From the Guidelines
Treatments for neuropathy beyond first-line options include several medication classes and non-pharmaceutical approaches, with gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers recommended as initial pharmacologic treatments for neuropathic pain in diabetes, as stated in the most recent guidelines 1.
Medication Classes
- Anticonvulsants like gabapentin (300-1200mg three times daily) and pregabalin (75-300mg twice daily) are commonly prescribed to reduce nerve pain by stabilizing overactive nerves, with evidence supporting their efficacy in treating pain in diabetic peripheral neuropathy 1.
- Antidepressants such as duloxetine (60-120mg daily), amitriptyline (10-150mg at bedtime), or venlafaxine (75-225mg daily) can help by affecting pain signaling neurotransmitters, with studies demonstrating their effectiveness in managing neuropathic pain 1.
- Topical treatments like lidocaine patches (5%, applied for 12 hours daily) or capsaicin cream (0.025-0.075%, applied 3-4 times daily) provide localized relief, with capsaicin receiving FDA approval for treatment of pain in diabetic peripheral neuropathy 1.
Non-Pharmaceutical Approaches
- Physical therapy can maintain strength and mobility, while transcutaneous electrical nerve stimulation (TENS) may interrupt pain signals, contributing to improved quality of life for patients with neuropathy.
- Lifestyle modifications are important, including blood sugar control for diabetic neuropathy, limiting alcohol consumption, maintaining optimal vitamin levels (especially B12), and regular gentle exercise, as emphasized in recent guidelines 1.
- Some patients benefit from complementary approaches like acupuncture or alpha-lipoic acid supplements (600mg daily), although the evidence for these treatments is less robust compared to pharmacologic interventions.
Individualized Treatment
Treatment should be individualized based on the underlying cause of neuropathy, with combination therapy often providing better relief than single treatments alone, as recommended by recent guidelines and supported by evidence from studies on neuropathic pain management 1.
From the FDA Drug Label
Management of neuropathic pain associated with diabetic peripheral neuropathy Management of neuropathic pain associated with spinal cord injury 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
Other treatments for neuropathy include:
- Pregabalin for management of neuropathic pain associated with diabetic peripheral neuropathy and spinal cord injury 2
- Duloxetine for management of neuropathic pain associated with diabetic peripheral neuropathy 3
From the Research
Other Treatments for Neuropathy
- Other treatments for neuropathy include:
- Nondrug therapies with low- to moderate-quality evidence include:
Treatment Considerations
- The choice of treatment is guided by the clinical status of the individual patient 4
- First-line drug therapy for painful diabetic peripheral neuropathy includes duloxetine, gabapentin, amitriptyline, and pregabalin 5
- Second-line drug therapy includes nortriptyline, imipramine, venlafaxine, carbamazepine, oxcarbazepine, topical lidocaine, and topical capsaicin 5
- Opioids should generally be avoided 5
- 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 5