Diabetic Neuropathies: The Nerve Damage of Diabetes

 
Diabetic Neuropathies: The Nerve Damage of Diabetes
Diabetic Neuropathies:
The Nerve Damage
of Diabetes
                   National Diabetes Information Clearinghouse

                  What are diabetic                                • neurovascular factors, leading to dam­
                                                                     age to the blood vessels that carry
                  neuropathies?                                      oxygen and nutrients to nerves
                  Diabetic neuropathies are a family of nerve
                                                                   • autoimmune factors that cause inflam­
                  disorders caused by diabetes. People with
U.S. Department                                                      mation in nerves
of Health and     diabetes can, over time, develop nerve dam­
Human Services    age throughout the body. Some people with        • mechanical injury to nerves, such as
                  nerve damage have no symptoms. Others              carpal tunnel syndrome
NATIONAL
INSTITUTES
                  may have symptoms such as pain, tingling,        • inherited traits that increase susceptibil­
OF HEALTH         or numbness—loss of feeling—in the hands,          ity to nerve disease
                  arms, feet, and legs. Nerve problems can
                                                                   • lifestyle factors, such as smoking or
                  occur in every organ system, including the
                                                                     alcohol use
                  digestive tract, heart, and sex organs.
                  About 60 to 70 percent of people with diabe­    What are the symptoms of
                  tes have some form of neuropathy. People
                  with diabetes can develop nerve problems at     diabetic neuropathies?
                  any time, but risk rises with age and longer    Symptoms depend on the type of neuropathy
                  duration of diabetes. The highest rates of      and which nerves are affected. Some people
                  neuropathy are among people who have            with nerve damage have no symptoms at all.
                  had diabetes for at least 25 years. Diabetic    For others, the first symptom is often numb­
                  neuropathies also appear to be more com­        ness, tingling, or pain in the feet. Symptoms
                  mon in people who have problems control­        are often minor at first, and because most
                  ling their blood glucose, also called blood     nerve damage occurs over several years,
                  sugar, as well as those with high levels of     mild cases may go unnoticed for a long time.
                  blood fat and blood pressure and those who      Symptoms can involve the sensory, motor,
                  are overweight.                                 and autonomic—or involuntary—nervous
                                                                  systems. In some people, mainly those with
                                                                  focal neuropathy, the onset of pain may be
                  What causes diabetic                            sudden and severe.
                  neuropathies?                                   Symptoms of nerve damage may include
                  The causes are probably different for differ­
                  ent types of diabetic neuropathy. Research­      • numbness, tingling, or pain in the toes,
                  ers are studying how prolonged exposure to         feet, legs, hands, arms, and fingers
                  high blood glucose causes nerve damage.          • wasting of the muscles of the feet or
                  Nerve damage is likely due to a combination        hands
                  of factors:
                                                                   • indigestion, nausea, or vomiting
                   • metabolic factors, such as high blood         • diarrhea or constipation
                     glucose, long duration of diabetes,
                     abnormal blood fat levels, and possibly       • dizziness or faintness due to a drop in
                     low levels of insulin                           blood pressure after standing or sitting up
Diabetic Neuropathies: The Nerve Damage of Diabetes
• problems with urination
  • erectile dysfunction in men or vaginal        Neuropathy Affects Nerves
    dryness in women                              Throughout the Body
  • weakness                                      Peripheral neuropathy affects
Symptoms that are not due to neuropathy,            • toes
but often accompany it, include weight loss
                                                    • feet
and depression.
                                                    • legs
                                                    • hands
What are the types of
                                                    • arms
diabetic neuropathy?
                                                  Autonomic neuropathy affects
Diabetic neuropathy can be classified as
peripheral, autonomic, proximal, or focal.          • heart and blood vessels
Each affects different parts of the body in         • digestive system
various ways.                                       • urinary tract
  • Peripheral neuropathy, the most                 • sex organs
    common type of diabetic neuropathy,
                                                    • sweat glands
    causes pain or loss of feeling in the toes,
    feet, legs, hands, and arms.                    • eyes
  • Autonomic neuropathy causes changes             • lungs
    in digestion, bowel and bladder func­         Proximal neuropathy affects
    tion, sexual response, and perspiration.        • thighs
    It can also affect the nerves that serve
    the heart and control blood pressure,           • hips
    as well as nerves in the lungs and eyes.        • buttocks
    Autonomic neuropathy can also cause             • legs
    hypoglycemia unawareness, a condition
    in which people no longer experience          Focal neuropathy affects
    the warning symptoms of low blood               • eyes
    glucose levels.                                 • facial muscles
  • Proximal neuropathy causes pain in the          • ears
    thighs, hips, or buttocks and leads to
                                                    • pelvis and lower back
    weakness in the legs.
                                                    • chest
  • Focal neuropathy results in the sud­
    den weakness of one nerve or a group            • abdomen
    of nerves, causing muscle weakness or           • thighs
    pain. Any nerve in the body can be              • legs
    affected.
                                                    • feet

