From the Guidelines
Diabetic neuropathy treatment should prioritize optimizing blood glucose control and addressing pain management through medications such as gabapentinoids, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, as recommended by the most recent guidelines 1.
Key Recommendations
- Optimize blood glucose control to prevent or delay the development of neuropathy in people with type 1 diabetes and to slow the progression of neuropathy in people with type 2 diabetes 1.
- Assess and treat pain related to diabetic peripheral neuropathy and symptoms of autonomic neuropathy to improve quality of life 1.
- Consider gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers as initial pharmacologic treatments for neuropathic pain in diabetes 1.
Medication Options
- Gabapentinoids: pregabalin (starting at 50mg three times daily, maximum 600mg daily) or gabapentin (starting at 300mg daily, gradually increasing to 1800-3600mg daily in divided doses) 1.
- Serotonin-norepinephrine reuptake inhibitors: duloxetine (60-120mg daily) or venlafaxine (150-225mg daily) 1.
- Tricyclic antidepressants: amitriptyline (10-25mg at bedtime, increasing gradually if needed) 1.
Non-Pharmacological Approaches
- Physical therapy and regular gentle exercise to improve mobility and reduce pain.
- Proper foot care with daily inspection and wearing appropriate footwear to prevent further complications.
- Alpha-lipoic acid (600mg daily) may help reduce symptoms through its antioxidant properties 1.
Important Considerations
- Treatment should be individualized based on pain severity, comorbidities, and potential drug interactions, with regular follow-up to assess efficacy and adjust therapy as needed 1.
- Opioids should generally be avoided due to dependency risks, but may be considered for severe pain unresponsive to other medications 1.
From the FDA Drug Label
Pregabalin is indicated for: Management of neuropathic pain associated with diabetic peripheral neuropathy The efficacy of duloxetine delayed-release capsules for the management of neuropathic pain associated with diabetic peripheral neuropathy in adults was established in 2 randomized, 12-week, double-blind, placebo-controlled, fixed-dose trials in adult patients having diabetic peripheral neuropathic pain (DPNP) for at least 6 months
Treatment Options for Diabetic Neuropathy:
- Pregabalin: indicated for the management of neuropathic pain associated with diabetic peripheral neuropathy 2
- Duloxetine: efficacy established for the management of neuropathic pain associated with diabetic peripheral neuropathy in adults 3
From the Research
Treatment Options for Diabetic Neuropathy
- Improved glycemic control is the cornerstone of treating diabetic neuropathy, as it can dramatically reduce the incidence of neuropathy in patients with type 1 diabetes and has a marginal effect on prevention in patients with type 2 diabetes 4, 5, 6
- Medications such as calcium channel agonists, tricyclic antidepressants, and selective serotonin/norepinephrine reuptake inhibitors are effective in reducing pain associated with diabetic neuropathy 4, 5, 7
- Anticonvulsants, antidepressants, and opioids are also used to manage painful symptoms in patients with diabetic neuropathy 5, 7
- Emerging treatment options include aldose reductase inhibitors, protein kinase-C inhibitors, and antioxidants such as a-lipoic acid, although their development and efficacy are still being researched 5
Pharmacological Treatments
- The United States Food and Drug Administration (FDA) has confirmed four drugs for painful diabetic neuropathy: pregabalin, duloxetine, tapentadol, and the 8% capsaicin patch 7
- A meta-analysis comparing duloxetine, pregabalin, and gabapentin found that all three drugs were superior to placebo in reducing pain severity, with some tolerability trade-offs 8
- Indirect comparisons between duloxetine and pregabalin found no differences in pain severity, but significant differences in Patient Global Impression of Improvement/Change, favoring pregabalin, and in dizziness, favoring duloxetine 8
Non-Pharmacological Treatments
- Spinal cord stimulation (SCS) and transcutaneous electrical nerve stimulation (TENS) have shown promise in reducing pain in patients with diabetic neuropathy 7
- These non-pharmacological treatments may be considered as alternative or adjunctive options for patients who do not respond to pharmacological treatments or have contraindications to certain medications 7