From the Guidelines
Treatment for neuropathy should prioritize optimizing glucose control, blood pressure, and serum lipid control to prevent or delay its development, alongside assessing and treating pain to improve quality of life, with gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers as initial pharmacologic treatments. When considering treatment options for neuropathy, it's essential to differentiate between the underlying causes and symptom severity. The most recent and highest quality study, 1, emphasizes the importance of optimizing glucose management and controlling blood pressure and serum lipids to reduce the risk or slow the progression of diabetic neuropathy.
Key Treatment Approaches
- Optimizing glucose control: This is crucial for preventing or delaying the development of neuropathy in people with type 1 diabetes and slowing its progression in those with type 2 diabetes, as highlighted in 1.
- First-line medications: Gabapentinoids, serotonin-norepinephrine reuptake inhibitors (like duloxetine), tricyclic antidepressants (such as amitriptyline), and sodium channel blockers are recommended for neuropathic pain management, according to 1.
- Lifestyle modifications: Regular exercise, blood sugar control, and management of cardiovascular risk factors are vital for improving quality of life and managing neuropathy, as suggested in 1 and 1.
- Topical treatments: For localized neuropathic pain, lidocaine patches or capsaicin cream may provide relief, as mentioned in 1.
- Non-medication approaches: Physical therapy, transcutaneous electrical nerve stimulation (TENS), and acupuncture can be beneficial, with the importance of addressing the underlying cause (such as diabetes control or vitamin deficiencies) being crucial for effective management, as noted in 1.
Considerations for Treatment
- Individualized treatment: Therapy should be tailored to the patient, often requiring combination therapy, with regular monitoring for efficacy and side effects, as emphasized in 1.
- Referral to specialists: When pain control is not achieved, referral to a neurologist or pain specialist is recommended, as stated in 1.
- Caution with opioids: While opioids may be considered for short-term use in severe cases, their long-term use carries significant risks and should be approached with caution, as mentioned in 1 and 1.
From the FDA Drug Label
Pregabalin is indicated for: Management of neuropathic pain associated with diabetic peripheral neuropathy Management of postherpetic neuralgia Management of neuropathic pain associated with spinal cord injury 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 options for neuropathy include:
- Pregabalin: for management of neuropathic pain associated with diabetic peripheral neuropathy, postherpetic neuralgia, and spinal cord injury 2
- Duloxetine: for management of neuropathic pain associated with diabetic peripheral neuropathy 3
From the Research
Treatment Options for Neuropathy
- The management of neuropathy involves treating its underlying cause, targeting its pathogenesis, and providing symptomatic pain relief 4.
- Four pharmacologic options are currently approved by the US Food and Drug Administration (FDA) to treat painful diabetic peripheral neuropathy, including duloxetine, pregabalin, tapentadol extended release, and capsaicin 8% topical system 4.
- Other strategies that may be used as part of individualized comprehensive pain management plans include tricyclic antidepressants, serotonin/norepinephrine reuptake inhibitors, gabapentinoids, and sodium channel blockers 4.
- Spinal cord stimulation (SCS) devices have also been approved by the FDA to treat refractory painful diabetic peripheral neuropathy 4.
Pharmacologic Treatment Options
- First-line medications for neuropathic pain include antidepressants, anticonvulsants, topical agents, and opioid analgesics 5, 6.
- Duloxetine has been shown to be noninferior to pregabalin in the treatment of pain associated with diabetic peripheral neuropathy 7.
- Combination therapies, such as duloxetine plus gabapentin, may also be effective in managing neuropathic pain 7.
Non-Pharmacologic Treatment Options
- Nonpharmacological therapies, such as cognitive-behavioral and rehabilitative therapies, may be used to manage neuropathic pain 5, 6.
- Interventional options, including anesthetic and steroid injections, nerve blocks, and spinal cord stimulation, may also be effective in managing neuropathic pain 5.