Treatment guidelines offered for painful diabetic neuropathy

New expert guidelines on treatment of painful diabetic neuropathy have evaluated the evidence base and identified some recommended medications.

The guidelines were developed by a panel representing the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine and the American Academy of Physical Medicine and Rehabilitation and were published online by Neurology on April 11.

The strongest evidence (Level A) was found to support offering pregabalin for relief of painful diabetic neuropathy. The guidelines also listed a number of treatments that are supported by Level B recommendations, and are probably effective so should be considered, including gabapentin, sodium valproate, amitriptyline, venlafaxine, duloxetine, dextromethorphan, morphine sulfate, tramadol, oxycodone, capsaicin and isosorbide dinitrate spray. The guideline writers noted that there was not sufficient evidence to prefer any of the listed antidepressants or opioids over another. Level C recommendations were made for adding venlafaxine to gabapentin and considering the Lidoderm patch.

A review of nonpharmacologic treatments was also conducted, and the experts made a Level B recommendation in favor of considering percutaneous electrical nerve stimulation. There was insufficient evidence on amitriptyline plus electrotherapy, and the other studied treatments (electromagnetic field treatment, low-intensity lasers, and Reiki therapy) should probably not be considered, the guidelines said.

Insufficient evidence was also found for topiramate, desipramine, imipramine, fluoxetine, vitamins, α-lipoic acid and the combination of nortriptyline and fluphenazine. Drugs that should probably not be considered for treatment of painful diabetic neuropathy include oxcarbazepine, lamotrigine, lacosamide, clonidine, pentoxifylline and mexiletine, according to the guidelines. In their recommendations for future research, the guideline authors called for longer, head-to-head trials of treatments with greater focus on quality of life, physical function and cost-effectiveness. A formalized process for rating pain scales is also needed, they said.