2 Diabetic Neuropathies: The Nerve Damage of Diabetes
What is peripheral
neuropathy?
Peripheral neuropathy, also called distal
symmetric neuropathy or sensorimotor
neuropathy, is nerve damage in the arms and
legs. Feet and legs are likely to be affected
before hands and arms. Many people with
diabetes have signs of neuropathy that a doc­
tor could note but feel no symptoms them­
selves. Symptoms of peripheral neuropathy
may include
 • numbness or insensitivity to pain or
   temperature
 • a tingling, burning, or prickling
   sensation
 • sharp pains or cramps
 • extreme sensitivity to touch, even light
   touch
 • loss of balance and coordination
These symptoms are often worse at night.
Peripheral neuropathy may also cause mus­       Peripheral neuropathy affects the nerves in the toes,
cle weakness and loss of reflexes, especially   feet, legs, hands, and arms.
at the ankle, leading to changes in the way
a person walks. Foot deformities, such as
hammertoes and the collapse of the midfoot,
may occur. Blisters and sores may appear on
numb areas of the foot because pressure or
injury goes unnoticed. If an infection occurs
and is not treated promptly, the infection
may spread to the bone, and the foot may
then have to be amputated. Many amputa­
tions are preventable if minor problems are
caught and treated in time.

3 Diabetic Neuropathies: The Nerve Damage of Diabetes
What is autonomic                                        Hypoglycemia Unawareness
neuropathy?                                              Normally, symptoms such as shakiness,
                                                         sweating, and palpitations occur when blood
Autonomic neuropathy affects the nerves                  glucose levels drop below 70 mg/dL. In
that control the heart, regulate blood pres­             people with autonomic neuropathy, symp­
sure, and control blood glucose levels.                  toms may not occur, making hypoglycemia
Autonomic neuropathy also affects other                  difficult to recognize. Problems other than
internal organs, causing problems with                   neuropathy can also cause hypoglycemia
digestion, respiratory function, urination,              unawareness.
sexual response, and vision. In addition, the
system that restores blood glucose levels to             Heart and Blood Vessels
normal after a hypoglycemic episode may
                                                         The heart and blood vessels are part of the
be affected, resulting in loss of the warning
                                                         cardiovascular system, which controls blood
symptoms of hypoglycemia.
                                                         circulation. Damage to nerves in the car­
                                                         diovascular system interferes with the body’s
                                                         ability to adjust blood pressure and heart
                                                         rate. As a result, blood pressure may drop
                                                         sharply after sitting or standing, causing a
                                                         person to feel light-headed or even to faint.
                                                         Damage to the nerves that control heart
                                                         rate can mean that the heart rate stays high,
                                                         instead of rising and falling in response to
                                                         normal body functions and physical activity.

                                                         Digestive System
                                                         Nerve damage to the digestive system most
                                                         commonly causes constipation. Damage can
                                                         also cause the stomach to empty too slowly,
                                                         a condition called gastroparesis. Severe
                                                         gastroparesis can lead to persistent nausea
                                                         and vomiting, bloating, and loss of appetite.
                                                         Gastroparesis can also make blood glucose
                                                         levels fluctuate widely due to abnormal food
                                                         digestion.
                                                         Nerve damage to the esophagus may make
                                                         swallowing difficult, while nerve damage to
                                                         the bowels can cause constipation alternat­
                                                         ing with frequent, uncontrolled diarrhea,
                                                         especially at night. Problems with the diges­
Autonomic neuropathy affects the nerves in the           tive system can lead to weight loss.
heart, stomach, intestines, bladder, sex organs, sweat
glands, eyes, and lungs.

