What is the management of polyneuropathy?

Management of Polyneuropathy

The management of polyneuropathy should focus on identifying and treating the underlying cause while simultaneously providing symptomatic relief for pain and functional impairments through a combination of pharmacological and non-pharmacological approaches.

Diagnostic Evaluation

Before initiating treatment, a thorough diagnostic workup is essential to identify the cause of polyneuropathy:

• Laboratory testing:

  • Diabetic screen (HbA1c, glucose)
  • Vitamin B12, folate, thiamine levels
  • Thyroid function tests (TSH)
  • HIV testing
  • Serum protein electrophoresis and immunofixation
  • Consider autoimmune markers (ANA, ESR, CRP, ANCA) 1

• Imaging and specialized testing:

  • MRI of spine with/without contrast (if radicular symptoms)
  • Electrodiagnostic studies (EMG/NCS) for moderate-severe cases
  • Consider lumbar puncture in rapidly progressive cases 1

Treatment Approach

1. Causal Treatment

Address the underlying etiology when identified:

• Diabetic polyneuropathy: Optimize glycemic control
• Alcohol-related: Alcohol cessation
• Nutritional deficiencies: Vitamin B12, folate supplementation
• Immune-mediated: Immunotherapy (for specific immune-related neuropathies)
• Toxic/medication-induced: Remove offending agent 2

2. Symptomatic Treatment of Neuropathic Pain

First-line medications:

• Calcium channel α2-δ ligands:

  • Pregabalin: Start 50mg TID, titrate to 100-200mg TID (maximum 600mg/day) 1, 3
  • Gabapentin: Start 300mg daily, titrate to 1200-3600mg/day in divided doses 1

• Antidepressants:

  • Duloxetine: 60-120mg once daily 1
  • Secondary amine TCAs (nortriptyline, desipramine): 25-100mg at bedtime (use with caution in patients with cardiac disease or elderly) 1

Second-line medications:

• Tapentadol: Extended-release formulation for severe pain 1
• Topical lidocaine: For localized peripheral neuropathic pain 1

3. Management of Autonomic Symptoms

• Orthostatic hypotension:

  • Increased salt/fluid intake
  • Compression stockings
  • Fludrocortisone, midodrine, or droxidopa (with caution in cardiac patients)
  • Pyridostigmine (less risk of fluid retention) 1

• Gastrointestinal symptoms:

  • Dietary modifications
  • Prokinetic agents for gastroparesis

• Genitourinary dysfunction:

  • Evaluate bladder function in patients with recurrent UTIs or incontinence 1

4. Non-pharmacological Approaches

• Physical therapy: To improve strength, balance, and gait
• Foot care: Regular inspection, proper footwear, orthotic devices
• Ergotherapy: For functional adaptations
• Exercise: Regular, moderate activity to improve circulation 4, 2

Graded Management Based on Severity

Mild Polyneuropathy (minimal symptoms, no functional limitation)

• Identify and treat underlying cause
• Non-pharmacological approaches
• Consider low-dose first-line medications if painful

Moderate Polyneuropathy (interfering with ADLs)

• All treatments for mild polyneuropathy
• Optimize first-line medications for pain control
• Physical therapy and assistive devices as needed

Severe Polyneuropathy (significant disability, limiting self-care)

• Consider combination therapy for pain
• Intensive rehabilitation
• Evaluate for respiratory or autonomic complications
• Consider referral to specialized center 2

Special Considerations

• Elderly patients: Start medications at lower doses and titrate slowly
• Patients with cardiac disease: Use TCAs with caution; consider ECG monitoring
• Patients with renal impairment: Adjust dosing of gabapentin/pregabalin
• Immune-related polyneuropathy: May require corticosteroids, IVIG, or plasmapheresis 1

Regular monitoring of symptoms, medication efficacy, and adverse effects is essential for optimal management of polyneuropathy.