Tackling the Tricky Trio of Pain, Diabetes, and Sleep Dysfunction

Although clinicians are increasingly forced to face the 3-headed monster of comorbid diabetes, sleep disturbance, and pain, the healthcare community is only beginning to understand how the conditions overlap.

In a supplement to the Journal of Family Practice, Victor Rosenfeld, MD, Neurology Department Head and Medical Director of the Sleep Center at the SouthCoast Medical Group in Savannah, GA, discussed the interesting dynamic, noting that sleep dysfunction comprised of fragmented sleep, sleep deprivation, and sleep complaints wreaks havoc on glucose control, while frequent pain related to diabetes interrupts sleep — thus starting the vicious cycle.

More than 50% of men and 20% of women with type 2 diabetes mellitus (T2DM) are thought to have obstructive sleep apnea (OSA), which presents unique complications such as intermittent hypoxia that leads to insulin resistance; increased norepinephrine levels; increased hepatic and muscle gluconeogenesis; increased cortisol levels; and increased inflammatory cytokines. Despite its high prevalence and negative consequences in T2DM patients, up to 85% of OSA cases go undiagnosed.

As a result, the International Diabetes Federation (IDF) recommends screening all type 2 diabetics for OSA and using polysomnography studies as indicated to appropriately assess for the condition. In terms of OSA treatment, continuous positive airway pressure (CPAP) has been shown to improve glucose control and decrease insulin requirements.

Since 60-70% of diabetics develop some form of nerve damage, vigilance in tight glucose control is crucial, given that lowered glycated hemoglobin levels slow the progression of neuropathy. According to Rosenfeld, the various medication classes available to treat diabetic neuropathy include tricyclic antidepressants, anticonvulsants, opioids, serotonin—norepinephrine reuptake inhibitors (SNRIs), and even nutraceuticals.

In addition to the chronic pain associated with neuropathy, diabetics experience other types of discomfort. For example, chronic musculoskeletal pain may cause sleep dysfunction that leads to poor glucose control for T2DM patients; in turn, poor glucose control aggravates the neuropathic pain that fuels the viscous cycle of poor patient outcomes.

Thus, recognizing the associations among diabetes, sleep dysfunction, and pain allows physicians to manage patients’ symptoms appropriately and delay or prevent further complications.