Evidence‐based Guideline: Treatment of Painful Diabetic Neuropathy

Abstract

Pregabalin is established as effective and should be offered for relief of PDN (Level A). Venlafaxine, duloxetine, amitriptyline, gabapentin, valproate, opioids (morphine sulphate, tramadol, and oxycodone controlled-release), and capsaicin are probably effective and should be considered for treatment of PDN (Level B). Other treatments have less robust evidence or the evidence is negative. Effective treatments for PDN are available, but many have side effects that limit their usefulness, and few studies have sufficient information on treatment effects on function and QOL.

Electrical stimulation and electromagnetic field use in patients with diabetic neuropathy: systematic review and meta-analysis

“…The treatment options are limited, which may explain why up to 50% of patients have not requested or received treatment for the condition 7 . Analgesics, antidepressants and anticonvulsants are often prescribed, with varied responses 8 . As several studies have suggested, nonpharmacological options, such as electrical stimulation, which represents one of the more benign therapies for this condition 9 , may contribute to a better quality of life and fewer complaints of pain 10 .…”

Evidence-based pharmacological management of chronic neuropathic pain

“…Some agents with not established efficacy in PDNP are capsaicin cream, oxcarbazepine, topiramate, lamotrigine, lacosamide, clonidine, pentoxyfylline and mexiletine. [15][16][17] …”

“…gasserian ganglion percutaneous techniques, gamma knife and microvascular decompression may be considered. 15,16,17,24 Central Neuropathic Pain Pregabalin/ gabapentin or TCAs are recommended as first-line drugs in central neuropathic pain. Though, TCAs have been suggested in central post-stroke pain (CPSP), they may not be tolerated in elderly patients with stroke.…”

“…The NNT for gabapentin/pregabalin was 4.7 (4.0 -5.6); for opioid, 2.5 (2.0-3.2) and for tramadol, 3.9 (2.7-6.7). The NNH for TCAs was 14.7 (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25), for gabapentin/pregabalin, 17.8 (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30), for opioid, 17.1 (10-66) and for tramadol, 9 (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18). If analgesia is the only criterion for selection, then the chronology of preference would probably be TCAs> opioids ≥ tramadol ≥ gabapentin/pregabalin.…”

“…19 Figure 1 illustrates an algorithm or the pharmacological treatment for peripheral neuropathic pain based on the available evidence and recommendations. [15][16][17][18][19][20][21] …”