4 Diabetic Neuropathies: The Nerve Damage of Diabetes
Urinary Tract and Sex Organs                      What is proximal
Autonomic neuropathy often affects the            neuropathy?
organs that control urination and sexual
                                                  Proximal neuropathy, sometimes called lum­
function. Nerve damage can prevent the
                                                  bosacral plexus neuropathy, femoral neurop­
bladder from emptying completely, allowing
                                                  athy, or diabetic amyotrophy, starts with pain
bacteria to grow in the bladder and kidneys
                                                  in the thighs, hips, buttocks, or legs, usually
and causing urinary tract infections. When
                                                  on one side of the body. This type of neu­
the nerves of the bladder are damaged,
                                                  ropathy is more common in those with type 2
urinary incontinence may result because a
                                                  diabetes and in older adults with diabetes.
person may not be able to sense when the
                                                  Proximal neuropathy causes weakness in the
bladder is full or control the muscles that
                                                  legs and the inability to go from a sitting to
release urine.
                                                  a standing position without help. Treatment
Autonomic neuropathy can also gradu­              for weakness or pain is usually needed. The
ally decrease sexual response in men and          length of the recovery period varies, depend­
women, although the sex drive may be              ing on the type of nerve damage.
unchanged. A man may be unable to have
erections or may reach sexual climax with­        What is focal neuropathy?
out ejaculating normally. A woman may
have difficulty with arousal, lubrication, or     Focal neuropathy appears suddenly and
orgasm.                                           affects specific nerves, most often in the
                                                  head, torso, or leg. Focal neuropathy may
Sweat Glands                                      cause
Autonomic neuropathy can affect the nerves          • inability to focus the eye
that control sweating. When nerve dam­
                                                    • double vision
age prevents the sweat glands from work­
ing properly, the body cannot regulate its          • aching behind one eye
temperature as it should. Nerve damage can          • paralysis on one side of the face, called
also cause profuse sweating at night or while         Bell’s palsy
eating.
                                                    • severe pain in the lower back or pelvis
Eyes                                                • pain in the front of a thigh
Finally, autonomic neuropathy can affect the        • pain in the chest, stomach, or side
pupils of the eyes, making them less respon­        • pain on the outside of the shin or inside
sive to changes in light. As a result, a person       of the foot
may not be able to see well when a light
is turned on in a dark room or may have             • chest or abdominal pain that is some­
trouble driving at night.                             times mistaken for heart disease, a
                                                      heart attack, or appendicitis
                                                  Focal neuropathy is painful and unpredict­
                                                  able and occurs most often in older adults
                                                  with diabetes. However, it tends to improve
                                                  by itself over weeks or months and does not
                                                  cause long-term damage.

5 Diabetic Neuropathies: The Nerve Damage of Diabetes
People with diabetes also tend to develop       A comprehensive foot exam assesses the
nerve compressions, also called entrapment      skin, muscles, bones, circulation, and sen­
syndromes. One of the most common is            sation of the feet. The doctor may assess
carpal tunnel syndrome, which causes numb­      protective sensation or feeling in the feet by
ness and tingling of the hand and sometimes     touching them with a nylon monofilament—
muscle weakness or pain. Other nerves           similar to a bristle on a hairbrush—attached
susceptible to entrapment may cause pain on     to a wand or by pricking them with a pin.
the outside of the shin or the inside of the    People who cannot sense pressure from a
foot.                                           pinprick or monofilament have lost protec­
                                                tive sensation and are at risk for developing
                                                foot sores that may not heal properly. The
Can diabetic neuropathies                       doctor may also check temperature percep­
be prevented?                                   tion or use a tuning fork, which is more sen­
The best way to prevent neuropathy is to        sitive than touch pressure, to assess vibration
keep blood glucose levels as close to the       perception.
normal range as possible. Maintaining safe
blood glucose levels protects nerves through­   Other Tests
out the body.                                   The doctor may perform other tests as part
                                                of the diagnosis.
How are diabetic                                  • Nerve conduction studies or electro­
neuropathies diagnosed?                             myography are sometimes used to help
                                                    determine the type and extent of nerve
Doctors diagnose neuropathy on the basis of         damage. Nerve conduction studies
symptoms and a physical exam. During the            check the transmission of electrical cur­
exam, the doctor may check blood pressure,          rent through a nerve. Electromyogra­
heart rate, muscle strength, reflexes, and          phy shows how well muscles respond to
sensitivity to position changes, vibration,         electrical signals transmitted by nearby
temperature, or light touch.                        nerves. These tests are rarely needed to
                                                    diagnose neuropathy.
Foot Exams
                                                  • A check of heart rate variability shows
Experts recommend that people with dia­
                                                    how the heart responds to deep breath­
betes have a comprehensive foot exam each
                                                    ing and to changes in blood pressure
year to check for peripheral neuropathy.
                                                    and posture.
People diagnosed with peripheral neuropa­
thy need more frequent foot exams.                • Ultrasound uses sound waves to pro­
                                                    duce an image of internal organs. An
                                                    ultrasound of the bladder and other
                                                    parts of the urinary tract, for example,
                                                    can be used to assess the structure
                                                    of these organs and show whether
                                                    the bladder empties completely after
                                                    urination.

