Pain is perhaps the most obvious symptom in most cases of diabetic neuropathy, but the options available for physicians and patients are too many to list one by one. Generally, diabetic neuropathy treatment options for pain fall into two categories: pharmacologic agents such as anticonvulsants, antidepressants, and opioids, and nonpharmacologic treatments like magnetic field treatment and transcutaneous electrical nerve stimulation.
Release of the Guidelines
Because of the numerous options available, new guidelines on how painful diabetic neuropathy should be treated were released by the American Academy of Neurology in 2011. The lead author was Dr. Vera Bril, from the University of Toronto, and the guidelines were developed in collaboration with the American Academy of Physical Medicine and Rehabilitation and the American Association of Neuromuscular and Electrodiagnostic Medicine.
The guidelines were published in Neurology and presented at the 63rd annual meeting of the American Academy of Neurology.
The study was undertaken because of the sheer volume of literature on diabetic neuropathy. The researchers started in 2007, and in the following years they closely examined more than 2200 papers on the subject. The evidence backing up claims for various forms of treatment were analyzed and evaluated.
The published guidelines contained the following classifications for various diabetic neuropathy treatment options:
Level A (strong evidence exists that it works well or not). Only one particular treatment received this classification, which was a bit of a surprise for the researchers themselves. This is the drug Pregabalin. The guidelines noted that it should be offered when it is clinically appropriate.
Level B (moderate evidence). For anticonvulsants, gabapentin and sodium valproate are recommended. Anticonvulsants that should not be considered as proper treatments include lacosamide, lamotrigine, and oxcarbazepine.
Antidepressants duloxetine, venlafaxine, and amitriptyline have moderate evidence to back up their pain relief claims and thus should be considered.
For opioids, recommended treatments in this category include oxycodone, tramadol, morphine sulphate, and dextromethorphan.
Isosorbide dinitrate spray and capsaicin cream are classified in this category. However, some people may not be able to tolerate the adverse effects of capsaicin. It may produce a burning pain in hot weather or when in contact with warm water. On the other hand, these treatments are not recommended: mexiletine, pentoxifylline, and clonidine.
Among nonpharmacologic treatments, TENS (transcutaneous electrical nerve stimulation) is recommended. What’s not recommended include Reiki therapy, low-intensity laser treatment, or electromagnetic field treatment.
Level C (weak evidence). Treatments which have weak evidence to back up their effectiveness include the Lidoderm patch and adding venlafaxine to gabapentin.
Level U (insufficient evidence). In this category, there’s simply not enough evidence to say whether a particular form of treatment is effective or not. This category includes the anticonvulsant topiramate, the antidepressants fluoxetine, imipramine, and desipramine, and the combination of fluphenazine and nortriptyline.
So when you go to your doctor to discuss your options on how to manage the pain brought by diabetic neuropathy, you may as well bring a copy of these guidelines with you and discuss how they suit your particular circumstances. You and your doctor may be able to choose the best treatments according to the recommendations of these guidelines.