Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update Summary

Abstract

ObjectiveTo update the 2011 American Academy of Neurology (AAN) guideline on the treatment of painful diabetic neuropathy (PDN) with a focus on topical and oral medications and medical class effects.MethodsThe authors systematically searched the literature from January 2008 to April 2020 using a structured review process to classify the evidence and develop practice recommendations using the AAN 2017 Clinical Practice Guideline Process Manual.ResultsGabapentinoids (standardized mean difference [SMD] 0.44; 95% confidence interval [CI], 0.21–0.67), serotonin-norepinephrine reuptake inhibitors (SNRIs) (SMD 0.47; 95% CI, 0.34–0.60), sodium channel blockers (SMD 0.56; 95% CI, 0.25–0.87), and SNRI/opioid dual mechanism agents (SMD 0.62; 95% CI, 0.38–0.86) all have comparable effect sizes just above or just below our cutoff for a medium effect size (SMD 0.5). Tricyclic antidepressants (TCAs) (SMD 0.95; 95% CI, 0.15–1.8) have a large effect size, but this result is tempered by a low confidence in the estimate.Recommendations SummaryClinicians should assess patients with diabetes for PDN (Level B) and those with PDN for concurrent mood and sleep disorders (Level B). In patients with PDN, clinicians should offer TCAs, SNRIs, gabapentinoids, and/or sodium channel blockers to reduce pain (Level B) and consider factors other than efficacy (Level B). Clinicians should offer patients a trial of medication from a different effective class when they do not achieve meaningful improvement or experience significant adverse effects with the initial therapeutic class (Level B) and not use opioids for the treatment of PDN (Level B).

Comparison of amitriptyline supplemented with pregabalin, pregabalin supplemented with amitriptyline, and duloxetine supplemented with pregabalin for the treatment of diabetic peripheral neuropathic pain (OPTION-DM): a multicentre, double-blind, randomised crossover trial

“…This will have real power to inform future clinical guidelines for the management of DPNP as available guidelines provide conflicting recommendations. 9, 30,31 Additionally, all monotherapies resulted in improvement of SF-36 quality-of-life domains, sleep, and measures of mood from baseline. However, amitriptyline was significantly better than duloxetine in improving physical functioning and sleep, and pregabalin was better than duloxetine in improving role limitation due to physical health.…”

Seizure Frequency Process and Outcome Quality Measures

“…The AANI previously submitted a request for pain assessment codes for polyneuropathy and believes creation of standardized codes for neurology will reduce clinician documentation burden. 17 LOINC is a common language to identify health measurements, observations, and documents and move the data across platforms from EHRs to payers, researchers, government agencies, and more. 18 LOINC codes exist to capture common laboratory tests (e.g., SARS-2/COVID-19 tests), clinical documents (e.g., discharge summary), and survey instruments (e.g., 9-Item Patient Health Questionnaire [PHQ-9]).…”

Supportive Care and Symptom Management for Patients With Immunoglobulin Light Chain (AL) Amyloidosis

“…Recommendations regarding symptomatic therapies for AL sensorimotor neuropathy are largely extrapolated from other settings, particularly diabetic neuropathy. However, the evidence base for the comparative effectiveness of pharmacologic agents even in the setting of these more common neuropathies is limited by a lack of direct comparisons and relatively short term follow up in studies ( 52 , 53 ). A trial of gabapentinoids (gabapentin, pregabalin) or serotonin-norepinephrine reuptake inhibitors (venlafaxine, duloxetine) is appropriate.…”