Neurologists update guideline on treatment of painful diabetic neuropathy

The updated guideline from the American Academy of Neurology supports offering tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, gabapentinoids, and/or sodium channel blockers to reduce pain from diabetic neuropathy.

A guideline on oral and topical treatments for painful diabetic neuropathy was recently updated to help neurologists and other physicians determine the best treatment. The update to the 2011 American Academy of Neurology guideline was published online Dec. 27, 2021, by Neurology and is endorsed by the American Association of Neuromuscular & Electrodiagnostic Medicine.

It recommends that physicians assess patients with diabetes for painful diabetic neuropathy (Level B recommendation) and those with painful diabetic neuropathy for concurrent mood and sleep disorders (Level B).

Physicians should offer tricyclic antidepressant (TCAs), serotonin-norepinephrine reuptake inhibitor (SNRIs), gabapentinoids, and/or sodium channel blockers to reduce pain (Level B), and they should consider factors other than efficacy (Level B). The guideline noted that gabapentinoids, SNRIs, sodium channel blockers, and SNRI/opioid dual mechanism agents all have effect sizes just above or just below the cutoff for a medium effect size, a standardized mean difference (SMD) of 0.5 (0.44 [95% CI, 0.21 to 0.67], 0.47 [95% CI, 0.34 to 0.60], 0.56 [95% CI, 0.25 to 0.87], and 0.62 [95% CI, 0.38 to 0.86], respectively). TCAs have a large effect size (SMD, 0.95 [95% CI, 0.15 to 1.8]), but there is low confidence in the estimate, the guideline authors noted.

Physicians should offer patients a trial from a different drug class when patients do not see meaningful improvement, or if they experience significant adverse effects with the first therapeutic class (Level B).

Considerations in treatment should include the cost of a drug, side effects, and patients' other medical problems. Opioids should not be used, although the guideline called for future research into whether this drug class might have a role.

The guideline states that doctors may offer topical treatments such as capsaicin, glyceryl trinitrate spray, or Citrullus colocynthis to reduce pain. It also says ginkgo biloba may be helpful, as well as nondrug treatments such as exercise, mindfulness, cognitive behavioral therapy, or tai chi.

The guideline noted that few studies have investigated the effect of interventions on quality of life, patient functioning, mood, or sleep; few comparative effectiveness studies have been done; and there is a lack of data beyond 16 weeks for any intervention.

“Given the chronicity of pain in those with diabetic neuropathy and the potential for evolving side effects, long-term studies are needed to better inform the long-term pain management in this population,” the guideline stated. The authors also noted, “The ability to target effective interventions to the right subgroup has the potential to improve pain management in those with diabetic neuropathy, but limited data are available to guide these choices.”