Update on the Management of Diabetic Neuropathy
Article Figures & Tables
Figures
- FIGURE 1.
Algorithm for management of patients with pain due to DSPN. *Pregabalin is FDA-approved for painful DSPN, whereas gabapentin is not. Pharmacokinetic profile, spectrum of AEs and drug interactions, comorbidities, and costs should be considered in selecting the agent of choice. **Duloxetine is FDA-approved for painful DSPN, whereas venlafaxine is not. Pharmacokinetic profile, spectrum of AEs, drug interactions, comorbidities, and costs should be considered in selecting the agent of choice. #None is FDA-approved for painful DSPN. Spectrum of AEs, drug interactions, and comorbidities should be considered in selecting these agents. Reprinted with permission from ref. 1.
Tables
- TABLE 1.
Diagnostic Steps and Management Recommendations for Diabetic Neuropathy
Type of Neuropathy Symptoms Clinical Signs Diagnosis Management Recommendations DSPN Burning pain Tests for small-fiber unction: Assess symptoms (history taking) Prevention Lancinating or shooting pain Pinprick (push pin) Assess clinical signs Glucose control targeting near-normal glycemia: strong evidence for type 1 diabetes; modest data for type 2 diabetes Paresthesias (tingling and prickling sensation) Temperature sensation discrimination Confirm pattern for symptoms and signs: Lifestyle modifications: emerging as effective treatment strategies in patients with IGT/metabolic syndrome or type 2 diabetes Hyperalgesia (exaggerated response to painful stimuli) Tests for large-fiber function: Distal-to-proximal (stocking-glove) Prevention of foot complications Allodynia (pain evoked by light touch) Vibration perception (128-Hz tuning fork) Symmetrical Pain treatment (see Figure 1) Note. Neuropathic pain may be the first symptom that prompts patients to seek medical care. Proprioception Combine at least two of the small- and large-fiber tests listed in the previous column (e.g., pinprick plus vibration) for higher sensitivity and specificity Anticonvulsants: Light touch to 10-g monofilament (on dorsal aspect of the great toe bilaterally) Differential (as applicable): Pregabalin* 150–600 mg/day Ankle reflexes Family/medication history Gabapentin 1,800–3,600 mg/day Serum B12 Monoamine reuptake inhibitors: Folic acid • Selective norepinephrine-serotonin reuptake inhibitors Thyroid function Duloxetine* 60–120 mg/day Complete blood count Venlafaxine 150–225 mg/day Metabolic panel Tricyclic antidepressants Serum protein immunoelectrophoresis Amitriptyline 25–100 mg/day (with titration) Note. Electrophysiological testing or referral to a neurologist is rarely needed in clinical practice except for situations in which clinical features are atypical and a different etiology is suspected (i.e., motor greater than sensory neuropathy, asymmetry of symptoms and signs, or rapid progression). Nortriptyline 25–100 mg/day (with titration) Desipramine titrate from 12.5 to 100–150 mg/day Warning. Opioids are not recommended for DSPN pain as first-, second-, or third-line agents given their high risk of addiction, abuse, and serious adverse events. Diabetic autonomic neuropathies CAN Lightheadedness Reduced HRV Document symptoms Prevention Weakness Resting tachycardia (>100 bpm) Document signs Glucose control targeting near-normal glycemia: strong evidence for type 1 diabetes, controversial data for type 2 diabetes Faintness Exercise intolerance Consider ECG recordings with deep breathing Lifestyle modifications: emerging as effective treatment strategies in patients with impaired glucose tolerance/metabolic syndrome, and type 2 diabetes Palpitations Orthostatic hypotension (a fall in systolic or diastolic blood pressure of >20 or >10 mmHg, respectively, upon standing) Differential (as applicable): Treatment for orthostatic hypotension Syncope Anemia Non-pharmacological: Note. All symptoms occur upon standing. Hyperthyroidism Physical activity Dehydration Volume repletion with fluids Adrenal insufficiency Pharmacological: Smoking Midodrine* (peripheral, selective, direct α1-adrenoreceptor agonist); 2.5–10 mg up to 3 times/day, with titration; use lowest effective dose, first dose before arising Alcohol Droxidopa** (α/β adrenergic agonist) Caffeine Dietary changes Medications (e.g., sympathomimetics, over-the-counter cold agents containing ephedrine or pseudoephedrine, recreational drugs, and dietary supplements) Eating multiple small meals Gastrointestinal neuropathy (gastroparesis) Early satiety Clinically silent in the majority of cases Careful medication history Decreasing fat and fiber intake Fullness and bloating Glucose variability and unexplained hypoglycemia (due to the dissociation between food absorption and the pharmacokinetic profiles of insulin and other agents) Esophagogastroduodenoscopy or barium study to exclude organic causes of gastric outlet obstruction or peptic ulcer disease Withdrawing drugs with effects on motility: opioids, anticholinergics, tricyclic antidepressants, GLP-1 receptor agonists, pramlintide Nausea, vomiting, or dyspepsia Gastric emptying with scintigraphy of digestible solids (gold standard if above tests are negative) Medication Abdominal pain 13C-octanoic acid breath test (emerged as an easier alternative) Metoclopramide*** 5–10 mg 3–4 times/day (prokinetic agent, weak evidence, risk of serious adverse effects, tardive dyskinesia) Note. Symptoms are nonspecific and do not correspond with severity of gastroparesis or abnormal gastric emptying
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August 2018, 31(3)
