From the Guidelines
The treatment of peripheral neuropathy in type 2 diabetes should focus on optimizing glucose control, assessing and treating pain, and improving quality of life, with first-line medications including gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers, as recommended by the most recent guidelines 1. The goal of treatment is to prevent or delay the development of neuropathy, slow its progression, and reduce pain and symptoms of autonomic neuropathy.
- Optimizing glucose control is essential to prevent or delay the development of neuropathy in patients with type 1 diabetes and to slow the progression of neuropathy in patients with type 2 diabetes, as stated in the 2024 guidelines 1.
- Assessing and treating pain related to diabetic peripheral neuropathy and symptoms of autonomic neuropathy is crucial to improve quality of life, with recommendations for initial pharmacologic treatments including gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers 1.
- First-line medications for neuropathic pain in diabetes include pregabalin, duloxetine, or gabapentin, with dosages and administration as follows:
- Pregabalin: starting at 50mg three times daily, maximum 300mg daily
- Gabapentin: starting at 300mg daily, gradually increasing to 1800-3600mg daily in divided doses
- Duloxetine: 60-120mg daily
- For patients who don't respond adequately to first-line treatments, referral to a neurologist or pain specialist is recommended to achieve adequate pain management 1.
- Regular foot care, including daily inspection, proper footwear, and regular podiatry visits, is crucial to prevent complications, along with physical therapy and lifestyle modifications like regular exercise and smoking cessation to improve circulation and reduce symptoms.
- Treatment should be individualized based on pain severity, comorbidities, and potential drug interactions, with regular follow-up to assess efficacy and adjust therapy as needed, as emphasized in the guidelines 1.
From the FDA Drug Label
14.4 Diabetic Peripheral Neuropathic Pain in Adults 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 (Study DPNP-1 and Study DPNP-2).
- Indications and Usage Pregabalin is indicated for: Management of neuropathic pain associated with diabetic peripheral neuropathy Management of postherpetic neuralgia Adjunctive therapy for the treatment of partial-onset seizures in patients 1 month of age and older Management of fibromyalgia Management of neuropathic pain associated with spinal cord injury
The treatment options for peripheral neuropathy in patients with Type 2 Diabetes Mellitus (T2DM) include:
- Duloxetine: a serotonin-norepinephrine reuptake inhibitor (SNRI) that has been shown to be effective in managing neuropathic pain associated with diabetic peripheral neuropathy 2
- Pregabalin: an anticonvulsant that is indicated for the management of neuropathic pain associated with diabetic peripheral neuropathy 3 It is essential to note that these medications may have different mechanisms of action, efficacy, and safety profiles, and the choice of treatment should be individualized based on patient-specific factors.
From the Research
Treatment Options for Peripheral Neuropathy in Patients with Type 2 Diabetes Mellitus (T2DM)
- The mainstay of treatment for painful diabetic neuropathy is pharmacotherapy, with first-line drugs including amitriptyline, duloxetine, pregabalin, and gabapentin 4, 5, 6, 7.
- Combination treatment with these drugs can provide significant pain relief to patients with inadequate response to monotherapy 4.
- Second-line drug therapy includes nortriptyline, imipramine, venlafaxine, carbamazepine, oxcarbazepine, topical lidocaine, and topical capsaicin 5.
- Non-drug therapies with low- to moderate-quality evidence include exercise and neuromodulation with spinal cord stimulation or transcutaneous electrical nerve stimulation 5, 6.
- Other treatments, such as acupuncture, alpha-lipoic acid, acetyl-L-carnitine, cannabidiol, and onabotulinumtoxinA, need further study in patients with diabetic peripheral neuropathy 5, 6.
- Tight glycaemic management and metabolic risk factor management are essential for preventing diabetic peripheral neuropathy, but have limited evidence in reducing symptoms and complications once painful DPN develops 7, 8.
- Treatment selection should be guided by the presence of comorbidities, potential for adverse effects, drug interactions, and costs 7.
Pharmacological Agents
- Anticonvulsants such as pregabalin and gabapentin are commonly used to address pain symptoms in DPN 4, 5, 6, 7.
- Serotonin-norepinephrine reuptake inhibitors like duloxetine and venlafaxine are also used as first-line agents 4, 5, 6, 7.
- Tricyclic antidepressants, including nortriptyline and desipramine, can be used as secondary agents 5, 7.