6 Diabetic Neuropathies: The Nerve Damage of Diabetes
How are diabetic                                  • anticonvulsants, such as pregabalin
                                                    (Lyrica), gabapentin (Gabarone, Neu­
neuropathies treated?                               rontin), carbamazepine, and lamotrig­
The first treatment step is to bring blood          ine (Lamictal)
glucose levels within the normal range to         • opioids and opioidlike drugs, such as
help prevent further nerve damage. Blood            controlled-release oxycodone, an opi­
glucose monitoring, meal planning, physical         oid; and tramadol (Ultram), an opioid
activity, and diabetes medicines or insulin         that also acts as an antidepressant
will help control blood glucose levels. Symp­
toms may get worse when blood glucose is        Duloxetine and pregabalin are approved by
first brought under control, but over time,     the U.S. Food and Drug Administration spe­
maintaining lower blood glucose levels helps    cifically for treating painful diabetic periph­
lessen symptoms. Good blood glucose con­        eral neuropathy.
trol may also help prevent or delay the onset   People do not have to be depressed for an
of further problems. As scientists learn        antidepressant to help relieve their nerve
more about the underlying causes of neurop­     pain. All medications have side effects, and
athy, new treatments may become available       some are not recommended for use in older
to help slow, prevent, or even reverse nerve    adults or those with heart disease. Because
damage.                                         over-the-counter pain medicines such as
As described in the following sections,         acetaminophen and ibuprofen may not work
additional treatment depends on the type of     well for treating most nerve pain and can
nerve problem and symptom.                      have serious side effects, some experts rec­
                                                ommend avoiding these medications.
Pain Relief                                     Treatments that are applied to the skin—
Doctors usually treat painful diabetic neu­     typically to the feet—include capsaicin
ropathy with oral medications, although         cream and lidocaine patches (Lidoderm,
other types of treatments may help some         Lidopain). Studies suggest that nitrate
people. People with severe nerve pain may       sprays or patches for the feet may relieve
benefit from a combination of medications       pain. Studies of alpha-lipoic acid, an
or treatments and should consider talking       antioxidant, and evening primrose oil
with a health care provider about treatment     suggest they may help relieve symptoms and
options.                                        improve nerve function in some patients.
Medications used to help relieve diabetic       A device called a bed cradle can keep sheets
nerve pain include                              and blankets from touching sensitive feet
 • tricyclic antidepressants, such as ami­      and legs. Acupuncture, biofeedback, or
   triptyline, imipramine, and desipramine      physical therapy may help relieve pain in
   (Norpramin, Pertofrane)                      some people. Treatments that involve elec­
                                                trical nerve stimulation, magnetic therapy,
 • other types of antidepressants, such as      and laser or light therapy may be helpful but
   duloxetine (Cymbalta), venlafaxine,          need further study. Researchers are also
   bupropion (Wellbutrin), paroxetine           studying several new therapies in clinical
   (Paxil), and citalopram (Celexa)             trials.

