From the Guidelines
Treatment for peripheral neuropathy should prioritize optimizing glucose control, managing pain, and improving quality of life, with gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers recommended as initial pharmacologic treatments for neuropathic pain in diabetes. The management of peripheral neuropathy involves a multifaceted approach, considering the underlying cause, symptom severity, and individual patient factors.
Key Considerations
- Optimizing glucose control is crucial to prevent or delay the development of neuropathy in people with type 1 diabetes and to slow the progression of neuropathy in people with type 2 diabetes, as emphasized by 1.
- Assessing and treating pain related to diabetic peripheral neuropathy and symptoms of autonomic neuropathy are vital to improve quality of life, with medications such as gabapentin, pregabalin, duloxetine, and tricyclic antidepressants like amitriptyline commonly prescribed for pain management.
- Lifestyle modifications, including regular exercise, maintaining a healthy weight, limiting alcohol consumption, and smoking cessation, are important supportive measures.
- For severe cases unresponsive to other treatments, surgical options like nerve decompression might be considered, although this should be approached with caution and typically in consultation with a specialist.
Pharmacologic Treatments
- Gabapentinoids, such as gabapentin and pregabalin, are effective for neuropathic pain management, with dosages ranging from 300-1200 mg three times daily for gabapentin and 75-300 mg twice daily for pregabalin.
- Serotonin-norepinephrine reuptake inhibitors, like duloxetine, are also recommended, with typical dosages of 30-60 mg daily.
- Tricyclic antidepressants, such as amitriptyline, can be used at dosages of 10-75 mg at bedtime, although their use may be limited by side effects.
- Sodium channel blockers may be considered for certain cases of neuropathic pain, although their use should be guided by specialist advice due to potential side effects and interactions.
Non-Pharmacologic Interventions
- Physical therapy can improve strength and balance, reducing the risk of falls and improving mobility.
- Transcutaneous electrical nerve stimulation (TENS) may provide additional pain relief for some patients.
- Nutritional supplements, such as vitamin B12, are essential for patients with deficiencies, which can contribute to neuropathy.
Individualized Approach
Treatment should be tailored to the specific type of neuropathy, underlying cause, and symptom presentation, with regular monitoring to assess effectiveness and adjust therapy as needed, as highlighted by 1, which provides the most recent and highest quality guidance on the management of peripheral neuropathy.
From the FDA Drug Label
Pregabalin is indicated for: Management of neuropathic pain associated with diabetic peripheral neuropathy 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
The treatment options for peripheral neuropathy include:
- Pregabalin for the management of neuropathic pain associated with diabetic peripheral neuropathy 2
- Duloxetine for the management of neuropathic pain associated with diabetic peripheral neuropathy in adults 3
From the Research
Treatment Options for Peripheral Neuropathy
The treatment options for peripheral neuropathy can be categorized into several areas, including:
- Pharmacological interventions:
- First-line drug therapy includes duloxetine, gabapentin, amitriptyline, and pregabalin 4, 5, 6
- Second-line drug therapy includes nortriptyline, imipramine, venlafaxine, carbamazepine, oxcarbazepine, topical lidocaine, and topical capsaicin 4
- Other medications such as tapentadol and 8% capsaicin patch are also approved by the FDA for the treatment of painful diabetic neuropathy 5
- Nondrug therapies:
- Exercise and neuromodulation with spinal cord stimulation or transcutaneous electrical nerve stimulation have low- to moderate-quality evidence 4
- Peripheral transcutaneous electrical nerve stimulation is well tolerated and inexpensive, but benefits are modest 4
- Other treatments, such as acupuncture, alpha-lipoic acid, acetyl-L-carnitine, cannabidiol, and onabotulinumtoxinA need further study in patients with diabetic peripheral neuropathy 4
- Lifestyle modifications:
- Addressing underlying risk factors such as poor glycemic control, vitamin B12 deficiency, elevated blood pressure, and obesity can help reduce the likelihood of developing neuropathy 4
- Intensive glycemic control with insulin in patients with type 1 diabetes may be associated with lower odds of distal symmetric polyneuropathy 5
Management of Painful Peripheral Neuropathies
The management of painful peripheral neuropathies is often challenging and requires a comprehensive approach, including:
- Pharmacological management:
- The best available evidence for the management of painful diabetic polyneuropathy is for amitriptyline, duloxetine, gabapentin, pregabalin, and venlafaxine as monotherapies and oxycodone as add-on therapy 6
- Tramadol appears to be effective when used as a monotherapy and add-on therapy in patients with PN of various etiologies 6
- Non-pharmacological interventions:
- Dorsal column spinal cord stimulation (SCS) has level I evidence for the treatment of PDN, delivering either a 10-kHz waveform or tonic waveform 5