What is the management of diabetic (Dm) foot pain, numbness, and nocturnal hotness?

From the Guidelines

For diabetic foot pain, numbness, and hotness at night, the most effective management approach is to optimize blood glucose control, use gabapentinoids or other recommended medications for neuropathic pain, and implement preventive foot care measures as outlined in the latest guidelines 1. To manage diabetic foot pain, numbness, and hotness at night, consider the following steps:

• Optimize blood glucose control to prevent further nerve damage
• Use medications like gabapentin (starting at 300mg at bedtime, gradually increasing to 300mg three times daily) or pregabentin (starting at 75mg twice daily, up to 300mg daily) for neuropathic pain relief, as recommended by recent guidelines 1
• Apply moisturizing lotion to feet daily, avoiding the area between the toes
• Wear loose cotton socks at night and consider elevating feet slightly with a pillow
• Inspect feet daily for injuries or sores, as numbness can mask wounds
• Avoid hot water bottles or heating pads, which can burn numb feet
• Educate patients on proper foot care, including daily washing and drying, use of emollients, and proper toenail cutting, as emphasized in the guidelines 1
• Consider coaching patients to self-monitor foot skin temperatures to identify early signs of foot inflammation and prevent foot ulcers, as suggested in the guidelines 1
• Provide structured education on foot self-care and consider prescribing therapeutic footwear for patients at high risk of foot ulcers, as recommended in the guidelines 1

From the FDA Drug Label

The efficacy of the maximum recommended dose of pregabalin for the management of neuropathic pain associated with diabetic peripheral neuropathy was established in three double-blind, placebo-controlled, multicenter studies with three times a day dosing, two of which studied the maximum recommended dose Treatment with pregabalin 100 and 200 mg three times a day statistically significantly improved the endpoint mean pain score and increased the proportion of patients with at least a 50% reduction in pain score from baseline 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 Treatment with duloxetine delayed-release capsules 60 mg one or two times a day statistically significantly improved the endpoint mean pain scores from baseline and increased the proportion of patients with at least a 50% reduction in pain scores from baseline

Management of Diabetic Foot Pain, Numbness, and Hotness at Night:

• Pregabalin: may be used for the management of neuropathic pain associated with diabetic peripheral neuropathy, with doses of 100-200 mg three times a day showing significant improvement in pain scores 2.
• Duloxetine: may be used for the management of neuropathic pain associated with diabetic peripheral neuropathy, with doses of 60 mg one or two times a day showing significant improvement in pain scores 3.
• Key Considerations:
  • Pregabalin and duloxetine have been shown to be effective in managing neuropathic pain associated with diabetic peripheral neuropathy.
  • The choice of medication and dosage should be individualized based on patient response and tolerability.
  • Patients should be monitored for adverse reactions and dose adjustments made as needed.

From the Research

Management of Diabetic Foot Pain, Numbness, and Hotness at Night

• The management of diabetic foot pain, numbness, and hotness at night can be achieved through various treatments, including medications and non-pharmacological interventions 4, 5, 6, 7.
• Medications such as duloxetine, pregabalin, and gabapentin are commonly used to treat diabetic peripheral neuropathic pain, with duloxetine showing greater efficacy in some studies 4, 6, 7.
• Non-pharmacological interventions, such as exercise and neuromodulation with spinal cord stimulation or transcutaneous electrical nerve stimulation, may also be effective in managing diabetic foot pain 5.
• It is essential to address underlying risk factors, such as poor glycemic control, vitamin B12 deficiency, elevated blood pressure, and obesity, to reduce the likelihood of developing neuropathy 5.

Treatment Options

• First-line drug therapy for painful diabetic peripheral neuropathy includes duloxetine, gabapentin, amitriptyline, and pregabalin 5.
• Second-line drug therapy includes nortriptyline, imipramine, venlafaxine, carbamazepine, oxcarbazepine, topical lidocaine, and topical capsaicin 5.
• Nondrug therapies, such as acupuncture, alpha-lipoic acid, acetyl-L-carnitine, cannabidiol, and onabotulinumtoxinA, may also be considered, although further study is needed to determine their effectiveness 5.

Prevention and Treatment of Diabetic Foot Ulcers

• Diabetic foot ulcers can be prevented through interventions such as pressure-relieving footwear, foot skin measurements with off-loading, and treatment of preulcer signs 8.
• First-line therapies for diabetic foot ulcers include surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection 8.
• Multidisciplinary care, consisting of podiatrists, infectious disease specialists, and vascular surgeons, in close collaboration with primary care clinicians, is associated with lower major amputation rates relative to usual care 8.