Download Management of Diabetic Peripheral Neuropathy

Management of Painful Diabetic Peripheral Neuropathy
Diabetic peripheral neuropathy (DPN) is one of the commonest complications of type 2 diabetes and
may be present at time of diagnosis.
Diabetes can affect all nerves and so diabetic neuropathies are heterogenous with diverse clinical
manifestations. They may also be focal or diffuse, the most common diffuse neuropathy is the
chronic sensorimotor neuropathy (“glove and stocking”) diabetic peripheral neuropathy and the
most common focal neuropathy is carpal tunnel syndrome (median nerve compression).
Prevalence
DPN may be present at time of diagnosis in over 10% of patients and may affect up to 50% of
patients with long standing diabetes. In 50% of diabetic peripheral neuropathy may be
asymptomatic but in 16% to 26% of patients with diabetes the neuropathy is painful.
Clinical Monitoring
Patients should be examined for DPN from time of diagnosis and their feet should be examined at
each clinic visit for signs of peripheral neuropathy using a 10g monofilament and vibration
perception (128 Hz tuning fork) – refer to national model of footcare
Diagnosis
The diagnosis of DPN is a diagnosis of exclusion but complex investigations are rarely needed to
exclude other conditions. Consider however other causes including alcohol excess, B12 deficiency
(patients on metformin), underlying vasculitis, inherited neuropathies, neurotoxic medications and
chronic inflammatory demyelinating polyneuropathy.
Treatment


The first step is to aim for stable and optimal glucose control
Refer to National Model of Footcare for care of the “at risk” foot
Medication type/classifications
Advantages of this medication
First line therapy - Pregabalin
Start at low dose of 25mg and increase
by 25mg 2-weekly to 75mg dose.
Symptom relief
Improve well being
Reduce anxiety
Reduce pain
Increase dose further according to
patient response to 75mg bd with
upward titration to the effective dose.
AVOID ABRUPT WITHDRAWAL (taper
dose over at least 1 to 2 weeks)
The maximum tolerated dose is 300mg
bd.
First line therapy – Amitryptiline
Anti-cholinergic
Start at low dose of 10mg daily, given
at night, and increase gradually
Potential side effects and/or notes of
caution when choosing this
medication
Drowsy
Dry mouth
Fatigue
Dizziness
Visual disturbance
Impaired memory
Relieve pain
Improve sleep pattern
Improve well being
Dry mouth
Urinary retention
Drowsy
Hyponatraemia
Medication type/classifications
Advantages of this medication
Potential side effects and/or notes of
caution when choosing this
medication
Fatigue
Mydriasis
Relieve pain
Improve sleep pattern
Improve well being
Reduce anxiety
Nausea, vomiting
Constipation
Diarrhoea
Weight changes
Dry mouth
Sweating
according to pain response to max
dose of 75mg daily.
First line therapy – Duloxetine
SNRI
Start at 60mg dose (in elderly patients
start at 30mg).
Increase dose according to pain
response to maximum of 120mg daily
AVOID ABRUPT WITHDRAWAL (taper
dose down over at least 1 to 2 weeks)
Second line therapy – combination of
the above treatments – see algorithm
Third Line Therapy – ask for specialist
advice, refer to consultant
endocrinologist/diabetes service
Recommended Care Pathway for the management of painful peripheral Neuropathy
Patient with Painful Peripheral
Diabetic Sensori-Motor Neuropathy
Refer immediately to specialist
Diabetes Service if patient in severe
pain or significantly disabled from
the pain
Exclude other potential causes –
alcohol history, medication list (for
example check Vitamin B12 and
Folate)
Optimise diabetes control and choose
options 1,2 or 3.
Option 1
Option 2
Start pregabalin and titrate
dose according to patient
response (see treatment
table for dose information)
Start amitryptiline and titrate
dose according to patient
response (see treatment table
for dose information)
Option 3
Start duloxetine and titrate
dose according to patient
response (see treatment
table for dose information)
No satisfactory response to treatment within 4 to 6 months
Switch to or combine with oral
amitryptiline
Switch to or combine with oral
pregabalin
Switch to or combine with oral
pregabalin
or
Switch to or combine with oral
duloxetine
No satisfactory response to combination treatment after a period of 6 months and patient remains in pain or
discomfort due to neuropathy then refer for specialist opinion
Suggested areas for auditing this process in line with the principle of continuous improvement in the
services delivered to patients with Type 2 Diabetes:

Frequency of checking a patient for Diabetic Peripheral Neuropathy (DPN)

Number of patients on oral treatment for Diabetic Peripheral Neuropathy (DPN) who have
responded to treatment .

Number of patients with Diabetic Peripheral Neuropathy (DPN) referred to Diabetes Service
for further treatment


Prevalence of diabetic peripheral neuropathy
Choice of and response to treatment