingling, or pain in the extremities
2. muscle wasting in the feet or hands; muscle weakness
3. gastrointestinal complaints of indigestion, nausea, or vomiting, diarrhea or constipation
4. blood pressure instability resulting in dizziness or faintness due to a drop in blood pressure after standing or sitting up
5. urinary symptoms including urgency, hesitancy and incontinence
6. erectile dysfunction

Sensory nerves, autonomic and motor nerves can be damaged by poorly controlled diabetes.  The autonomic nerves tend to be the first to be affected, followed by the sensory nerves, and lastly by the motor nerves.  Nerve damage is usually symmetric, beginning in the lower extremities and working toward the trunk. 

Focal neuropathy can appear in specific nerves, most often in the head, torso, or lower extremity. These focal neuropathies may cause:

1. inability to focus the eye, double vision, unilateral eye pain
2. facial paralysis
3. pain in the lower back or pelvis, thigh, chest and  stomach
4. pain on the outside of the shin or inside of the foot

Focal neuropathy is sudden in nature, painful and unpredictable.

Compressive neuropathies are common in diabetics. Carpal tunnel syndrome is very common in diabetics as well as in patients with hypothyroidism. Entrapment of the Medial and Lateral Plantar Nerves occur commonly, as well. 

Co-Morbid Pathological States

Hypothyroidism is common in the general population, but it is even more common in the diabetic patient population. Unrecognized hypothyroidism can result in difficult diabetic control, and hypothyroidism commonly predisposes to focal entrapment neuropathies.  Autoimmune hypothyroidism is more common in diabetics than in the non-diabetic population, and diagnostic blood work must take this possibility into consideration.

Diabetes affects the gastrointestinal tract thereby impairing absorption.  Malabsorption of micronutrients, including zinc, selenium, vanadium, chromium, magnesium and manganese can result in adrenal dysfunction resulting in steroidal hormone imbalance.  Malabsorption of B-complex vitamins, Vitamin K-2 can result in adrenal dysfunction and promote inflammatory conditions. 

Due to the anticipated Malabsorption state, diabetics require far greater doses of these micronutrients than would be expected of the otherwise healthy patient.  Thoughtful supplementation of these micronutrients can improve diabetic blood sugar control, facilitate weight loss, improve vascular flow and reduce pain.

Diagnostic Dilemma

Unfortunately, foot and hand pain is a complaint commonly encountered in the general population.  Often caused by commonly encountered clinical disorders, such as median nerve entrapment and plantar nerve entrapment, and equally often precipitated by clinical conditions such as hypothyroidism, obesity and fluid retention.   In the non-diabetic patient, the diagnostic workup often includes electromyography, sensory nerve conduction velocity testing and somatosensory evoked potential testing (SSEP).  The EMG may demonstrate pathology late in diabetic neuropathy due to the late involvement of motor fibers.  Sensory nerve conduction testing demonstrates nerve pathology earlier. SSEP is useful for evaluation of optic, auditory and certain specific neuropathies.

In the diabetic patient, all too often, the foot pain is dismissed as ‘diabetic neuropathy’ with very incomplete workup.  This is probably the single factor that leads to the inadequacy of treatment and symptom management. Entrapment neuropathy is treated very differently than metabolic neuropathy.

First and foremost, the patient must be properly evaluated for the presence of entrapment neuropathic syndromes as well as musculoskeletal problems that result in referred hand and foot pain.

Treatment

There are many approaches to the treatment of diabetic polyneuropathy.  The need for strict blood glucose control cannot be over-emphasized.  After that, it is necessary to appreciate the nutritional issues that can prevent neural self-repair. 

Mineral Supplementation:  First attention should be placed with mineral supplementation.  Minerals are poorly absorbed unless ingested as organic salts, sometimes referred to as ‘chelates.’  The most common vitamin and mineral preparations use inorganic salts, and these minerals are very poorly absorbed, if at all. Adequate amounts of zinc, selenium, vanadium and chromium are essential.   Additional vanadium and chromium can be introduced after a few weeks or so, which can be expected to result in lower blood sugars.

B-Complex:  Diabetics can be expected to be relatively deficient in B-12 as well as in Pantothenic acid, B-2, B-6 and inositol.  Generous dosages of a B-complex are an easy and inexpensive intervention. 

Alpha Lipoic Acid (ALA) has been used widely for the treatment of diabetic neuropathy. Dosages of 250 to 500 mg, taken 3 to 4 times daily, ALA can provide pain relief in as little as a few days, but it frequently takes a few weeks or more to reach peak effectiveness. 

ALA may upset the stomach, but the effect is transient and minimal in most cases. It is most effective if co-administered with a high-quality fish oil, 1-2 grams, twice daily.

Lyrica® (pregabalin) is an interesting calcium channel modulator.  While many anti-convulsants demonstrate efficacy in the treatment of DPN, Lyrica® may be unique in the medication armamentarium.  One salutary side-effect of Lyrica® is sleep restoration. Starting with bed time dosages of 50-75 mg, the dosage is increased linearly, by 50-75 mg increments, on a weekly or biweekly basis.  Generally, effective dosages will range between 75 and 300 mg.  Absorption is linear, and side effects are mild, if dose-titration is done slowly and with care.

Summary

The painful symptoms of diabetic neuropathy may be best controlled using a blend of nutritional and traditional medicine.  Diabetic control can be facilitated with the use of a variety of ‘natural medicines,’ only a few of which are presented, above.

When combined with the traditional pharmacological medical approach, clinical improvement is more rapid and patient satisfaction improves.

Only a few, basic suggestions are outlined above.  The molecular basis for the recommendations made above are well founded in the medical and scientific literature. 

David S. Klein, MD, FACA, FACPM

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