para>Anticholinergic effects of TCAs may cause urinary retention and arrhythmias.
Second Line
- Antidepressants
- Venlafaxine (2),(3)[B] (75 to 225 mg daily) (off-label)
- Serotonin-norepinephrine reuptake inhibitor
- Anticonvulsants
- Carbamazepine (3)[C] (off-label)
- Blocks sodium channels
- Dose 100 to 800 mg/day
- Topical therapies
- Capsaicin 0.075% cream applied TID
- Depletes C fibers in skin of substance P
- Lidocaine 5% (700 mg) patches applied daily to feet (off-label):
- Causes sodium channel blockade
- Opiate analgesia
- Tramadol (3)[B] (off label) : 100 to 400 mg/day, NNT 3 to 8
- Binds opiate receptors; also inhibits reuptake of norepinephrine and serotonin; fewer opiate side effects
- Tapentadol (3)[B]
- Binds to μ-opiate receptor and inhibits norepinephrine uptake
- α-lipoic acid (3)[C]
- Antioxidant properties may limit free radical-mediated damage.
- 600 mg/day PO dose showed benefit in small studies; intravenous more effective.
ISSUES FOR REFERRAL
If CIDP is suspected, refer to neurologist for investigation and treatment.
ADDITIONAL THERAPIES
- Transcutaneous electrical nerve stimulation
- Percutaneous nerve stimulation
- Electrical spinal cord stimulation
- Actovegin, dextromethorphan with quinidine
- C-peptide
COMPLEMENTARY & ALTERNATIVE MEDICINE
Acupuncture, Reiki, electromagnetic field treatment: no convincing trial data
SURGERY/OTHER PROCEDURES
Electrical spinal cord stimulation
ONGOING CARE
PROGNOSIS
- Generalized symmetric polyneuropathies
- Usually slow, chronic progression
- Insensitive but painless foot as pain lessens
- Focal neuropathies
- Recovery over months to years
COMPLICATIONS
- Claw foot deformity
- Neurotropic ulceration
- Painless ulcers on weight-bearing area
- Callus formation is a precursor to ulceration.
- Neuropathic arthropathy
- Results in complete disorganization of joint structure in foot, Charcot joint
REFERENCES
11 Albers JW, Pop-Busui R. Diabetic neuropathy: mechanisms, emerging treatments, and subtypes. Curr Neurol Neurosci Rep. 2014;14(8):473.22 Griebeler ML, Morey-Vargas OL, Brito JP, et al. Pharmacologic interventions for painful diabetic neuropathy: an umbrella systematic review and comparative effectiveness network meta-analysis. Ann Intern Med. 2014;161(9):639-649.33 Kaku M, Vinik A, Simpson DM. Pathways in the diagnosis and management of diabetic polyneuropathy.Curr Diab Rep. 2015;15(6):609.
ADDITIONAL READING
- Bril V, England J, Franklin GM, et al. Evidence-based guideline: treatment of painful diabetic neuropathy: report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2011;76(20):1758-1765.
- Javed S, Petropoulos IN, Alam U, et al. Treatment of painful diabetic neuropathy. Ther Adv Chronic Dis. 2015;6(1):15-28.
- Saarto T, Wiffen PJ. Antidepressants for neuropathic pain: a Cochrane review. J Neurol Neurosurg Psychiatry. 2010;81(12):1372-1373.
- Tesfaye S, Boulton AJ, Dickenson AH. Mechanisms and management of diabetic painful distal symmetrical polyneuropathy. Diabetes Care. 2013;36(9):2456-2465.
SEE ALSO
Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2
CODES
ICD10
- E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy
- E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy
- E13.42 Oth diabetes mellitus with diabetic polyneuropathy
- E08.42 Diabetes due to underlying condition w diabetic polyneurop
- E09.42 Drug/chem diabetes w neurological comp w diabetic polyneurop
ICD9
- 357.2 Polyneuropathy in diabetes
- 250.61 Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled
- 250.60 Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled
- 250.62 Diabetes with neurological manifestations, type II or unspecified type, uncontrolled
- 250.63 Diabetes with neurological manifestations, type I [juvenile type], uncontrolled
SNOMED
- 49455004 diabetic polyneuropathy (disorder)
- 422297002 Polyneuropathy associated with type I diabetes mellitus
- 421707005 Polyneuropathy associated with type II diabetes mellitus
- 126535008 Diabetic motor polyneuropathy (disorder)
- 127011001 Diabetic sensory polyneuropathy (disorder)
CLINICAL PEARLS
- Occasionally, when glycemic control improves dramatically, as can occur when treatment for diabetes is initiated, there may be a worsening of neuropathy symptoms. Symptoms usually stabilize and gradually improve as glycemic control is maintained.
- It is common to combine agents with different mechanisms of action in the management of neuropathic pain. Topical therapies can be combined with systemic therapies. There is limited evidence-based data to support combination therapy.