7 Diabetic Neuropathies: The Nerve Damage of Diabetes
Gastrointestinal Problems                       To treat erectile dysfunction in men, the doc­
To relieve mild symptoms of gastroparesis—      tor will first do tests to rule out a hormonal
indigestion, belching, nausea, or vomiting—     cause. Several methods are available to treat
doctors suggest eating small, frequent          erectile dysfunction caused by neuropathy.
meals; avoiding fats; and eating less fiber.    Medicines are available to help men have
When symptoms are severe, doctors may           and maintain erections by increasing blood
prescribe erythromycin to speed digestion,      flow to the penis. Some are oral medica­
metoclopramide to speed digestion and help      tions and others are injected into the penis
relieve nausea, or other medications to help    or inserted into the urethra at the tip of the
regulate digestion or reduce stomach acid       penis. Mechanical vacuum devices can also
secretion.                                      increase blood flow to the penis. Another
                                                option is to surgically implant an inflatable
To relieve diarrhea or other bowel prob­        or semirigid device in the penis.
lems, doctors may prescribe an antibiotic
such as tetracycline, or other medications as   Vaginal lubricants may be useful for women
appropriate.                                    when neuropathy causes vaginal dry­
                                                ness. To treat problems with arousal and
Dizziness and Weakness                          orgasm, the doctor may refer women to a
                                                gynecologist.
Sitting or standing up slowly may help
prevent the light-headedness, dizziness, or     Foot Care
fainting associated with blood pressure and
circulation problems. Raising the head of       People with neuropathy need to take special
the bed or wearing elastic stockings may also   care of their feet. The nerves to the feet
help. Some people benefit from increased        are the longest in the body and are the ones
salt in the diet and treatment with salt-       most often affected by neuropathy. Loss
retaining hormones. Others benefit from         of sensation in the feet means that sores or
high blood pressure medications. Physical       injuries may not be noticed and may become
therapy can help when muscle weakness or        ulcerated or infected. Circulation problems
loss of coordination is a problem.              also increase the risk of foot ulcers. Smok­
                                                ing increases the risk of foot problems and
Urinary and Sexual Problems                     amputation. A health care provider may be
                                                able to provide help with quitting smoking.
To clear up a urinary tract infection, the
doctor will probably prescribe an antibiotic.   More than 60 percent of all nontraumatic
Drinking plenty of fluids will help prevent     lower-limb amputations in the United States
another infection. People who have incon­       occur in people with diabetes. Nontraumatic
tinence should try to urinate at regular        amputations are those not caused by trauma
intervals—every 3 hours, for example—           such as severe injuries from an accident.
because they may not be able to tell when       In 2004, about 71,000 nontraumatic amputa­
the bladder is full.                            tions were performed in people with diabe­
                                                tes. Comprehensive foot care programs can
                                                reduce amputation rates by 45 to 85 percent.

