Diabetes, a silent killer, is a leading cause of neuropathy. Around 50% of diabetic patients develop peripheral neuropathy in 25 years. Painful diabetic neuropathy manifests as burning, excruciating, stabbing or intractable type of pain or presents with tingling or numbness.

The pathophysiology of this condition is due to primarily metabolic and vascular factors that lead to direct damage to the nerves. The first step in the management of painful diabetic neuropathy is a tight glycaemic control.

Currently there is no drug which can halt or reverse the progression of the disease. Most of the therapies prevalent aim at providing symptomatic relief.

TAKE-HOME MESSAGE

• This is an update from the Guideline Subcommittee of the American Academy of Neurology on the treatment of painful diabetic neuropathy (PDN), with a focus on topical and oral medications. The medication classes with the strongest effect are tricyclic antidepressants (but the level of confidence is low, with large heterogeneity), opioid–serotonin-norepinephrine reuptake inhibitor (SNRI) combinations (but the adverse effects of opioids make this an undesirable choice), sodium channel blockers, SNRIs, and gabapentinoids (with the strongest evidence available for gabapentin).
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• The key recommendations are that clinicians should assess patients with diabetes for PDN and assess patients with PDN for mood and sleep disorders; the PDN treatments offered include tricyclic antidepressants, SNRIs, gabapentinoids, and/or sodium channel blockers; if one class is not effective or causes adverse effects, a trial of medications from a different class should be offered.

Peripheral Neuropathy Guidelines 2022

The American Academy of Neurology added research points out that the most common medications used for peripheral neuropathy are opioids, even though this class of medications is strongly discouraged for this condition.

The guidelines summarize classes of medicine based on their effect and the confidence of the effect. 

Summary:

Glyceryl trinitrate is a nitrate spray that causes vasodilation. This and Ginkgo biloba both work by improving circulation through promoting nitric oxide.

The guidelines encourage realistic expectations. Patients often want complete relief, but a more pragmatic expectation is 30%. Sleep disturbance is also a common comorbidity, so consider dosing before bed and combining oral and topical treatments.

Examples to start with include titrating oral gabapentin to 900 mg or amitriptyline to 75 mg at bedtime combined with topical glyceryl trinitrate spray (nitroglycerin sublingual) spray 400 mcg to the top of both feet at bedtime (this is the same medicine used under the tongue for angina).

Or can use nitroglycerin 2% topical ointment, 1 inch to each foot at bedtime.

Have patients wear gloves when applying, so they don’t get a headache. Capsaicin 8% patch can also be used but requires a topical anesthetic to be applied before application.

Maintaining good glucose control in diabetics is an obvious goal, and consider adding the strong antioxidant, alpha-lipoic acid 600 mg daily, which is supported by a meta-analysis and a good safety profile, and may also improve insulin sensitivity.

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