Diabetic Neuropathy – Treatment

Epidemiology:
  • 30% of hospitalized diabetics; 25% of outpatient diabetics
  • Approx 26% of patients with diabetic peripheral neuropathy have distal symmetric polyneuropathy (stocking-glove distribution, pain, paresthesias, numbness).
  • Good evidence for decreased DPN in type 1 diabetics tightly-controlled, but not in type 2 diabetics.
  • Other cardiovascular risk factors also associated with DPN.
Pharmacologic Treatment Options:
Drug Class                                        Examples                                        Side-effects                                Drug Interactions
Anticonvulsants
pregabalin*; gabapentin*
somnolence, dizziness, wt gain
CNS depressants, SSRIs, TZDs, Mg, hydroxyzine
Tricyclic Antidepressants
amitriptyline*
dry mouth, insomnia, fatigue
QT prolonging, sulfonylureas, serotonergics, MAOIs
SNRIs
duloxetine*; venlafaxine
N, somnolence, dizzy, constipation
CNS depressants, antiplts, alpha- and beta-agonists, warfarin
Opioid-like Medications
tramadol; tapentadol
constip, N, drowsiness
CNS depressants, serotonergic
Topicals
lidocaine; capsaicin; iso. dinit.
cap: burning
none signficant
Others
SSRIs; opioids
SSRI: sexual; opioids: usual
CNS depressants
*first-line therapies
pregabalin and duloxetine FDA-approved for this indication
DDx of peripheral neuropathy includes: malignancy, EtOH abuse, HIV, isoniazid use, chemotherapy.
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