From the Guidelines
To manage diabetic neuropathy, optimizing glucose control is crucial to prevent or delay its development, and first-line medications for neuropathic pain include gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers, as recommended by the most recent guidelines 1. The goal of treatment is to improve quality of life by alleviating pain and preventing further nerve damage.
- Key aspects of management include:
- Optimizing 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.
- Assessing and treating pain related to diabetic peripheral neuropathy and symptoms of autonomic neuropathy to improve quality of life 1.
- Using medications such as gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers as initial pharmacologic treatments for neuropathic pain in diabetes 1.
- Considering referral to a neurologist or pain specialist when pain control is not achieved within the scope of practice of the treating physician 1. Additionally, lifestyle modifications such as regular exercise, healthy diet, and avoidance of smoking can help improve overall health and reduce the risk of complications.
- Other treatments that may be considered include:
- Topical treatments like capsaicin cream or lidocaine patches for localized pain 1.
- Physical therapy and exercise to improve strength and balance.
- Daily foot inspections and proper footwear to prevent complications, along with regular podiatry visits. It is essential to prioritize the patient's quality of life and adjust treatment plans accordingly, taking into account the latest guidelines and evidence-based recommendations 1.
From the FDA Drug Label
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
4 Diabetic Peripheral Neuropathic Pain in Adults 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 (Study DPNP-1 and Study DPNP-2).
Diabetic Neuropathy Treatment Options:
- Pregabalin: Effective in managing neuropathic pain associated with diabetic peripheral neuropathy, as shown in three double-blind, placebo-controlled studies 2.
- Duloxetine: Also effective in managing neuropathic pain associated with diabetic peripheral neuropathy, as demonstrated in two 12-week, double-blind, placebo-controlled trials 3.
Key Points:
- Both pregabalin and duloxetine have been shown to be effective in reducing pain scores in patients with diabetic neuropathy.
- The studies used different dosing regimens and patient populations, but both drugs demonstrated statistically significant improvements in pain management compared to placebo.
From the Research
Definition and Prevalence of Diabetic Neuropathy
- Diabetic neuropathy is a common complication of diabetes mellitus, affecting 30-50% of patients 4, 5, 6.
- It is estimated that up to 50% of adults with diabetes will develop neuropathy in their lifetime 7, 5, 6.
- Diabetic peripheral neuropathy (DPN) is the major form of neuropathy, found in 75% of diabetic neuropathy incidences 7.
Symptoms and Treatment Options
- Patients with diabetic neuropathy typically present with numbness, tingling, pain, and loss of sensation in the extremities 5.
- First-line pharmacologic therapy for painful diabetic neuropathy (PDN) includes gabapentinoids (pregabalin and gabapentin) and duloxetine 8, 6.
- Additional pharmacologic modalities that are approved by the Food and Drug Administration (FDA) but are considered second-line agents include tapentadol and 8% capsaicin patch 8.
- Nonpharmacological treatments such as spinal cord stimulation (SCS) and transcutaneous electrical nerve stimulation (TENS) both show promise in reducing pain in DM patients 5, 6.
Prevention and Management
- Strict diabetes control prevents diabetic neuropathy and may restore neurologic deficits in the early stages 4.
- Addressing underlying risk factors such as poor glycemic control, vitamin B12 deficiency, elevated blood pressure, and obesity can reduce the likelihood of developing neuropathy 6.
- Periodic, objective monitoring of medication response is critical because patients may not obtain desired pain reduction, adverse effects are common, and serious adverse effects can occur 6.
- Opioids should generally be avoided due to the risk of adverse effects and addiction 6.