Nerve pain caused by diabetic peripheral neuropathy can be severe, constant, and difficult to treat. It may start as a tingling sensation, followed by numbness and pain. But there are two key points that everyone with diabetes and peripheral neuropathy should know:

• Controlling your blood sugar levels can help prevent worsening nerve pain and improve your overall health at the same time.
• Medications can help relieve nerve pain, make you more comfortable, and improve your quality of life.

"We know that better glucose control is the single most important factor" in preventing neuropathy, slowing its progress once you have it, and relieving many symptoms, says Christopher Gibbons, MD, director of the Neuropathy Clinic at the Joslin Diabetes Center in Boston and instructor of neurology at Harvard Medical School.

If you have diabetes and peripheral neuropathy, talk to your doctor about ways to better control your blood sugar. You may need to take insulin for better control, says Gibbons.

Once you are doing all that you can to keep blood sugar levels under control - including diet, meal planning, exercise, and medication - you should assess with your doctor which pain medication is best to relieve your remaining symptoms.

Fortunately, medications can help relieve nerve pain from peripheral neuropathy so you can function at near-normal levels. You have many pain relief drugs from which to choose. But you may need to try several different types of pain relievers before you find the one that helps you.

Over-the-Counter Pain Relievers for Peripheral Neuropathy

Some people find relief for mild nerve pain right on their drug store shelves. Common pain relievers and some topical creams may help, depending on the severity of pain.

"As a first line of treatment, these can be very helpful," Gibbons says.

Anyone with diabetes should talk to their doctor before taking any medication. Even over-the-counter medications can interact with other drugs or cause severe side effects in people with diabetes.

Here are some over-the-counter pain relief options to consider:

NSAIDs (nonsteroidal anti-inflammatory drugs). These medicines reduce inflammation and relieve pain. NSAIDs available without a prescription include aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve).

But NSAIDs can cause harmful side effects such as stomach irritation and bleeding in some people if taken for weeks or months. When taken long-term they can also lead to kidney and liver damage, which may be more likely in people with diabetes.

However, says Gibbons, "In many cases, especially with younger people who are relatively healthy, the risk is quite low."

Acetaminophen. Tylenol and other over-the-counter pain relievers containing acetaminophen relieve pain without reducing inflammation. These medications do not cause the stomach irritation that NSAIDs do. However, taking more acetaminophen than recommended can lead to liver damage. It is important to read labels and check with your pharmacist.

Capsaicin. Found naturally in chili peppers, capsaicin is found in drug stores under various brand names, including Capzasin-P and Zostrix. "Capsaicin has been shown to relieve pain, but there is some concern," Gibbons tells WebMD. "It may not be the best approach."

Capsaicin is thought to ease pain by reducing a chemical called substance P, which is involved in transmitting pain signals through the nerves. On a short-term basis, it is an effective approach, says Gibbons.

"But we are concerned about the long-term consequences. These same nerves play a big role in wound healing. We're concerned that capsaicin could prevent wound healing, which is already a big problem for diabetes patients."

Lidocaine. Lidocaine is an anesthetic that numbs the area it has been applied to. It is available in gels and creams, both over the counter and by prescription. Some product names include Topicaine and Xylocaine.

Other Topical Creams. Salicylate is a chemical similar to aspirin, and is found in pain-relieving creams like Aspercreme and Bengay. Cortisone creams contain corticosteroids, which are potent anti-inflammatory drugs that can help relieve pain. Both are available at drug stores, but there is no clear evidence that they help relieve nerve pain from peripheral neuropathy.

Prescription Medications for Nerve Pain From Peripheral Neuropathy

Many people need to turn to prescription medication to find relief for nerve pain from peripheral neuropathy. Your choices include:

NSAIDs. Although some nonsteroidal anti-inflammatory drugs are available over the counter, your doctor may suggest higher doses, or different NSAIDs, that require a prescription. There are many prescription NSAIDs to choose from including, Celebrex, Lodine, and Relafen. People with diabetes are more at risk of kidney damage that can occur with NSAIDs. In addition, people with diabetes are at high risk of heart disease, and prescription NSAIDs may raise the risk of heart problems.

