Diabetic neuropathy: symptoms, treatment and how to protect your nerves

The NHS lists the main symptoms of peripheral neuropathy as numbness and tingling in the feet or hands, burning, stabbing or shooting pain, loss of balance and coordination, and muscle weakness, especially in the feet. They are usually constant but may come and go. The NHS advises seeing a GP for pain, tingling or loss of sensation in the feet, loss of balance or weakness, or a cut or ulcer on the foot that is not getting better, and says people at highest risk, such as people with diabetes, should have regular check-ups.

Diabetes UK adds that symptoms can include changes to normal body functions, such as constipation or diarrhoea, bladder leaking or difficulty getting an erection, as well as weakness and loss of reflexes. It explains that pain can feel worse at night, possibly because of cooler temperatures, end-of-day stress and fewer distractions, though the reason is not certain.

The main safety concern with sensory neuropathy is loss of feeling in the feet. Diabetes UK says this is dangerous because you may not notice minor injuries, for example stepping on something sharp or a blister from badly fitting shoes, and ignored injuries can become infections or ulcers. It says people with diabetes are more likely to be admitted to hospital with a foot ulcer than with any other diabetes complication, and that neuropathy raises the risk of Charcot foot.

Both Diabetes UK and the NHS emphasise that keeping diabetes well managed, with cholesterol and blood pressure in target range, can help improve symptoms and stop nerve damage getting worse. The NHS adds stopping smoking and cutting down on alcohol as part of this. Diabetes UK says that sometimes neuropathy can get better over time if the cause is treated, but in some people damage may be permanent or worsen, and that treatment is often for symptoms rather than the nerve damage itself.

The NHS explains that neuropathic pain does not usually get better with common painkillers such as paracetamol and ibuprofen. Medicines recommended for it include amitriptyline, duloxetine, pregabalin and gabapentin, which are also used for conditions such as depression, epilepsy, anxiety or headaches. If you are given an antidepressant, the NHS says it may treat pain even if you are not depressed, and does not mean the doctor suspects depression. These medicines are usually started at the lowest dose and increased gradually, and common side effects include tiredness, dizziness or feeling drunk. NICE guidance says to offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin first and to try one of the others if the first is ineffective or not tolerated, with regular reviews. Capsaicin cream may be considered for localised pain when someone cannot or does not want to take tablets.

Other symptoms are treated individually, according to the NHS: for example physiotherapy and walking aids for muscle weakness. Diabetes UK mentions treatment for sickness, for erectile dysfunction and for autonomic problems, and notes research into TENS (electrical nerve stimulation) is ongoing. NICE advises considering referral to a specialist pain service if pain is severe or limits daily activities or sleep. Medicines should only be started, changed or stopped with a prescriber, and the NHS advises not driving if the medicine makes you drowsy or blurs vision.

Nerves carry messages between the brain and every part of the body, and also carry signals that control things like heart rate and breathing, as Diabetes UK explains. Over time, high blood glucose can damage the small blood vessels that supply the nerves. This stops essential nutrients reaching the nerves, so nerve fibres can become damaged and may disappear.

The NHS describes peripheral neuropathy as damage to nerves in the extremities such as the hands, feet and arms, and notes that in the UK it is estimated almost 1 in 10 people aged 55 or over are affected, from all causes. In people with diabetes it is sometimes called diabetic polyneuropathy. Polyneuropathy typically begins in the feet, because the longest nerves are affected first, and can seem to spread upwards and later reach the hands.

Diabetes UK describes four types, and says your healthcare team should tell you which areas are affected. Treatment depends on the type.

The NHS says untreated nerve damage can lead to serious complications, such as a foot ulcer that becomes infected, which can lead to gangrene and in severe cases amputation. Diabetes UK says loss of feeling in the feet is dangerous because you may not notice minor injuries.

Contact your GP or diabetes foot protection team promptly if you have a cut, blister, sore, or any change in colour, swelling or heat in a foot, rather than waiting for pain. The NHS says to see a GP if you have a cut or ulcer on your foot that is not getting better, and that the sooner peripheral neuropathy is diagnosed, the better the chance of limiting the damage.

Diabetes UK says your doctor or diabetes nurse will screen for signs of neuropathy at your annual review: checking feeling in your feet and your reflexes with special equipment, checking cholesterol and blood pressure, which affect risk, and asking about other symptoms. It stresses that not all types of neuropathy are screened for, so you should talk to your GP about any new or worsening symptoms.

The NHS says a GP will ask about symptoms and may arrange tests to find the underlying cause, and that you may be referred to a neurologist. Because diabetes is not the only cause, the NHS lists others including physical injury, viral infection such as shingles, certain medicines and drinking too much alcohol, and its treatment page mentions vitamin B12 deficiency as a treatable cause. The NHS also notes that, generally, the sooner neuropathy is diagnosed the better the chance of limiting the damage.

NICE guideline CG173 says to offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain, and that if the first drug is not effective or not tolerated, you should be offered one of the remaining three. It says to consider capsaicin cream for people with localised pain who wish to avoid, or cannot tolerate, oral treatments, and to consider tramadol only if acute rescue therapy is needed.

The NHS says these medicines are usually started at the minimum dose and increased gradually. The most common side effects are tiredness, dizziness or feeling "drunk", which should improve after a week or two as your body gets used to the medicine. If side effects continue, tell a GP, because it may be possible to change to a medicine that suits you better. Even if the first medicine does not help, others may.

Diabetes UK suggests being physically active, eating a balanced diet that includes essential vitamins and minerals, keeping blood sugar as close to target as possible and managing cholesterol and blood pressure. You should check your feet every day and have them examined by a healthcare professional once a year, particularly if you think you have lost feeling.

If you have a cut, blister, sore or any change in colour, swelling or heat in a foot, treat it as a reason to contact your foot protection team or GP promptly rather than waiting for pain, because with neuropathy pain may be absent. The diabetic foot ulcer guide on this site sets out the warning signs in more detail.

The NHS says the outlook varies depending on the underlying cause and which nerves are damaged. Some cases improve with time when the cause is treated, while in others the damage may be permanent or gradually worsen. Untreated, complications can include foot ulcers that become infected, which can lead to gangrene and in severe cases amputation, and neuropathy affecting the heart and circulation may need treatment to raise blood pressure or, rarely, a pacemaker.

Diabetes UK recognises that living with long-term pain can be very distressing and affect mental health and wellbeing. If you are having frequent pain you struggle to cope with, contact your GP, who can review medicines, sleep and referral options.

Screening, foot protection services and first-line treatment of nerve pain are delivered through GP practices and diabetes teams on the NHS, with referral to neurology, pain services or podiatry when needed.

A private neurologist or pain specialist can offer faster nerve testing or a second opinion on persistent pain, and may suggest tests such as nerve conduction studies. Tell your diabetes team about any treatment you start privately, since several nerve pain medicines interact with other drugs and affect alertness.