Diabetic Peripheral Neuropathy: Current Concepts and Future Perspectives
Journal Title: Journal of Endocrinology and Diabetes - Year 2015, Vol 2, Issue 5
Abstract
Background: Peripheral Diabetic Neuropathy (PDN) is the clinical condition and one of the most common complications of diabetes affecting approximately 50% of people. Out of it, 16% to 33% of the patients manifest Neuropathic Pain (NP) associated with PDN. Neuropathic Pain in PDN arises due to nerve fiber injury both at the central and peripheral level and the pain is so severe that these patients have higher health care costs due to hospitalizations that are more frequent and thus, it affects their quality of life. Management of PDN includes both preventions of hyperglycemia and cardiovascular risk factors known to exacerbate neuropathy and the treatment of neuropathic pain. This review article focuses on current aspect and future perspective of epidemiology, basic understanding and recent advances of the mechanisms and therapeutics of PDN. Methods: All relevant data, RCTs, meta-analysis, review article and case reports (1976-2014) with relevance to PDN were accessed and incorporated in this review article. Results: In the results we describe here the treatment protocol of neuropathic pain including PDN according to (NeuPSIG) The Neuropathic Pain Special Interest Group of the International Association for the Study of Pain guidelines, Canadian pain society (CNS), European Federation of Neurological Societies guidelines (EFNS), American Academy of Neurology (AAN), American Association of Neuromuscular and Electrodiagnostic Medicine guidelines (AANEM). NeuPSIG guidelines recommend the use of TCAs, duloxetine, Venlafaxine, gabapentin, pregabalin and topical lidocaine as first line therapy. Tramadol and opioids as a second line and certain antidepressant medications (eg., bupropion, citalopram and paroxetine), certain antiepileptic medications (eg., carbamazepine, lamotrigine, oxcarbazepine, topiramate, and valproic acid), topical low-concentration capsaicin, dextromethorphan, memantine, and mexiletine as third line therapy. According to Canadian Pain Society, the analgesic agents for Neuropathic Pain including PDN are certain antidepressants (tricyclics) and anticonvulsants (gabapentin and pregabalin) as a first line. Second-line treatments recommended are serotonin-noradrenaline reuptake inhibitors and topical lidocaine. Tramadol and controlled-release opioid analgesics are recommended as third-line treatments for moderate to severe pain. Fourth-line treatments include cannabinoids, methadone, and anticonvulsants (lamotrigine, topiramate and valproic acid), but this line of medications has lesser evidence of efficacy. EFNS Guidelines recommended TCA, gabapentin, pregabalin and SNRI [selective serotonin norepinephrine reuptake inhibitors (duloxetine, venlafaxine)] as first-line treatment in Painful Peripheral Neuropathy (PPN) particularly in PDN. Tramadol is recommended as second line except for patients with exacerbations of pain (for the tramadol/ acetaminophen combination) or those with predominant coexisting non-neuropathic pain. Third-line therapy includes strong opioids. According to AAN, AANEM, and AAPM&R evidence-based guidelines for the treatment of painful diabetic neuropathy, they classified the therapy into recommended and non-recommended drugs where recommended drugs include pregabalin, gabapentin, valproate, Venlafaxine, duloxetine, amitriptyline, Dextromethorphan, morphine sulfate, tramadol, oxycodone, capsaicin, isosorbide dinitrate spray and electrical stimulation. Conclusion: In conclusion, PDN, being the most important underlying causes for neuropathic pain, remains a challenging condition to manage. It requires increased level of awareness and special communication between patients and pain specialist to the extent that all decisions about which therapy to start with and when to switch over to the next option with an alternative mechanism of action are especially needed.
Authors and Affiliations
Ashok K Saxena, Shivika Nath, Ruchi Kapoor
Keywords
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- EP ID EP333356
- DOI 10.15226/2374-6890/2/5/00138
- Views 98
- Downloads 0
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