From the Guidelines
The management of nondiabetic peripheral neuropathy, specifically in the context of amyloid neuropathy, should prioritize disease-directed therapy with TTR silencers such as patisiran, inotersen, or vutrisiran, alongside symptom management with medications like pregabalin, gabapentin, or duloxetine for neuropathic pain, and interventions for autonomic dysfunction. When considering treatment options, it's crucial to weigh the benefits and risks, especially in patients with cardiac involvement, as noted in the 2023 ACC expert consensus decision pathway 1. For symptom management, medications such as pregabalin, gabapentin, duloxetine, and tricyclic antidepressants can be beneficial for neuropathic pain, although tricyclic antidepressants may have increased side effects in patients with orthostatic hypotension or other autonomic symptoms 1. Key considerations include:
- Disease-directed therapy with TTR silencers for slowing progression and/or reversing disease in ATTRv.
- Symptom management for neuropathic pain and autonomic dysfunction, including the use of pregabalin, gabapentin, duloxetine, and tricyclic antidepressants.
- Monitoring for side effects, particularly in older patients, and consulting geriatric specialist guidelines such as the Beers Criteria 1.
- Non-pharmacological approaches like physical therapy and lifestyle modifications can also play a crucial role in managing symptoms and improving quality of life. Given the complexity and the need for personalized care, treatment should be tailored to the individual patient's needs and response to therapy, with regular follow-up to adjust the treatment plan as necessary, based on the most recent and highest quality evidence available 1.
From the Research
Treatment and Management of Nondiabetic Peripheral Neuropathy
- The treatment of peripheral neuropathy focuses on managing the underlying etiology 2.
- Several classes of medications, including gabapentinoids and antidepressants, can help alleviate neuropathic pain 2.
- Vitamin supplementation may serve as an effective therapeutic strategy for peripheral neuropathy, especially in cases where vitamin deficiency is a risk factor 3.
- Accurate diagnosis is important since peripheral neuropathies caused by vitamin deficiencies, medications, or toxins are often treatable and preventable 4.
Identifying the Underlying Cause
- A comprehensive history, physical examination, and judicious laboratory testing are necessary for diagnosis 2.
- Initial laboratory evaluation includes a complete blood count, comprehensive metabolic profile, fasting blood glucose, vitamin B12, and thyroid-stimulating hormone levels, and serum protein electrophoresis with immunofixation 2.
- If the initial evaluation is inconclusive, referral to a neurologist for additional testing, such as electrodiagnostic studies, specific antibody assays, or nerve biopsy, should be considered 2.
Nondrug Therapies
- Nondrug therapies with low- to moderate-quality evidence include exercise and neuromodulation with spinal cord stimulation or transcutaneous electrical nerve stimulation 5.
- Peripheral transcutaneous electrical nerve stimulation is well tolerated and inexpensive, but benefits are modest 5.
- Other treatments, such as acupuncture, alpha-lipoic acid, acetyl-L-carnitine, cannabidiol, and onabotulinumtoxinA, need further study in patients with peripheral neuropathy 5.
Role of Vitamins
- Vitamin deficiency is a risk factor in the development of peripheral neuropathy 3.
- Deficiencies of almost all vitamins are associated with diabetic neuropathy, and vitamin supplementation may be an effective therapeutic strategy 3.
- Vitamins play critical roles in maintaining physiological functions, and vitamin deficiencies can cause peripheral neuropathy with various severe and complex diseases 3.