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Diabetic Polyneuropathy

- 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

- 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

- Generalized symmetric polyneuropathies - Usually slow, chronic progression - Insensitive but painless foot as pain lessens

- Focal neuropathies - Recovery over months to years

- 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

para>Anticholinergic effects of TCAs may cause urinary retention and arrhythmias.

Second Line

  • AntidepressantsVenlafaxine (2),(3)[B] (75 to 225 mg daily) (off-label)Serotonin-norepinephrine reuptake inhibitor
  • AnticonvulsantsCarbamazepine (3)[C] (off-label)Blocks sodium channelsDose 100 to 800 mg/day
  • Topical therapiesCapsaicin 0.075% cream applied TIDDepletes C fibers in skin of substance PLidocaine 5% (700 mg) patches applied daily to feet (off-label):Causes sodium channel blockade
  • Opiate analgesiaTramadol (3)[B] (off label) : 100 to 400 mg/day, NNT 3 to 8Binds opiate receptors; also inhibits reuptake of norepinephrine and serotonin; fewer opiate side effectsTapentadol (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 polyneuropathiesUsually slow, chronic progressionInsensitive but painless foot as pain lessens
  • Focal neuropathiesRecovery over months to years

COMPLICATIONS

  • Claw foot deformity
  • Neurotropic ulcerationPainless ulcers on weight-bearing areaCallus formation is a precursor to ulceration.
  • Neuropathic arthropathyResults 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.