The American Diabetes Association recommends starting with pregabalin (Lyrica) or gabapentin (Gralise, Neurontin) for Neuropathy Treatment near Grapevine TX. Some of these medications ease nerve pain even if you're not depressed. Tricyclic antidepressants may also be helpful for mild to moderate nerve pain in this area. Drugs in this class include amitriptyline, nortriptyline (Pamelor), and desipramine (Norpramin). Side effects may include dry mouth, constipation, drowsiness, and trouble concentrating.
These medications can also cause dizziness when changing position, such as from lying down to standing. This is a symptom of a sudden drop in blood pressure called orthostatic hypotension. Another type of antidepressant may help with nerve pain and have fewer side effects. It's called a serotonin and norepinephrine reuptake inhibitor (SNRI).
The American Diabetes Association recommends the administration of duloxetine (Cymbalta) as an initial treatment. Another medication that can be used is venlafaxine (Effexor). XR). Side effects may include nausea, drowsiness, dizziness, lack of appetite, and constipation.
The exact cause of DPN is unknown. Proposed theories include metabolic, neurovascular, and autoimmune pathways. Mechanical compression (e.g., carpal tunnel), genetics, and social and lifestyle factors, such as chronic alcohol consumption and smoking, have been implicated. Permanently high blood sugar leads to insulin resistance, which promotes oxidative stress, inflammation and cell damage.
First, distal sensory and autonomic nerve fibers are damaged; damage continues with proximal progression, causing a gradual loss of protective sensation in the skin and joints of the foot. The treatment of DPN consists of several strategies, including preventive measures (e.g., patient education, proper foot care, proper shoe use, and annual foot exams), glucose control, dietary modifications, weight loss, and pain management. Half of diabetic peripheral neuropathies may be asymmetric. If preventive foot care is not recognized and implemented, patients are at greater risk of injury due to the insensitivity of their feet.
Tricyclic antidepressants have been shown to be effective in treating PND; however, their adverse effect profile limits their use. Autonomic neuropathy can also cause hypoglycemia without realizing it. This means you don't experience the typical warning signs of low blood sugar, such as tremors, confusion and intense hunger. Permanently high blood sugar levels can damage the small blood vessels that provide oxygen and nutrients to nerves.
Without enough oxygen and nutrients, nerve cells can die and affect nerve function. Treating diabetes-related neuropathy involves carefully monitoring your blood sugar level. This is the most important step in preventing nerve damage from worsening. Your healthcare provider and other diabetes specialists, such as a certified diabetes care and education specialist (CDCES), will work with you to achieve realistic blood sugar goals. Without appropriate treatment, peripheral neuropathy can affect your quality of life.
That's why it's essential to seek medical help as soon as you notice signs of the disease. It's also important to self-examine your feet every day for blisters, wounds, or skin injuries. This can help you quickly detect signs of neuropathy or its complications. You should visit your healthcare provider regularly if you have diabetes-related neuropathy. This is so they can control their symptoms and see if they worsen or improve.
You'll also need to visit your diabetes professional (such as an endocrinologist) regularly to make adjustments to your diabetes management plan. RODGERS, MD, VINCENT SAVATH, MD, AND KEVIN HETTINGER, MD Peripheral neuropathy is a common complication of diabetes mellitus, occurring in between 30 and 50 percent of patients with the disease.1 It involves loss of sensation in a symmetric distribution between socks and gloves, which begins on the toes and progresses proximally. Approximately 10 to 20 percent of patients with diabetes have diabetic peripheral neuropathic pain, which is severe burning, tingling, or discomfort that worsens at night.1,2 Patients with diabetic peripheral neuropathic pain may also experience allodynia and hyperalgesia. Diabetic peripheral neuropathic pain interferes with sleep quality, mood, and activity level.
Initial treatment goals include controlling hyperglycemia, which can acutely worsen pain. 3 While total relief is ideal, for most patients taking maximum doses of medication, only a 30 to 50 percent reduction in pain can be expected, 4,5 The available evidence on the treatment of diabetic peripheral neuropathic pain is limited to small studies and few comparative trials. Although the American Society of Pain Educators has published consensus treatment guidelines, they offer little guidance on choosing a first-tier agent.6,7 Figure 1 presents a treatment algorithm for diabetic peripheral neuropathic pain based on available evidence.4 There are five main classes of medications and some alternative options used to treat diabetic peripheral neuropathic pain. Table 1 shows the doses, costs and quantities needed to treat (NNT) of selected drugs, 5,8—29 Table 2 lists common adverse drug effects, 5,8—11,14,18—20,30 Studies on medications used to treat diabetic peripheral neuropathic pain evaluate efficacy primarily by measuring pain reduction.
Few studies have examined the effects of diabetic peripheral neuropathic pain on quality of life. However, one study used the Nottingham Health Profile, a validated quality of life questionnaire, to examine the quality of life of patients with diabetic peripheral neuropathic pain 31. The study showed a decrease in quality of life in the areas of sleep, energy and exercise tolerance, as well as an increase in emotional reactivity, suggesting considerable benefits of the treatment of diabetic peripheral neuropathic pain. Tricyclic antidepressants (TCAs) are recommended as first-line treatment for diabetic peripheral neuropathic pain in appropriate patients, although their mechanism of action is uncertain. For years, doctors have been using antivirals, such as amitriptyline and nortriptyline (Pamelor), to treat neuropathic pain, without the U.S.
Food and Drug Administration (FDA) approving their labeling. In a Cochrane review, 12 studies were examined in which 404 participants with various types of neuropathic pain participated. The review found an NNT of 2.5 for achieving moderate pain relief with carbamazepine. 12 Adverse effects included drowsiness, dizziness, constipation, nausea, and ataxia.
