From the Guidelines
Treatment for neuropathy should prioritize optimizing glucose control and utilizing first-line medications such as gabapentinoids, serotonin-norepinephrine reuptake inhibitors, or tricyclic antidepressants to manage pain and improve quality of life. When managing neuropathy, it is essential to address the underlying cause while controlling symptoms. The most recent and highest quality study, 1, recommends optimizing glucose management 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. Some key treatment approaches include:
- Optimizing blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic neuropathy
- Assessing and treating pain related to diabetic peripheral neuropathy and symptoms of autonomic neuropathy to improve quality of life
- Using gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers as initial pharmacologic treatments for neuropathic pain in diabetes
- Referring to a neurologist or pain specialist when adequate pain management is not achieved within the scope of practice of the treating clinician. Additionally, lifestyle modifications such as regular gentle exercise, a balanced diet, and avoiding alcohol and smoking are crucial in preventing further nerve damage and supporting nerve health, as suggested by 1, 1, and 1. First-line medications for painful neuropathy may include anticonvulsants like gabapentin or pregabalin, and antidepressants such as duloxetine or amitriptyline, as recommended by 1. Topical treatments like lidocaine patches or capsaicin cream can provide localized relief, and non-medication approaches like physical therapy and transcutaneous electrical nerve stimulation (TENS) can also be effective, as noted in 1 and 1. Overall, treatment for neuropathy should be individualized and focused on improving quality of life, reducing pain, and slowing disease progression, as emphasized by the most recent study 1.
From the FDA Drug Label
- Indications and Usage Section 1 INDICATIONS AND USAGE Pregabalin is indicated for: Management of neuropathic pain associated with diabetic peripheral neuropathy Management of postherpetic neuralgia
- Clinical Studies 14. 1 Neuropathic Pain Associated with Diabetic Peripheral Neuropathy The efficacy of the maximum recommended dose of pregabalin for the management of neuropathic pain associated with diabetic peripheral neuropathy was established in three double-blind, placebo-controlled, multicenter studies with three times a day dosing, two of which studied the maximum recommended dose
Treatment for Neuropathy: Pregabalin is indicated for the management of neuropathic pain associated with diabetic peripheral neuropathy and postherpetic neuralgia.
- The efficacy of pregabalin was established in clinical studies, including three double-blind, placebo-controlled, multicenter studies for diabetic peripheral neuropathy.
- Pregabalin is also indicated for the management of postherpetic neuralgia, as established in three double-blind, placebo-controlled, multicenter studies 2. Key points:
- Pregabalin is used to manage neuropathic pain associated with diabetic peripheral neuropathy and postherpetic neuralgia.
- Clinical studies have established the efficacy of pregabalin for these indications 2.
From the Research
Treatment Options for Neuropathy
- First-line drug therapy for painful diabetic peripheral neuropathy includes duloxetine, gabapentin, amitriptyline, and pregabalin 3, 4, 5
- Second-line drug therapy includes nortriptyline, imipramine, venlafaxine, carbamazepine, oxcarbazepine, topical lidocaine, and topical capsaicin 3, 4
- Nondrug therapies with low- to moderate-quality evidence include exercise and neuromodulation with spinal cord stimulation or transcutaneous electrical nerve stimulation 3
- FDA-approved medications for painful diabetic neuropathies include duloxetine, pregabalin, tapentadol extended release, and capsaicin (for foot PDN only) 5
- Spinal cord stimulation system is also approved by the FDA for the treatment of diabetic neuropathy pain 5
Combination Therapies
- Combination treatment of amitriptyline supplemented with pregabalin, pregabalin supplemented with amitriptyline, and duloxetine supplemented with pregabalin showed similar analgesic efficacy 6
- Mean NRS reduction in patients on combination therapy was greater than in those who remained on monotherapy 6
Novel Therapies
- Current research is exploring alternative pain management treatments, including NMDA receptor and the endocannabinoid system 7
- New treatments, such as palmitoylethanolamide and endocannabinoid targets, show promising results but require further clinical trials 7
- Capsaicin and spinal cord stimulators (SCS) have been beneficial in addressing painful diabetic neuropathy 7