From the Guidelines
Duloxetine is the recommended first-line treatment for peripheral neuropathy, with a dosage of 60-120mg daily, due to its level I evidence for reducing neuropathic pain 1.
Treatment Options
The treatment of peripheral neuropathy should focus on reducing or relieving neuropathic pain, and may include:
- Anticonvulsants such as gabapentin (starting at 300mg daily, gradually increasing to 1800-3600mg daily in divided doses) and pregabalin (starting at 75mg twice daily, up to 300-600mg daily)
- Antidepressants, particularly duloxetine (60-120mg daily) and amitriptyline (10-25mg at bedtime, increasing gradually if needed)
- Topical treatments like lidocaine patches (5%) or capsaicin cream for localized symptoms
- Physical exercise and functional training, such as vibration training, to reduce CIPN symptoms
Considerations
When treating peripheral neuropathy, it is essential to consider the underlying cause of the condition, such as diabetes, and address any related issues, such as glucose control or vitamin supplementation. Treatment should be individualized, and side effects should be monitored and managed accordingly.
Additional Therapies
Other therapies that may be considered for the treatment of peripheral neuropathy include:
- Venlafaxine, tramadol, or strong opioids for neuropathic pain
- Topical low-concentration menthol cream for localized symptoms
- Acupuncture for selected patients to treat CIPN symptoms It is crucial to note that the most recent and highest quality study 1 recommends duloxetine as the first-line treatment, and other options should be considered based on individual patient needs and responses to treatment.
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
The treatment options 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
From the Research
Treatment Options for Peripheral Neuropathy
The treatment options for peripheral neuropathy include:
- Pharmacological treatments such as pregabalin 4, 5, 6, 7, 8
- Tricyclic antidepressants (TCAs) such as amitriptyline, nortriptyline, desipramine, and imipramine 5, 7
- Serotonin noradrenaline reuptake inhibitors (SNRIs) such as venlafaxine and duloxetine 5, 6, 7
- Selective serotonin reuptake inhibitors (SSRIs) 5
- Antiepileptic agents such as carbamazepine, phenytoin, valproic acid, lamotrigine, oxcarbazepine, and topiramate 5
- alpha2delta Ligands such as gabapentin and pregabalin 5, 6, 8
- Opioids such as oxycodone and tramadol 5, 6
- Topical agents such as lidocaine 5% patches and topical capsaicin 5, 6
- Combination therapy 5, 6, 8
- Transcutaneous electrical nerve stimulation (TENS) 6
- High-frequency repetitive transcranial magnetic stimulation (rTMS) 6
- Spinal cord stimulation 6
- Botulinum toxin A 6
Dosing and Administration
- Pregabalin dosing strategies vary, with some studies suggesting higher doses may be more effective 4, 8
- The maximum approved dose of pregabalin for the treatment of painful diabetic peripheral neuropathy (pDPN) differs between the United States (300 mg/day) and European Union (600 mg/day) 8
- Amitriptyline, pregabalin, and duloxetine can be effective for treating pDPN, with amitriptyline showing more favorable findings in one study 7
Special Considerations
- Treatment-refractory patients may benefit from pregabalin or other pharmacological treatments 8
- Adverse events such as drowsiness, dizziness, and dry mouth are common with pharmacological treatments 7
- Combination therapy may be considered for challenging cases, although evidence to support its use is sparse 5, 6, 8