12 Laboratory monitoring is important to consider when prescribing carbamazepine. Before starting treatment, the patient's blood levels of urea nitrogen, creatinine, transaminases and iron should be monitored, and a complete blood count (including platelets), a reticulocyte count, a liver function test and a urinalysis should be performed. It is also recommended to perform a lipid analysis and measure drug levels every six to 12 months.37,38 In addition, carbamazepine contains a warning for serious dermatological reactions, such as toxic epidermal necrolysis and Stevens-Johnson syndrome.37 The risk increases 10-fold in combination with human leukocyte antigen B*1502, which occurs almost exclusively in Asians. Physicians should perform genetic testing before starting carbamazepine in this population, 12 Due to the need for laboratory monitoring and the risk of drug interactions, newer anticonvulsants are preferred to carbamazepine, 12 Valproate and phenytoin have not been as thoroughly researched as carbamazepine, but they have many of the same drawbacks, 4,6,39 Phenytoin has the additional complication of raising glucose levels, causing its use in patients with diabetic peripheral neuropathic pain , 9 common topical treatments for peripheral diabetics Neuropathic pain includes capsaicin cream (Zostrix) and 5% lidocaine patches (Lidoderm).Capsaicin stimulates C fibers to release and then exhaust substance P.
Many patients who use capsaicin experience a stinging sensation during the first week of treatment, which dissipates with continued use. In a 2004 meta-analysis involving six trials with 656 patients, capsaicin found that capsaicin had an NNT of 6.4 and 5.7, reducing pain by 50 percent at four and eight weeks, respectively; 19 patches of 5% lidocaine block neural sodium channels. Small efficacy trials have been conducted with this medication. An RCT conducted in 2003 revealed an NNT of 4.4 to reduce pain by 50 percent. 20 The adverse effects are mainly dermatological and disappear when the patch is removed.
The main advantage of topical treatment is that it can be added to systemic treatment at any time. As with many chronic diseases that interfere with quality of life, patients with diabetic peripheral neuropathic pain can explore complementary and alternative medicine (CAM) options. Complementary and alternative medicine therapies are being applied to diabetic peripheral neuropathic pain, although data are limited. Asking patients about the complementary and alternative medicine treatments they use can help doctors provide more comprehensive patient care.
The most promising complementary and alternative medicine therapies include l-carnitine and alpha-lipoic acid, which are available without a prescription. Early studies have shown positive results, but more long-term data are needed. 22,45 Data related to acupuncture is limited. However, a pilot study and a small RCT have shown promise 24,25 A Cochrane review is currently under way 26. Because of the complicated interaction profiles between medications used to treat diabetic peripheral neuropathic pain (Table 34), it is advisable to exhaust monotherapy options before considering combination therapy, with the exception of topical drugs.
Few studies have considered the role of combination therapy, although one study showed a lower need for opiates when combined with gabapentin, 15 If combination therapy is necessary, doctors should consider the mechanism of action when choosing medications and consider consulting a pain management specialist.7 It is important to avoid combining ATCs with SSRIs or SNRIs to avoid serotonin syndrome, a potentially fatal condition with autonomic and neurological symptoms, 47 Before starting the treatment, doctors should thoroughly review drug lists for possible interactions in patients with comorbidities. Drugs that may interact with treatments for peripheral neuropathic pain in diabetics include statins, beta-blockers, sulfonylureas, levothyroxine, warfarin (Coumadin) and chain diuretics. Drug interactions are mainly due to liver metabolism through the cytochrome P450 system or to the fact that the drug is highly bound to proteins. Treatment for peripheral neuropathy may include treatment of any underlying cause or symptom.
Treatment may be more effective for certain underlying causes. For example, ensuring that diabetes is well controlled can help improve neuropathy or, at least, prevent it from worsening. In addition, a PubMed search was conducted with the terms “pain treatment for diabetic neuropathy”, “anticonvulsants”, “tricyclic antidepressants”, “alpha lipoic acid”, “evening primrose oil” and “alternative medicine”. There are many possible causes of peripheral neuropathy; the most prevalent subtype, diabetic peripheral neuropathy (DPN), can cause significant complications ranging from paresthesia to loss of a limb and life.
When choosing a treatment for painful diabetic peripheral neuropathy, doctors should carefully consider the patient's goals and functional status, as well as the potential adverse effects of medication. Studies suggest that diabetic peripheral neuropathic pain is related to an unbalanced release of norepinephrine and serotonin from neurons. Everyone with diabetes should have a dietary consultation and receive information about what foods to eat and what to avoid. Peripheral neuropathy is a common complication of diabetes mellitus, occurring in 30 to 50 percent of patients with the disease.
The most common topical treatments for diabetic peripheral neuropathic pain include capsaicin cream (Zostrix) and 5% lidocaine patches (Lidoderm). Impact of low-frequency transcutaneous electrical nerve stimulation on symptomatic diabetic neuropathy using the new Salutaris device. Patients with peripheral neuropathy often have varying degrees of numbness, tingling, pain, burning sensation, limb weakness, hyperalgesia, allodynia, and pain. A nurse skilled in the treatment of diabetes should educate the patient about all aspects of diabetes and the importance of euglycaemia.
Initially, DPN usually causes degeneration and loss of small fibers, which can cause a new onset of pain and dysesthesia, especially in the feet, what is called painful DPN. While tapentadol has an FDA indication for DPN, its dubious efficacy and worrisome adverse effect profiles limit its clinical use and, therefore, it is not considered a first-line option according to the American Diabetes Association. Poorly treated diabetics have higher rates of morbidity and complications associated with DPN than well-controlled diabetics.
