Treatment of Hand Neuropathy
For neuropathic pain in the hands, start with duloxetine 60 mg once daily or pregabalin 150-300 mg/day in divided doses, combined with regular physical activity. 1, 2, 3
First-Line Pharmacological Treatment
Duloxetine is the preferred initial medication, particularly if the neuropathy is related to diabetes or chemotherapy, as it has the strongest evidence base for neuropathic pain with numbness and tingling. 1, 2
- Start duloxetine at 60 mg once daily, with option to increase to 120 mg daily if needed for additional benefit 2
- Pregabalin is equally effective as first-line therapy, FDA-approved for diabetic peripheral neuropathy at doses of 150-600 mg/day divided into 2-3 doses 3, 4
- Gabapentin (up to 1200-3600 mg/day in divided doses) is an alternative first-line option if duloxetine or pregabalin are not tolerated 2, 4
- Tricyclic antidepressants (amitriptyline 25-75 mg/day or nortriptyline) are effective but have significant anticholinergic side effects including dry mouth, constipation, and orthostatic hypotension 2, 5
Important caveat: Expect modest pain reduction—average improvement is only 20-30%, and only 20-35% of patients achieve 50% pain reduction with any single medication. 5
Non-Pharmacological Interventions (Essential, Not Optional)
Physical activity should be offered to all patients as it has demonstrated efficacy for neuropathic pain and should not be considered optional. 1, 2
- Acupuncture can be offered for pain management 1
- Physical therapy or occupational therapy referral for hand-specific symptoms 1
- Cognitive behavioral therapy for patients with significant pain-related disability 1
Assessment Requirements Before Treatment
Assess for reversible causes that may be contributing to hand neuropathy:
- Check fasting blood glucose and HbA1c (diabetes is the most common cause, affecting 206 million people worldwide) 2, 4
- Vitamin B12 with methylmalonic acid and/or homocysteine 2, 6, 4
- Thyroid function (TSH) 2, 6
- Serum protein electrophoresis with immunofixation (for monoclonal gammopathies) 6, 4
- Review medication history for neurotoxic agents (chemotherapy agents like cisplatin, paclitaxel, vincristine; amiodarone; HIV medications) 6, 4
When Single-Agent Therapy Fails
Combination therapy should be considered when monotherapy provides insufficient relief, as it may provide added benefit. 4, 7
- Combine medications from different classes (e.g., gabapentinoid + SNRI, or gabapentinoid + tricyclic antidepressant) 8
- For refractory cases, consider interventional options including nerve blocks, spinal cord stimulation, or intrathecal drug delivery 7
Common Pitfalls to Avoid
Do not assume efficacy extrapolates across all neuropathy types—chemotherapy-induced neuropathy and HIV-associated neuropathy may be relatively refractory to standard first-line treatments that work well for diabetic neuropathy. 1
Monitor for medication side effects:
- Gabapentin/pregabalin: dizziness (21-29%), somnolence (12-16%), peripheral edema (9-12%), weight gain (4-6%) 3
- Duloxetine: nausea, dry mouth, constipation 2
- Tricyclic antidepressants: obtain ECG before starting; avoid in cardiac disease and epilepsy 5
Do not use topical treatments as first-line for hand neuropathy—topical lidocaine patches are only recommended for localized neuropathic pain and lack long-term efficacy data. 5
Expected Outcomes and Monitoring
Complete reversal of nerve damage is uncommon even with treatment of underlying causes. 4
- Optimizing glucose control in diabetic neuropathy prevents progression but doesn't reverse neuronal loss 6
- With pregabalin 1200 mg daily, only 38% of patients with painful diabetic neuropathy achieved at least 50% pain reduction 4
- Pain often persists despite medical management, necessitating a multidisciplinary approach 7, 8