Recommendations for Neuromodulation in Diabetic Neuropathic Pain

Abstract

Over 50% of the 34 million people who suffer from diabetes mellitus (DM) are affected by diabetic neuropathy. Painful diabetic neuropathy (PDN) impacts 40–50% of that group (8.5 million patients) and is associated with a significant source of disability and economic burden. Though new neuromodulation options have been successful in recent clinical trials (NCT03228420), still there are many barriers that restrict patients from access to these therapies. We seek to examine our tertiary care center (Albany Medical Center, NY, USA) experience with PDN management by leveraging our clinical database to assess patient referral patterns and utilization of neuromodulation. We identified all patients with a diagnosis of diabetes type 1 (CODE: E10.xx) or diabetes type 2 (CODE: E11.xx) AND neuralgia/neuropathic pain (CODE: M79.2) or neuropathy (CODE: G90.09) or chronic pain (CODE: G89.4) or limb pain (CODE: M79.6) OR diabetic neuropathy (CODE: E11.4) who saw endocrinology, neurology, and/or neurosurgery from January 1, 2019, to December 31, 2019. We then determined which patients had received pain medications and/or neuromodulation to divide the cohort into three groups: no treatment, conservative treatment, and neuromodulation treatment. The cohorts were compared with chi-square or one-way ANOVA with multiple comparisons to analyze the differences. A total of 2,635 PDN patients were identified, of which 700 received no treatment for PDN, 1,906 received medication(s), and 29 received neuromodulation (intrathecal therapy, spinal cord stimulation, or dorsal root ganglion stimulation). The patients who received pain medications for PDN visited neurology more often than the pain specialists. Of the patients that received neuromodulation, 24 had seen neurology, 6 neurology pain, and 3 anesthesia pain. They averaged 2.78 pain medications prior to implant. Approximately 41% of the patients in the conservative management group were prescribed three or more medications. Of the 1,935 treated patients, only 1.5% of the patients received neuromodulation. The patients on three or more pain medications without symptomatic relief may be potential candidates for neuromodulation. An opportunity, therefore, exists to educate providers on the benefits of neuromodulation procedures.

Spinal Cord Stimulation for Painful Diabetic Neuropathy

“…At a tertiary care center in 2019, only 1% of patients who saw endocrinology, neurology, or neurosurgery specialists received SCS treatment. 68 In the past year, two SCS systems have been cleared by the FDA for the specific purpose of treating PDN. On July 19, 2021, the Nevro Corporation (Redwood City, California) announced approval by the FDA of their Senza System to treat chronic pain associated with PDN (Figure 4).…”

“…At a tertiary care center in 2019, only 1% of patients who saw endocrinology, neurology, or neurosurgery specialists received SCS treatment. 68…”

The Potential of Electrical Stimulation and Smart Textiles for Patients with Diabetes Mellitus

“…For example, many patients with diabetes suffer from neuropathy or angiopathy in particular of the lower limbs or the diabetic foot syndrome. These conditions may potentially benefit from transcutaneous electrical nerve stimulation 7 8 9 10 11 12 . In addition, many patients exhibit sensory impairments that promote the development of foot ulceration and negatively affect balance control and gait (Peters, 2016; Ziegler, 2022).…”

Painful Diabetic Neuropathy: The Need for New Approaches

“…2 Painful diabetic neuropathy (PDN), contrasting with painless peripheral DN, is a form of DPN that manifests in sensations such as burning, tingling, numbness, and severe pain, especially in the lower extremities. 1,3,4 PDN has been reported to affect approximately one-third of individuals with diabetes 1,3,[5][6][7][8] and can also affect people with prediabetes. 9 PDN affects approximately one-fifth of individuals with type 1 diabetes (T1D) 10 and approximately one-fourth to one-half of individuals with type 2 diabetes (T2D).…”