From the Guidelines
I strongly recommend prioritizing improved glycemic control for this diabetic patient with an A1C of 10.1, as it is crucial for preventing worsening neuropathy and other complications, and aim for an HbA1c level between 7% and 8% as recommended by the American College of Physicians 1. The patient's treatment plan should include medications for neuropathic pain, such as amitriptyline, and inflammatory components, such as naproxen. Daily foot care with Lubriderm is essential to prevent dry skin and cracks that could lead to infections. Custom insoles for size 14 shoes will provide proper support and reduce pressure points that could lead to ulcers. Additionally, the patient should be educated on self-care of the feet, including daily inspection, washing, and drying, as well as avoiding walking barefoot or in thin-soled slippers 1. The patient's strong family history of diabetes and current A1C level indicate a need for close monitoring and management to prevent further complications. It is also important to consider the patient's individual characteristics, such as life expectancy, comorbid conditions, and risk for hypoglycemia, when determining the target HbA1c level and treatment plan 1. Overall, a comprehensive approach that includes medication, lifestyle modifications, and foot care is necessary to manage this patient's diabetes and prevent further complications.
From the FDA Drug Label
- Indications and Usage Pregabalin is indicated for: Management of neuropathic pain associated with diabetic peripheral neuropathy Management of postherpetic neuralgia Adjunctive therapy for the treatment of partial-onset seizures in patients 1 month of age and older Management of fibromyalgia Management of neuropathic pain associated with spinal cord injury
The patient's symptoms of left foot pain and tingling sensation are consistent with neuropathic pain associated with diabetic peripheral neuropathy.
- Pregabalin is indicated for the management of this condition 2.
- However, the patient is being prescribed amitriptyline for nerve pain, not pregabalin.
- The FDA drug label for pregabalin supports its use for neuropathic pain associated with diabetic peripheral neuropathy, but it does not provide information on the use of amitriptyline for this condition.
- Therefore, based on the provided drug label, amitriptyline is not the preferred treatment option for this patient's condition, pregabalin would be a more suitable option according to the label 2.
From the Research
Patient Treatment
The patient is being treated for neuropathic pain with amitriptyline 25 mg QPM, which is a common treatment for this condition 3, 4. The dosage of 25 mg is considered low and has been shown to be effective in some studies 5.
Efficacy of Amitriptyline
Studies have shown that amitriptyline can be effective in treating neuropathic pain, particularly in patients with painful diabetic neuropathy (PDN) 3. However, the evidence is not always consistent, and some studies have found that amitriptyline is not effective in treating neuropathic pain 4, 6.
Comparison with Other Treatments
A study comparing the efficacy of pregabalin, amitriptyline, and gabapentin for neuropathic pain found that all three medications were similarly effective in alleviating pain, but gabapentin had fewer adverse effects 7.
Adverse Events
Amitriptyline has been associated with adverse events, including anticholinergic effects, and more participants experienced at least one adverse event compared to those taking placebo 3, 4.
Treatment Considerations
The patient's treatment plan also includes naproxen 500 mg and insoles for foot care, which can help to alleviate pain and prevent further complications. The use of Lubriderm for foot care is also a good practice to prevent dry skin and foot ulcers.
Family History
The patient's family history of diabetes is notable, as it may increase the patient's risk of developing complications related to diabetes, including neuropathic pain.
Monitoring and Follow-up
Regular monitoring and follow-up appointments will be necessary to assess the patient's response to treatment and adjust the treatment plan as needed.