Treatment of Diabetic Peripheral Neuropathy in a 70-Year-Old Woman
This patient has diabetic peripheral neuropathy (meralgia paresthetica pattern) affecting the right thigh, and treatment should focus on optimizing glycemic control and initiating first-line neuropathic pain medication, specifically duloxetine or gabapentin. 1
Immediate Glycemic Optimization
The fasting blood glucose of 135 mg/dL indicates suboptimal control that requires intensification of therapy:
Add basal insulin (insulin glargine) to the current oral hypoglycemic regimen, as fasting hyperglycemia is driven by excessive hepatic glucose production overnight that requires adequate basal insulin suppression. 2, 3
Titrate insulin glargine by 2-4 units every 3 days if fasting blood glucose remains >130 mg/dL, targeting a fasting glucose of 80-130 mg/dL. 2
Monitor blood glucose daily during titration and reassess every 3-4 days to detect hypoglycemia early, which is critical in elderly patients. 2
Set an HbA1c target of 7.5-8.0% rather than <7.0% to minimize hypoglycemia risk in this 70-year-old patient, as overly aggressive targets increase morbidity in older adults. 2
Neuropathic Pain Management
Initiate duloxetine as first-line therapy for the painful neuropathy, as it has the strongest evidence for reducing neuropathic pain and improving quality of life. 1, 4
Alternative first-line options if duloxetine is contraindicated or not tolerated:
- Gabapentin (start low, titrate slowly in elderly patients) 1
- Pregabalin (FDA-approved for diabetic neuropathy) 1, 4
- Amitriptyline (use cautiously due to anticholinergic effects in elderly) 1
Monitor medication response objectively every 4-6 weeks, as patients may not obtain desired pain reduction and adverse effects are common. 1
Critical Safety Assessments
Before initiating treatment, verify:
- Renal function to ensure metformin safety and adjust medications if declining. 2
- Vitamin B12 levels if the patient is on metformin long-term, as deficiency can worsen neuropathy. 1
- Blood pressure control, as elevated blood pressure increases neuropathy risk. 1
- Patient's ability to self-administer insulin or arrange caregiver assistance if visual or motor skills are impaired. 2
Preventing Complications
The greatest risk from this small-fiber neuropathy is foot ulceration leading to gangrene and amputation. 4
- Educate the patient on daily foot inspection for ulcers or injuries 4
- Refer for diabetic foot care and proper footwear 4
- Screen for loss of protective sensation using monofilament testing 1
Medications to Avoid
Do not prescribe opioids for this neuropathic pain, as they should generally be avoided in diabetic peripheral neuropathy due to poor risk-benefit ratio. 1
Second-Line Options
If first-line medications fail after adequate trial (8-12 weeks at therapeutic doses):
- Venlafaxine, nortriptyline, or topical lidocaine 1
- Consider transcutaneous electrical nerve stimulation (TENS), which is well-tolerated, inexpensive, and has modest benefits. 1
Common Pitfall
Do not attribute all thigh pain to neuropathy without considering diabetic myonecrosis, especially if there is focal swelling or mass effect, though this patient's presentation of tingling and pain without swelling makes typical neuropathy most likely. 5