What is the treatment for numbness due to peripheral neuropathy?

Treatment for Numbness Due to Peripheral Neuropathy

First-line treatment for numbness due to peripheral neuropathy should include pregabalin or gabapentin, with duloxetine as an alternative first-line option. 1, 2

First-Line Pharmacological Options

• Pregabalin (300-600 mg/day) is established as effective and should be offered as first-line treatment for peripheral neuropathic pain, acting by binding to the α-2-δ subunit of voltage-gated calcium channels 1, 3
• Gabapentin (900-3600 mg/day) is an alternative to pregabalin with similar efficacy but may require more frequent dosing 1, 2
• Duloxetine (60-120 mg/day) is effective for diabetic peripheral neuropathy with a number needed to treat of 5.2 for 60 mg/day 2, 4
• Tricyclic antidepressants (TCAs) such as amitriptyline (25-75 mg/day) are effective with a number needed to treat of 1.5-3.5, but have more side effects than newer agents 1, 2

Topical Treatments for Localized Neuropathic Pain

• Topical lidocaine (5% patches) should be considered for localized peripheral neuropathic pain, particularly with allodynia 2
• Topical capsaicin (0.075%) applied sparingly three to four times per day can provide relief for neuropathic pain with minimal systemic effects 1, 2
• Topical menthol (1% cream) applied twice daily to the affected area may provide rapid relief of peripheral neuropathy symptoms 1, 2

Second-Line Treatment Options

• If first-line medications provide inadequate relief, consider adding another first-line agent from a different class 1, 2
• Venlafaxine (150-225 mg/day) is a serotonin-norepinephrine reuptake inhibitor that can be considered if duloxetine is not tolerated 1, 5
• Tramadol (200-400 mg/day) can be considered as a second-line treatment with its dual mechanism as a weak μ-opioid agonist and inhibitor of serotonin/norepinephrine reuptake 1, 2

Treatment Algorithm

1. Start with pregabalin or gabapentin as first-line therapy 1, 2
2. If partial response after adequate trial (at least 2 weeks), add duloxetine or a TCA 2
3. If inadequate response to first-line agents, switch to or add second-line treatments 2
4. For localized peripheral neuropathic pain, consider topical agents as first-line 1, 2

Special Considerations

• For elderly patients, start with lower doses and titrate more slowly due to increased risk of side effects 2
• TCAs should be used with caution in patients with cardiac disease, glaucoma, or orthostatic hypotension 1, 2
• Adjust gabapentin and pregabalin doses in patients with renal impairment 2, 3
• Pregabalin and gabapentin may cause edema, weight gain, and dizziness 3
• Duloxetine is contraindicated in patients with hepatic disease 1

Non-Pharmacological Approaches

• Exercise and functional training can help reduce neuropathic symptoms 2, 6
• Transcutaneous electrical nerve stimulation (TENS) may provide modest benefits and is well-tolerated and inexpensive 2, 6
• Alpha-lipoic acid (600 mg IV daily for 3 weeks) has shown some efficacy in reducing neuropathic pain in diabetic neuropathy 1

Common Pitfalls and Caveats

• None of these medications restore sensation to affected extremities; they only manage symptoms 6
• Evidence for long-term benefit and safety of first-line treatment options is lacking 6
• Strong opioids should generally be avoided due to risks of addiction and other adverse effects 2, 6
• Regular monitoring of medication response is essential as adverse effects are common 6
• Addressing underlying risk factors such as poor glycemic control, vitamin B12 deficiency, elevated blood pressure, and obesity is crucial for patients with diabetic neuropathy 6