The American Academy of Neurology (AAN) has released updated guidelines on treating painful diabetic neuropathy, which were published in the journal Neurology.
The last few years have seen several advances in treating pain from diabetic peripheral neuropathy, which usually affects the legs and feet and may cause numbness, tingling, or burning sensations. Peripheral neuropathy is one of the most commonly diagnosed complications of diabetes, affecting as many as half of people with diabetes at some point. But like many potential diabetes complications, your risk for it is lower if you have a history of good blood glucose control. Studies have shown that if you do develop peripheral neuropathy, your symptoms may improve if you lose excess body weight, and if you treat insufficient vitamin D in your blood by taking a vitamin D supplement. You may also be able to reduce your risk for developing a foot ulcer — which is much more common in people with peripheral neuropathy — if you limit your sedentary time and get enough physical activity through the day.
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In just the last three years, the U.S. Food and Drug Administration (FDA) has approved generic versions of the neuropathy drug Lyrica (pregabalin), as well as several new treatments. Those new treatments include Qutenza, a patch worn on the skin that delivers capsaicin — a compound derived from chili peppers — to reduce neuropathic pain, as well as HFX, an implantable spinal cord stimulation treatment for severe cases of painful neuropathy. At the same time, recent research has shown that one of the most commonly prescribed drugs for type 2 diabetes, metformin, is linked to more severe neuropathy pain, possibly as a result of vitamin B12 deficiency.
The latest guidelines for treating painful neuropathy take many recent studies and approved treatments into consideration. They include many different recommendations, some of which note that currently available treatments may not be effective at eliminating pain from neuropathy in some people — and that in such cases the goal should be to reduce, not eliminate, pain. And while the guidelines recommend screening for painful neuropathy, they state that “the optimal frequency of such assessment is not clear,” and that most methods for pain assessment don’t take into account how it affects people’s functioning and well-being. This means that a person’s preferences and feedback are key to making sure neuropathy pain is being treated effectively.
When it comes to oral drugs for treating painful neuropathy, the guidelines recommend several options to choose from, including tricyclic antidepressants (TCAs), serotonin-norepinephrine reuptake inhibitors (SNRIs), sodium channel blockers, and gabapentinoids. They do not recommend using opioids to treat painful neuropathy, due to the lack of proven efficacy and the potential for harm. Research has shown that despite the lack of evidence and recommendations to support their use, many doctors still prescribe opioids to treat painful neuropathy.
The recommendations also emphasize that pain perception is subjective, and can depend on many different factors including mood disorders (like major depression) and sleep disorders (like obstructive sleep apnea) — both of which are more common in people with diabetes than in the general population. For this reason, it’s important to screen for and treat any mood or sleep disorders as part of an overall plan to treat painful neuropathy. Above all, the guidelines emphasize flexibility — that when people “do not achieve meaningful improvement or experience significant adverse effects” from one treatment, it’s important to offer a trial of another treatment from a different class or category of drugs.
Want to learn more about neuropathy? Read “Coping With Painful Neuropathy,” “Diabetic Peripheral Neuropathy,” and “Controlling Neuropathic Pain.”
