What is the best treatment for neuropathy?

From the Guidelines

The best treatment for neuropathy is a combination of pain management and addressing the root condition, with first-line medications including anticonvulsants like gabapentin or pregabalin, and serotonin-norepinephrine reuptake inhibitors like duloxetine, as recommended by the most recent guidelines 1. The treatment approach should prioritize optimizing 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. Some key points to consider in the treatment of neuropathy include:

• Optimizing blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic neuropathy 1
• Assessing and treating pain related to diabetic peripheral neuropathy and symptoms of autonomic neuropathy to improve quality of life 1
• Using gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers as initial pharmacologic treatments for neuropathic pain in diabetes 1
• Referring to a neurologist or pain specialist when adequate pain management is not achieved within the scope of practice of the treating clinician 1
• Considering lifestyle modifications, such as avoiding alcohol, maintaining a healthy weight, and quitting smoking, to help manage symptoms and slow progression of neuropathy. It is essential to individualize treatment based on symptom severity, comorbidities, and medication tolerability, and to start with lower doses of medications and gradually increase to minimize side effects.

From the FDA Drug Label

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 with pregabalin 100 and 200 mg three times a day statistically significantly improved the endpoint mean pain score and increased the proportion of patients with at least a 50% reduction in pain score from baseline 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 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 best treatment for neuropathy is pregabalin or duloxetine, as both have been shown to be effective in managing neuropathic pain associated with diabetic peripheral neuropathy.

• Pregabalin has been established to be effective in three double-blind, placebo-controlled, multicenter studies, with doses of 100 and 200 mg three times a day statistically significantly improving endpoint mean pain scores and increasing the proportion of patients with at least a 50% reduction in pain score from baseline 2.
• Duloxetine has been established to be effective in two randomized, 12-week, double-blind, placebo-controlled, fixed-dose trials, with doses of 60 mg one or two times a day statistically significantly improving endpoint mean pain scores and increasing the proportion of patients with at least a 50% reduction in pain scores from baseline 3.

From the Research

Treatment Options for Neuropathy

The best treatment for neuropathy can vary depending on the individual case and the severity of the condition. Here are some treatment options that have been recommended by various studies:

• First-line treatments:
  • Antidepressants (tricyclic antidepressants and serotonin-noradrenaline reuptake inhibitors) 4, 5, 6, 7
  • Anticonvulsants (pregabalin and gabapentin) 4, 5, 6, 7
  • Topical lidocaine 4, 5, 6
• Second-line treatments:
  • Opioids (although not considered a first choice due to adverse effects and risk of abuse) 4
  • Tramadol 5, 6, 7
  • Combination therapy (first-line medications) 5
• Third-line treatments:
  • Serotonin-specific reuptake inhibitors/anticonvulsants/NMDA antagonists 5
  • Interventional therapies 5
  • Neurostimulation 5, 6
• Alternative treatments:
  • Dietary lifestyle interventions (such as low-fat plant-based, plant-based fasting-mimicking, low-calorie, potassium-reduced, gluten-free, and intermittent high-protein/Mediterranean diets) 8
  • Transcutaneous electrical nerve stimulation 6
  • Botulinum toxin A (for peripheral neuropathic pain) 6, 7
  • High-concentration capsaicin patches (for peripheral neuropathic pain) 6

Important Considerations

When treating neuropathy, it's essential to consider the individual patient's needs and the specific neuropathic disease. A clear understanding of the mechanism of action of available drugs is crucial for an effective clinical approach 4. Additionally, dietary lifestyle interventions may offer a low-risk, low-cost, and low-tech option for chronic neuropathic pain management, but further research is needed to substantiate these findings 8.