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Diabetic Neuropathy
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Diabetic Neuropathy
, Peripheral Neuropathy in Diabetes Mellitus
See Also
Diabetic Neuropathy Testing
Diabetic Foot Care
Epidemiology
Occurs in Type I and
Type II Diabetes Mellitus
Occurs in 42% of
Type II Diabetes Mellitus
Onset within 10 years of disease
Higher risk with higher
Glycosylated Hemoglobin
Partanen (1995) N Engl J Med 333:89-94 [PubMed]
Types
Bilateral Peripheral Polyneuropathy in Diabetes
(
Diabetic Distal Symmetric Polyneuropathy
)
Diabetic Focal Neuropathy
(
Diabetic Mononeuropathy
)
Diabetic Autonomic Neuropathy
Diabetic Amyotrophy
(
Symmetric Diabetic Proximal Motor Neuropathy
)
Diagnosis
See also
Peripheral Neuropathy Testing
Differential Diagnosis
See
Leg Pain
See
Autonomic Neuropathy
Peripheral
Polyneuropathy
Vitamin B12 Deficiency
Especially when using
Metformin
Folic Acid Deficiency
Iron Deficiency Anemia
Hypothyroidism
Uremia
Chemical Toxin
exposure (heavy metal toxicity)
Alcohol Abuse
Sarcoidosis
Leprosy
Periarteritis nodosum
Systemic Lupus Erythematosus
Leukemia
Other important causes of
Leg Pain
Lumbar Disc Disease
with radiculopathy
Lumbar central spinal stenosis
Claudication
Night Cramp
s
Restless Leg Syndrome
Degenerative Joint Disease
Hip
Osteoarthritis
Knee Osteoarthritis
Ankle
Osteoarthritis
Complications (of distal symmetric Polyneuropathy)
See
Charcot Foot
See
Foot Wound
See
Suspected Osteomyelitis in Diabetes Mellitus
See
Peripheral Neuropathy Tremor
Management
Approach
See dosing regimens in next section
Step 1
See prevention below for diabetes care optimization including glycemic control
Set realistic patient expectations (e.g. 30-50% symptom improvement with medications)
Evaluate for other causes of
Peripheral Neuropathy
(see differential diagnosis above)
Step 2
Tricyclic Antidepressant
s (e.g.
Amitriptyline
,
Nortriptyline
,
Desipramine
): NNT 2-4
Step 3
Anticonvulsants (e.g.
Gabapentin
,
Pregabalin
): NNT 3-8
Step 4
Serotonin
-
Norepinephrine
reuptake inhibitors (e.g.
Duloxetine
,
Venlafaxine
): NNT 4-11
Step 5
Reconsider differential diagnosis
Chronic
Analgesic
s (
Opioid
s,
Tramadol
)
Consider
SSRI
(e.g.
Escitalopram
), although lack of adequate studies to support use
Consider pain management referral
Adjuncts (add at any point)
Topical
Lidocaine
(
Lidoderm
5% patch) or the OTC, less expensive
Lidocare
4% patch (but still expensive!)
Capsaicin
0.075% cream (often intolerable due to burning)
Transcutaneous electrical nerve stimulation
(
TENS
)
Isosorbide Dinitrate
spray 30 mg applied to bottom of feet at bedtime
Acupuncture
(no large, high quality studies in Diabetic Neuropathy to support use)
Management
Medications for Painful
Peripheral Neuropathy
Tricyclic Antidepressant
s
May be more effective in burning, steady pain
Avoid in the elderly due to strong
Anticholinergic
effects (see
Beers List
)
Amitriptyline
(
Elavil
) or
Nortriptyline
(
Pamelor
)
Started at 10-30 mg at bedtime
Increase to 50-75 mg (maximum 150 mg) at bedtime
Desipramine
(
Norpramin
) starting at 25 mg at bedtime
Anticonvulsants
May be more effective in sharp lancinating pain
Gabapentin
(
Neurontin
)
Adjust for renal dysfunction
Start at 100 mg at bedtime to 100 mg orally three time daily
Advance to 300 orally three times daily (maximum 1200 mg three times daily)
Pregabalin
(
Lyrica
)
Very similar to
Gabapentin
, but no generic yet available and expensive
More convenient dosing (twice daily), and no
Renal Dosing
adjustment as contrasted with
Gabapentin
Start at 50 mg orally two to three times daily
Titrate to 100 mg orally three times daily or 150 mg twice daily (maximum 300 mg twice daily)
Other agents
Other anticonvulsants (including
Carbamazepine
,
Topiramate
) do not have adequate evidence to support use
Serotonin
-
Norepinephrine
Reuptake Inhibitors
Duloxetine
(
Cymbalta
)
Start at 20 mg twice daily
Advance to 60 mg daily (or divided 30 mg twice daily)
Venlafaxine
(
Effexor
)
Extended release (preferred):
Venlafaxine
XR 37.5 mg daily (titrate to 225 mg daily)
Regular (generic):
Venlafaxine
37.5 mg twice daily (titrate to 225 mg divided twice daily)
Topical pain management
TENS
Unit
Lidocaine
5% patch (
Lidoderm
) up to 3 patches applied daily to affected area (applied for no more than 12 hours daily)
Capsaicin
0.075% cream applied to affected area twice daily (start with small amount and slowly increase)
Isosorbide Dinitrate
spray 30 mg applied to bottom of feet at bedtime
Analgesic
s
NSAID
S are not typically recommended in
Diabetes Mellitus
Risk of renal, gastrointestinal and cardiovascular risks
Tramadol
(
Ultram
)
See
Tramadol
for precautions (lower efficacy with adverse effect risk)
Opioid
s (avoid unless no other option available)
Prevention
See
Diabetic Foot Care
Optimize
Diabetes Mellitus
management (
Hemoglobin A1C
<7-8%)
Optimize
Hypertension
and
Hyperlipidemia Management
References
(2017) Presc Lett 24(9): 50
Aring (2005) Am Fam Physician 71:2123-30 [PubMed]
Backonja (1998) JAMA 280:1831-36 [PubMed]
Kochar (2004) QJM 97:33-8 [PubMed]
Lindsay (2010) Am Fam Physician 82(2): 151-8 [PubMed]
Lipnick (1996) Am Fam Physician 54(8):2478-84 [PubMed]
McQuay (1996) Pain 68:217-27 [PubMed]
Simmons (2000) Clinical Diabetes 18:116-7 [PubMed]
Sindrup (1990) Pain 42:135-44 [PubMed]
Snyder (2016) Am Fam Physician 94(3): 227-34 [PubMed]
Veves (2008) Pain Med 9(6): 660-74 [PubMed]
Wong (2007) BMJ 335(7610): 87 [PubMed]
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