What are the best treatments and adjunct therapies for peripheral neuropathy?

From the Guidelines

The most effective treatment approach for peripheral neuropathy involves a combination of optimizing glucose control, managing pain with medications such as gabapentinoids, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, and utilizing adjunct therapies like physical therapy and lifestyle modifications. For patients with diabetic peripheral neuropathy, optimizing glucose control is crucial 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, as recommended by the most recent guidelines 1.

Key Treatment Recommendations

• Optimize 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.
• Assess and treat pain related to diabetic peripheral neuropathy and symptoms of autonomic neuropathy to improve quality of life, using medications such as gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers as initial pharmacologic treatments 1.
• Refer to a neurologist or pain specialist when adequate pain management is not achieved within the scope of practice of the treating clinician 1.

Adjunct Therapies

• Physical therapy to maintain strength and mobility
• Transcutaneous electrical nerve stimulation (TENS)
• Acupuncture
• Alpha-lipoic acid supplementation (600mg daily)

Lifestyle Modifications

• Blood sugar control for diabetic patients
• Regular moderate exercise
• Smoking cessation
• Limiting alcohol consumption
• Maintaining a balanced diet rich in B vitamins

Foot Care

• Daily inspection for injuries
• Wearing proper footwear
• Regular podiatry visits

These treatments and lifestyle modifications work by addressing the underlying pathology, modulating pain signals in the nervous system, or protecting damaged nerves from further injury, ultimately aiming to improve morbidity, mortality, and quality of life outcomes for patients with peripheral neuropathy. The most recent and highest quality study 1 supports these recommendations, emphasizing the importance of a multifaceted approach to managing peripheral neuropathy.

From the FDA Drug Label

Pregabalin is indicated for: Management of neuropathic pain associated with diabetic peripheral neuropathy 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

The best treatments and adjunct therapies for peripheral neuropathy include:

• Pregabalin for the management of neuropathic pain associated with diabetic peripheral neuropathy 2
• Duloxetine for the management of neuropathic pain associated with diabetic peripheral neuropathy in adults 3 Key points:
• Pregabalin and duloxetine have been shown to be effective in managing neuropathic pain associated with diabetic peripheral neuropathy
• Duloxetine has been established in 2 randomized, 12-week, double-blind, placebo-controlled, fixed-dose trials to be effective in adults with diabetic peripheral neuropathic pain 3

From the Research

Treatments for Peripheral Neuropathy

• First-line drug therapy for painful diabetic peripheral neuropathy includes duloxetine, gabapentin, amitriptyline, and pregabalin 4, 5, 6
• Second-line drug therapy includes nortriptyline, imipramine, venlafaxine, carbamazepine, oxcarbazepine, topical lidocaine, and topical capsaicin 4, 6
• Opioids should generally be avoided due to potential side effects and lack of long-term benefit 4, 6

Adjunct Therapies

• Nondrug therapies with low- to moderate-quality evidence include exercise and neuromodulation with spinal cord stimulation or transcutaneous electrical nerve stimulation 4
• Peripheral transcutaneous electrical nerve stimulation is well tolerated and inexpensive, but benefits are modest 4
• Other treatments, such as acupuncture, alpha-lipoic acid, acetyl-L-carnitine, cannabidiol, and onabotulinumtoxinA, need further study in patients with diabetic peripheral neuropathy 4, 5
• Novel therapies, such as palmitoylethanolamide and endocannabinoid targets, show promising results but require more clinical trials 5

Safety and Efficacy

• The safety profile of agents commonly used in the treatment of diabetic peripheral neuropathic pain is an important consideration 7
• Pregabalin and duloxetine have been established as effective treatments for painful diabetic neuropathy, but may have side effects that limit their usefulness 6, 8
• The efficacy and safety of duloxetine and pregabalin may vary depending on the population being studied, with different regions and genetic backgrounds potentially affecting treatment outcomes 8