All patients with painful diabetic neuropathy should be examined for mood disorders such as depression and sleep disorders like obstructive sleep apnea, recommends the American Academy of Neurology (AAN) in its new guideline on the treatment of painful diabetic neuropathy. According to the guideline, it’s important to diagnose and manage them as their concurrent present also impacts pain perception and quality of life.

The new guideline is an update of the clinical practice guideline last published in 2011.

All patients with diabetes should be evaluated for peripheral neuropathic pain and its impact on their activities and quality of life. The guideline cautions the treating physician to counsel the patient that treatment will reduce pain and not completely eliminate pain and also that many medications need to be tried before deciding on the one that provides maximum benefit. As per the guideline, “about 30% pain reduction is considered a success”.

Four classes of medications can be prescribed to reduce pain. These include: tricyclic antidepressants (TCAs) (such as amitriptyline, nortriptyline and imipramine), serotonin-norepinephrine reuptake inhibitors (SNRIs) (such as duloxetine, venlafaxine or desvenlafaxine), gabapentinoids (such as gabapentin or pregabalin) and/or sodium channel blockers (such as carbamazepine, oxcarbazepine, lamotrigine or lacosamide). Selection of the drug, however, should not just be based on efficacy. Factors such as cost, adverse effects, comorbidities including patient preferences should also be taken into consideration.

Those who are looking for nonpharmacological ways to reduce pain may be offered topical treatments such as capsaicin, glyceryl trinitrate spray, Citrullus colocynthis to reduce pain. Ginkgo biloba or interventions such as exercise, Tai Chi, mindfulness, cognitive behavioral therapy (CBT) may also help.

When evaluating the response to the prescribed drug, the guideline states that “Clinicians should determine that an individual intervention to reduce neuropathic pain is a failure either when the medication has been titrated to a demonstrated efficacious dose for approximately 12 weeks without clinically significant pain reduction or when side effects from the medication outweigh any benefit in reduced neuropathic pain”. In such cases, change to another class of drug or add a drug from a different class to the current medication.

Opioids, dual μ-opioid agonists and SNRI drugs like tramadol and tapentadol are not recommended for treatment. They should be tapered safely and alternative nonopioid treatment options should be discussed, if the patient is currently on any of these drugs.

Valproic acid should only be considered when other drugs have failed. It should not be prescribed to women in the reproductive age group.

The complete guideline is published in the journal Neurology.

Reference

1. Price R, et al. Oral and topical treatment of painful diabetic polyneuropathy: practice guideline update summary: report of the AAN Guideline Subcommittee. Neurology. 2022 Jan 4;98(1):31-43. doi: 10.1212/WNL.0000000000013038.