From the Guidelines
Treatment for various neuropathies, including radiculopathy, mononeuropathy, polyneuropathy, diabetic amyotrophy, and autonomic neuropathy, should prioritize symptom management and prevention of further nerve damage, with a focus on optimizing glucose control and using pharmacologic treatments like gabapentinoids, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, as recommended by the most recent guidelines 1.
Overview of Treatments
- Radiculopathy treatment includes pain medications like NSAIDs, muscle relaxants, physical therapy, and in severe cases, epidural steroid injections or surgery.
- Mononeuropathy treatment depends on the cause but may include splinting, physical therapy, and medications like gabapentin or pregabalin.
- Polyneuropathy treatment focuses on symptom management with anticonvulsants, antidepressants like amitriptyline, and topical agents like lidocaine patches.
- Diabetic amyotrophy treatment involves strict blood glucose control and pain management using medications like duloxetine.
- Autonomic neuropathy treatment is symptom-specific, with options like midodrine for orthostatic hypotension, metoclopramide for gastroparesis, and phosphodiesterase-5 inhibitors for erectile dysfunction.
Pharmacologic Treatments
- Gabapentinoids, such as pregabalin and gabapentin, are effective for neuropathic pain management, with eight high-quality studies and seven medium-quality studies supporting their use 1.
- Serotonin-norepinephrine reuptake inhibitors, like duloxetine, are also recommended, with two high-quality studies and five medium-quality studies supporting their effectiveness 1.
- Tricyclic antidepressants, such as amitriptyline, can be used for pain management, but may have dose-limiting side effects, particularly in older adults 1.
Lifestyle Modifications
- Regular exercise, balanced nutrition, limiting alcohol, and smoking cessation are important complementary approaches for all neuropathic conditions.
- Optimizing glucose control is crucial for preventing or delaying the development of neuropathy in patients with type 1 diabetes and slowing the progression of neuropathy in patients with type 2 diabetes, as recommended by the American Diabetes Association 1.
From the FDA Drug Label
Pregabalin is indicated for: Management of neuropathic pain associated with diabetic peripheral neuropathy Treatment with duloxetine delayed-release capsules 60 mg one or two times a day statistically significantly improved the endpoint mean pain scores from baseline and increased the proportion of patients with at least a 50% reduction in pain scores from baseline
The treatments for the conditions are as follows:
- Radiculopathy: The FDA drug label does not answer the question.
- Mononeuropathy: The FDA drug label does not answer the question.
- Polyneuropathy:
- Diabetic peripheral neuropathic pain can be managed with duloxetine 2
- Diabetic Amyotrophy: The FDA drug label does not answer the question.
- Autonomic Neuropathy: The FDA drug label does not answer the question.
From the Research
Treatments for Neuropathies
- Radiculopathy: treatments include "watchful waiting," physical therapy and rarely surgical intervention, which may be urgently needed for nerve decompression and reversal of motor defects 3
- Mononeuropathy: therapies include "watchful waiting," physical therapy and rarely surgical intervention, which may be urgently needed for nerve decompression and reversal of motor defects 3
- Polyneuropathy: management includes optimised glycaemic control, treatment of cardiovascular risk factors, and symptomatic treatment aiming at improving life quality 4
- Diabetic Amyotrophy: the prognosis is dependent upon cooperation with intensive rehabilitation, and therapies include "watchful waiting," physical therapy and rarely surgical intervention 3, 5, 6
- Autonomic Neuropathy: although both diabetic lumbosacral radiculoplexus neuropathy (DLRPN) and nondiabetic lumbosacral radiculoplexus neuropathy (LRPN) are monophasic illnesses, patients have prolonged morbidity from pain and weakness, and many patients become wheelchair-dependent, controlled trials with immune-modulating therapies in DLRPN are in progress, and preliminary data suggest that such therapy may be beneficial in LRPN 5
Treatment Approaches
- A multidisciplinary approach is recommended to offer a better outcome and reduce side effects 7
- Current guidelines on the assessment and pharmacological treatment of neuropathic pain can be applied to plexopathy, radiculopathy, mononeuropathy, peripheral neuropathy 7
- High quality studies are requested to address the unmet needs in this field 7