8 Diabetic Neuropathies: The Nerve Damage of Diabetes
Careful foot care involves
  • cleaning the feet daily using warm—             Points to Remember
    not hot—water and a mild soap. Soak­              • Diabetic neuropathies are nerve
    ing the feet should be avoided. A soft              disorders caused by many of the
    towel can be used to dry the feet and               abnormalities common to diabetes,
    between the toes.                                   such as high blood glucose.
  • inspecting the feet and toes every day            • Neuropathy can affect nerves
    for cuts, blisters, redness, swelling,              throughout the body, causing
    calluses, or other problems. Using a                numbness and sometimes pain in
    mirror—handheld or placed on the                    the hands, arms, feet, or legs, and
    floor—may be helpful in checking the                problems with the digestive tract,
    bottoms of the feet, or another person              heart, sex organs, and other body
    can help check the feet. A health care              systems.
    provider should be notified of any                • Treatment first involves bringing
    problems.                                           blood glucose levels within the
  • using lotion to moisturize the feet.                normal range. Good blood glucose
    Getting lotion between the toes should              control may help prevent or delay
    be avoided.                                         the onset of further problems.
  • filing corns and calluses gently with a           • Foot care is an important part of
    pumice stone after a bath or shower.                treatment. People with neuropathy
  • cutting toenails to the shape of the                need to inspect their feet daily for
    toes and filing the edges with an emery             any injuries. Untreated injuries
    board each week or when needed.                     increase the risk of infected foot
                                                        sores and amputation.
  • always wearing shoes or slippers to pro­
    tect feet from injuries. Wearing thick,           • Treatment also includes pain relief
    soft, seamless socks can prevent skin               and other medications as needed,
    irritation.                                         depending on the type of nerve
                                                        damage.
  • wearing shoes that fit well and allow the
    toes to move. New shoes can be broken             • Smoking increases the risk of foot
    in gradually by first wearing them for              problems and amputation. A
    only an hour at a time.                             health care provider may be able to
                                                        provide help with quitting.
  • looking shoes over carefully before put­
    ting them on and feeling the insides to
    make sure the shoes are free of tears,
    sharp edges, or objects that might injure     Hope through Research
    the feet.
                                                  The National Institute of Diabetes and Diges­
People who need help taking care of their         tive and Kidney Diseases (NIDDK) conducts
feet should consider making an appointment        and supports research to help people with
to see a foot doctor, also called a podiatrist.   diabetes.
                                                  Participants in clinical trials can play a more
                                                  active role in their own health care, gain access
                                                  to new research treatments before they are
                                                  widely available, and help others by contribut­
                                                  ing to medical research. For information about
                                                  current studies, visit www.ClinicalTrials.gov.
9 Diabetic Neuropathies: The Nerve Damage of Diabetes
For More Information                             For more information, contact the following
                                                 organizations:
See the following publications from the
NIDDK for more information about topics          American Diabetes Association
related to diabetic neuropathies:                1701 North Beauregard Street
                                                 Alexandria, VA 22311
  • Gastroparesis—stomach nerve dam-
                                                 Phone: 1–800–DIABETES (342–2383)
    age—available online at www.diges-
                                                 Email: AskADA@diabetes.org
    tive.niddk.nih.gov/ddiseases/pubs/
                                                 Internet: www.diabetes.org
    gastroparesis
  • Hypoglycemia—available online at             American Podiatric Medical Association
    www.diabetes.niddk.nih.gov/dm/pubs/          9312 Old Georgetown Road
    hypoglycemia                                 Bethesda, MD 20814–1621
                                                 Phone: 1–800–FOOTCARE (366–8227)
  • Nerve Disease and Bladder Control—              or 301–581–9200
    available online at www.kidney.niddk.        Fax: 301–530–2752
    nih.gov/kudiseases/pubs/nervedisease         Email: askapma@apma.org
  • Prevent diabetes problems: Keep your         Internet: www.apma.org
    feet and skin healthy and Prevent diabe-
    tes problems: Keep your nervous system       American Urological Association
    healthy, two publications in the Prevent     Foundation
    Diabetes Problems Series—available           1000 Corporate Boulevard
    online at www.diabetes.niddk.nih.gov/        Linthicum, MD 21090
    dm/pubs/complications                        Phone: 1–800–828–7866
                                                    or 410–689–3700
  • Sexual and Urologic Problems of              Fax: 410–689–3998
    Diabetes—available online at www.            Email: auafoundation@auafoundation.org
    diabetes.niddk.nih.gov/dm/pubs/sup           Internet: www.UrologyHealth.org
  • Take Care of Your Feet for a Lifetime,
                                                 Centers for Disease Control and Prevention
    available from the National Diabe-
                                                 National Center for Chronic Disease Pre-
    tes Education Program by calling
                                                 vention and Health Promotion
    1–888–693–NDEP (6337) or visiting
                                                 Division of Diabetes Translation
    www.ndep.nih.gov/campaigns/Feet/
                                                 4770 Buford Highway NE, Mail Stop K–10
    Feet_overview.htm
                                                 Atlanta, GA 30341–3717
These publications are also available by call-   Phone: 1–800–CDC–INFO (232–4636)
ing 1–800–860–8747.                                 or 770–488–5000
                                                 Email: cdcinfo@cdc.gov
                                                 Internet: www.cdc.gov/diabetes

