From the Guidelines
New treatment options for diabetic neuropathy include several medications and approaches beyond traditional pain relievers, with gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers recommended as initial pharmacologic treatments for neuropathic pain in diabetes. According to the most recent guidelines 1, the initial treatment of pain should also focus on the concurrent treatment of both sleep and mood disorders because of increased frequency of these problems in individuals with diabetic peripheral neuropathy (DPN).
Some key treatment options for diabetic neuropathy include:
- Pregabalin (Lyrica) at 150-300mg daily
- Duloxetine (Cymbalta) at 60-120mg daily
- Topical treatments like 8% capsaicin patches and 5% lidocaine patches applied to painful areas
- Spinal cord stimulation for refractory cases
- High-frequency transcutaneous electrical nerve stimulation (TENS) devices for non-invasive pain relief
- Sodium channel blockers like lacosamide (100-200mg twice daily) and cenobamate for neuropathic pain
It's essential to note that opioids, including tramadol and tapentadol, should not be used for neuropathic pain treatment in diabetes given the potential for adverse events 1. Treatment selection should be individualized based on pain characteristics, comorbidities, and potential side effects, with combination therapy often providing better outcomes than monotherapy for this challenging condition.
The American Diabetes Association recommends optimizing glucose management to prevent or delay the development of neuropathy in people with type 1 diabetes and to slow the progression of neuropathy in people with type 2 diabetes 1. Additionally, optimizing blood pressure and serum lipid control can reduce the risk or slow the progression of diabetic neuropathy 1. Assessing and treating pain related to diabetic peripheral neuropathy and symptoms of autonomic neuropathy is crucial to improve quality of life 1.
In terms of specific medications, gabapentinoids, such as pregabalin, have been shown to be effective in reducing neuropathic pain in diabetic neuropathy 1. Duloxetine, a selective norepinephrine and serotonin reuptake inhibitor, has also been found to be effective in treating pain associated with diabetic peripheral neuropathy (DPN) 1. Sodium channel blockers, such as lacosamide, are being investigated specifically for neuropathic pain 1.
Overall, the treatment of diabetic neuropathy should be tailored to the individual patient's needs, taking into account their pain characteristics, comorbidities, and potential side effects. A comprehensive treatment plan that includes pharmacologic and non-pharmacologic interventions can help improve quality of life and reduce morbidity and mortality in patients with diabetic neuropathy.
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).
Duloxetine is a new treatment option for diabetic neuropathy. It has been shown to be effective in managing neuropathic pain associated with diabetic peripheral neuropathy in adults. The recommended dosage is 60 mg once daily or 60 mg twice daily.
- Key benefits:
- Statistically significant improvement in endpoint mean pain scores from baseline
- Increased proportion of patients with at least a 50% reduction in pain scores from baseline
- Important considerations:
- May worsen glycemic control in some patients with diabetes
- Should be used with caution in patients with conditions that may slow gastric emptying, such as some diabetics 2
From the Research
New Treatment Options for Diabetic Neuropathy
- The US Food and Drug Administration (FDA) has approved several treatment options for painful diabetic neuropathy, including duloxetine, pregabalin, tapentadol extended release, and capsaicin 8% topical system 3.
- Spinal cord stimulation (SCS) devices have also been approved by the FDA to treat refractory painful diabetic neuropathy 3, 4.
- Other treatment options include tricyclic antidepressants, serotonin/norepinephrine reuptake inhibitors, gabapentinoids, and sodium channel blockers, although these are not FDA-approved specifically for painful diabetic neuropathy 3, 5, 6.
- Non-pharmacological treatments such as transcutaneous electrical nerve stimulation (TENS) also show promise in reducing pain in diabetic neuropathy patients 7.
Pharmacological Treatment Options
- First-line pharmacologic therapy for painful diabetic neuropathy includes gabapentinoids (pregabalin and gabapentin) and duloxetine 4, 6.
- Additional pharmacologic modalities that are approved by the FDA but are considered second-line agents include tapentadol and 8% capsaicin patch 4.
- The selection of pharmacological agents should be guided by the presence of comorbidities, potential for adverse effects, drug interactions, and costs 6.
Emerging Solutions
- Novel potential candidates, including erythropoietin analogues, angiotensin II receptor type 2 antagonists, and sodium channel blockers, are currently being evaluated in phase II clinical trials 5.
- There is a growing need for head-to-head studies of different single-drug and combination pharmacotherapies to determine the most effective treatment options for diabetic neuropathy 5.