Diabetic peripheral neuropathic pain: Consensus guidelines for treatment

[Guest guest]

J Fam Pract. 2006 Jun;55(6):1-20.

Diabetic peripheral neuropathic pain: Consensus guidelines for

treatment.

Argoff CE, Backonja MM, Belgrade MJ, GJ, MR, Cole BE,

Fishbain DA, Irving GA, McCarberg BH, McLean MJ.

New York University School of Medicine/Cohn Pain Management Center,

North Shore University Hospital, Manhasset, NY USA.

Diabetic peripheral neuropathy (DPN) affects approximately half of

patients with diabetes mellitus (DM). Although most patients with DPN

do not have pain (and, in fact, many lack sensation), approximately

11% experience chronic, painful symptoms that diminish quality of

life, disrupt sleep, and may lead to depression.

Little consensus has existed about the pathophysiology, best

diagnostic tools, and primary treatment choices for diabetic

peripheral neuropathic pain (DPNP). Its pathogenesis is unknown, and

while it shares clinical features with other forms of neuropathic

pain, DPNP is distinct in its apparent association with glucose-

related metabolic changes.

Not all patients with DPNP have a neuropathic condition; the

underlying source of pain in some patients may be something other

than DM, which is important to remember when making a diagnosis.

The diagnosis of DPNP relies heavily on a thorough physical

examination and patient history along with clinical judgment rather

than on any particular neurologic test or finding.

The classic presentation of DPNP is pain or tingling in the feet that

can be described not only as " burning " or " shooting " but also as

severe aching pain. Less commonly, patients may describe the pain as

itching, tearing, or like a toothache. The pain may be accompanied by

allodynia and hyperalgesia and an absence of symptoms, such as

numbness or feeling " dead. " Symptoms tend to be worse at night.

Pronounced motor signs or asymmetrical distribution of symptoms

should suggest a nondiabetic origin of the neuropathy. Although no

treatments are considered a cure for DPNP, 2 agents are now approved

by the US Food and Drug Administration (FDA) specifically for DPNP:

duloxetine, an antidepressant, and pregabalin, an anticonvulsant.

Other agents have also demonstrated efficacy in clinical trials. This

publication reviews the evidence from several well-designed clinical

trials and offers practical suggestions for primary care physicians

who treat patients with DPNP.