Antidepressants. Although antidepressants were developed for depression, these drugs have also become important in relieving chronic pain - whether the person is depressed or not. Doctors have been prescribing antidepressants for many years for pain control, says Gibbons. Antidepressants used to treat pain include:

• Tricyclic antidepressants (TCAs) primarily affect the levels of the brain chemicals norepinephrine and serotonin. "These are the most commonly used, the best studied, and the most effective of the antidepressants used for pain," says Gibbons.

  Of the TCAs, Elavil has been a very good option for pain, yet it has troublesome side effects. "It tends to have more side effects -- drowsiness, weight gain, dry mouth, dry eyes," Gibbons says. For people with peripheral neuropathy, there can be additional side effects. Many patients develop blood pressure and heart rate problems and get dizziness when taking Elavil, he says.

  A newer drug in this class, Pamelor, is "quite effective, with fewer side effects, so it is better tolerated," says Gibbons. "Norpramin is also good and has the least side effects of all."

• Selective Serotonin Reuptake Inhibitors (SSRIs) are a newer form of antidepressant. These drugs work by altering the amount of the brain chemical serotonin. "These are very effective for depression, but less effective for pain," says Gibbons. "They've been shown effective in some studies, but they're clearly not as effective as TCAs for pain."
  
• Serotonin and norepinephrine reuptake inhibitors (SNRIs) are another newer form of antidepressant medicine. They treat depression by increasing availability of the brain chemicals serotonin and norepinephrine.

  Effexor and Cymbalta "are quite effective for pain," says Gibbons. "They are equally effective, but have fewer side effects than the SSRIs or TCAs." Cymbalta is FDA-approved for painful neuropathy; Effexor is not.

Antiseizure Drugs. Drugs that prevent epileptic seizures can also relieve certain pain conditions, including neuropathy. "The majority of pain patients can be treated with any of these," says Gibbons. The drugs work by controlling the abnormal firing of nerve cells - in the brain and in other parts of the body, like legs and arms, he explains.

• Neurontin is the antiseizure drug most commonly used for nerve pain from peripheral neuropathy. "It's quite effective in treatment of painful neuropathy," says Gibbons. "It does tend to cause sedation or dizziness at higher doses. But if the dosage is increased slowly, it is quite well tolerated."
• Lyrica is a seizure medication that is FDA-approved for painful neuropathy. "It is designed as the next generation of Neurontin," says Gibbons. "But whether it's going to be more effective with fewer side effects -- that will take time to find out."

Opioid Medicines. When pain is very severe, patients want immediate relief, says Gibbons. That's when they may need to see a pain specialist. Sometimes people need strong painkillers called Ultram or Ultracet, possibly in combination with Neurontin. "The combination gets people past that acute stage of pain while I can slowly increase the Neurontin."

Both Ultram and Ultracet are FDA-approved painkillers that contain tramadol, a weak opioid (morphine-like) substance. The drug also weakly affects the brain chemicals serotonin and norepinephrine, similar to antidepressants, which reduces the perception of pain.

"Often we use tramadol as a back-up for what we call 'breakthrough pain' - pain that suddenly, for no apparent reason, is worse at times," says Gibbons. Tramadol is a good replacement for over-the-counter stuff at those times."

Neuropathy specialists shy away from strong narcotic opioid medications, he notes. Narcotics can cause severe constipation, and there is the potential for addiction. "There's also a stigma about using a narcotic drug," he says. "Depending on the type of work a person does, it could be a problem."

More Treatment Options for Peripheral Neuropathy

For severe, intractable pain, injections of local anesthetics such as lidocaine - or patches containing lidocaine - are used to numb the painful area.

Doctors can also:

• Surgically destroy nerves or relieve a nerve compression that causes pain.
• Implant a device that relieves pain.
• Perform electrical nerve stimulation which may relieve pain. In this treatment, small amounts of electricity are used to block pain signals as they pass through the skin. "It's debatable whether this is effective," says Gibbons.

Other useful aides to improve quality of life and function include:

• Hand or foot braces can compensate for muscle weakness or help relieve nerve compression.
• Orthopaedic shoes can improve gait (walking) problems, which will prevent foot injuries.

SOURCES: Christopher Gibbons, MD, director, Neuropathy Clinic, Joslin Diabetes Center, Boston, instructor of neurology, Harvard Medical School. National Institute of Neurological Disorders and Stroke: "Peripheral Neuropathy Fact Sheet." American Chronic Pain Association: ACPA Medications & Chronic Pain, September 2005.