What's the best approach for a 39-year-old male patient with severe nerve damage, reported diabetic neuropathy (DN) without a diabetes diagnosis, normal hemoglobin A1C (HbA1C) level, and radiating cervical and low back pain to the right leg, currently being treated with naproxen (naproxen) and duloxetine (duloxetine)?

From the Guidelines

The best approach for this 39-year-old male patient with complex pain symptoms is to continue naproxen for inflammatory pain and duloxetine for neuropathic components, while further investigating the underlying cause of his symptoms through nerve conduction studies, glucose tolerance test, and MRI imaging of the cervical and lumbar spine. The patient's reported diabetic neuropathy without a diabetes diagnosis and normal HbA1C level is inconsistent and warrants further investigation to rule out prediabetes or other neuropathic conditions 1. For his radiating cervical and low back pain, MRI imaging of both areas is essential to identify potential nerve compression or disc pathology. Adding physical therapy focusing on spine stabilization exercises would be beneficial, as it can help improve mobility and reduce pain. Pregabalin or gabapentin could be considered as adjunctive medication specifically for neuropathic symptoms, starting at low doses (pregabalin 75mg twice daily or gabapentin 300mg three times daily) and titrating as needed, as supported by high-quality studies 1. Some key points to consider in the management of this patient include:

• The use of duloxetine, which has been shown to be effective in the treatment of neuropathic pain associated with diabetic peripheral neuropathy (DPN) 1.
• The potential risks and benefits of using opioids for chronic neuropathic pain, with a general recommendation to avoid their use due to the high risk of addiction and safety concerns 1.
• The importance of a multidisciplinary approach to pain management, including possible referrals to neurology and pain management specialists if symptoms persist. Pain management should focus on identifying and addressing the underlying cause of symptoms, rather than just controlling symptoms, to improve the patient's quality of life and reduce morbidity and mortality.

From the FDA Drug Label

Duloxetine delayed-release capsules are a prescription medicine used to treat a certain type of depression called Major Depressive Disorder (MDD) Duloxetine delayed-release capsules belong to a class of medicines known as SNRIs (or serotonin-norepinephrine reuptake inhibitors). Duloxetine delayed-release capsules are also used to treat or manage:

• Generalized Anxiety Disorder (GAD)
• Diabetic Peripheral Neuropathic Pain (DPNP)
• Fibromyalgia (FM)
• Chronic Musculoskeletal Pain

The best approach for a 39-year-old male patient with severe nerve damage, reported diabetic neuropathy (DN) without a diabetes diagnosis, normal hemoglobin A1C (HbA1C) level, and radiating cervical and low back pain to the right leg, currently being treated with naproxen and duloxetine, is to monitor the patient's condition closely.

• The patient's normal HbA1C level suggests that diabetes may not be the primary cause of the neuropathy, and further evaluation may be necessary to determine the underlying cause of the nerve damage.
• Duloxetine may be an effective treatment for the patient's neuropathic pain, as it is approved for the management of diabetic peripheral neuropathic pain (DPNP) 2.
• However, the patient's lack of diabetes diagnosis and normal HbA1C level may require caution when using duloxetine, as the drug may affect glycemic control in some patients with diabetes 2.
• The patient's treatment plan should be individualized, and the healthcare provider should closely monitor the patient's response to treatment and adjust the plan as needed.
• It is also important to address the patient's cervical and low back pain, which may be contributing to the nerve damage and neuropathic pain.
• The patient's treatment plan may need to be modified based on the underlying cause of the nerve damage and the patient's response to treatment.
• The healthcare provider should consider alternative treatments if the patient's condition does not improve with the current treatment plan.
• The patient should be educated on the potential risks and benefits of duloxetine and the importance of close monitoring and follow-up appointments with the healthcare provider.

From the Research

Patient Profile

• The patient is a 39-year-old male with severe nerve damage and reported diabetic neuropathy (DN) without a diabetes diagnosis.
• The patient's last hemoglobin A1C (HbA1C) level was 5.4, which is within the normal range.
• The patient is experiencing cervical pain and low back pain radiating to the right leg.

Treatment Approach

• The patient is being treated with naproxen 500 mg twice daily and duloxetine 30 mg at bedtime.
• The use of duloxetine is supported by studies such as 3 and 4, which demonstrate its efficacy in managing diabetic peripheral neuropathic pain.
• Duloxetine is a serotonin and norepinephrine reuptake inhibitor (SNRI) that has been shown to be safe and effective in reducing symptoms of diabetic neuropathy 3, 4.
• The patient is also being prescribed Apex X520M along with size 13.0 insoles, which may help to alleviate pain and discomfort associated with diabetic neuropathy.

Diabetic Neuropathy Management

• Diabetic neuropathy is a common complication of diabetes that can affect up to 50% of patients with diabetes mellitus (DM) during their lifetime 5.
• The management of diabetic neuropathy typically involves a combination of preventative care and pain management strategies 6, 5, 7.
• First-line treatments for diabetic neuropathic pain include anticonvulsants, such as pregabalin and gabapentin, and antidepressants, such as duloxetine 6, 5.
• Other treatment options, such as spinal cord stimulation (SCS) and transcutaneous electrical nerve stimulation (TENS), may also be effective in reducing pain in patients with diabetic neuropathy 5.