10 Diabetic Neuropathies: The Nerve Damage of Diabetes
Juvenile Diabetes Research Foundation       National Institute of Neurological Disorders
International                               and Stroke
26 Broadway, 14th Floor                     P.O. Box 5801
New York, NY 10004                          Bethesda, MD 20824
Phone: 1–800–533–CURE (2873)                Phone: 1–800–352–9424
Fax: 212–785–9595                              or 301–496–5751
Email: info@jdrf.org                        Internet: www.ninds.nih.gov
Internet: www.jdrf.org
                                            National Kidney and Urologic Diseases
Lower Extremity Amputation Prevention       Information Clearinghouse
Program                                     3 Information Way
Health Resources and Services               Bethesda, MD 20892–3580
Administration                              Phone: 1–800–891–5390
5600 Fishers Lane                           TTY: 1–866–569–1162
Rockville, MD 20857                         Fax: 703–738–4929
Phone: 1–888–ASK–HRSA (275–4772)            Email: nkudic@info.niddk.nih.gov
Internet: www.hrsa.gov/leap                 Internet: www.kidney.niddk.nih.gov
National Diabetes Education Program         Pedorthic Footwear Association
1 Diabetes Way                              2025 M Street NW, Suite 800
Bethesda, MD 20814–9692                     Washington, DC 20036
Phone: 1–888–693–NDEP (6337)                Phone: 1–800–673–8447
TTY: 1–866–569–1162                            or 202–367–1145
Fax: 703–738–4929                           Fax: 202–367–2145
Email: ndep@mail.nih.gov                    Email: info@pedorthics.org
Internet: www.ndep.nih.gov                  Internet: www.pedorthics.org
National Digestive Diseases Information
Clearinghouse
2 Information Way
Bethesda, MD 20892–3570
Phone: 1–800–891–5389
TTY: 1–866–569–1162
Fax: 703–738–4929
Email: nddic@info.niddk.nih.gov
Internet: www.digestive.niddk.nih.gov
National Heart, Lung, and Blood Institute
Information Center
P.O. Box 30105
Bethesda, MD 20824–0105
Phone: 301–592–8573
Fax: 240–629–3246
Email: nhlbiinfo@nhlbi.nih.gov
Internet: www.nhlbi.nih.gov

11 Diabetic Neuropathies: The Nerve Damage of Diabetes
You may also find additional information about this     National Diabetes
topic by visiting MedlinePlus at www.medlineplus.gov.
This publication may contain information about med-
                                                        Information Clearinghouse
ications. When prepared, this publication included         1 Information Way
the most current information available. For updates        Bethesda, MD 20892–3560
or for questions about any medications, contact            Phone: 1–800–860–8747
the U.S. Food and Drug Administration toll-free at
1–888–INFO–FDA (463–6332) or visit www.fda.gov.            TTY: 1–866–569–1162
Consult your doctor for more information.                  Fax: 703–738–4929
                                                           Email: ndic@info.niddk.nih.gov
                                                           Internet: www.diabetes.niddk.nih.gov

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                                                        answers inquiries, develops and distributes
                                                        publications, and works closely with professional
                                                        and patient organizations and Government
                                                        agencies to coordinate resources about diabetes.
                                                        Publications produced by the Clearinghouse are
                                                        carefully reviewed by both NIDDK scientists and
                                                        outside experts. This publication was originally
                                                        reviewed by Peter J. Dyck, M.D., Peripheral
                                                        Neuropathy Research Laboratory, Mayo Clinic
                                                        Rochester, Rochester, MN; Eva L. Feldman,
                                                        M.D., Ph.D., Department of Neurology,
                                                        University of Michigan, Ann Arbor, MI; and
                                                        Aaron I. Vinik, M.D., Ph.D., Strelitz Diabetes
                                                        Research Institute, Eastern Virginia Medical
                                                        School, Norfolk, VA. Dr. Feldman also reviewed
                                                        the updated version of the publication.

                                                         This publication is not copyrighted. The Clearinghouse
                                                         encourages users of this fact sheet to duplicate and
                                                         distribute as many copies as desired.
                                                         This fact sheet is also available at
                                                         www.diabetes.niddk.nih.gov.

                                                                          U.S. DEPARTMENT OF HEALTH
                                                                          AND HUMAN SERVICES
                                                                          National Institutes of Health

                                                                          NIH Publication No. 09–3185
                                                                          February 2009
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