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Neuropathy – diabetic
DAVID CLINE
n Agents
n Opioids
n Tricyclic antidepressants
n SSRIs
n Selective serotonin–norepinephrine reuptake inhibitors
n Anticonvulsants
n Local anesthetics
n Evidence
Treatment decisions regarding diabetic neuropathy (DN) can be based upon
useful evidence. Many agents have been assessed for therapy of DN pain, and
many have some role in relief of symptoms. The breadth of therapeutic
options is fortunate, given the often-refractory nature of the pain. The difficulty
of controlling DN is ameliorated by the availability of several nonpharmacologic
approaches (e.g. transcutaneous electrical nerve stimulator
[TENS] units) that can improve pain relief provided by drug therapy. 1,2
Although their side effects may relegate them to second-line use, the
opioids do help in DN. Data from RCTs have demonstrated the utility of
controlled-release oxycodone (starting dose 10 mg PO BID, with up-titration
to a maximum of 60 mg daily). 3
The opioid tramadol, which has additional (monoamine-related) mechanisms
of analgesia, has particular utility in DN. Data from RCTs show that one
in four patients achieves significant pain relief; analgesic benefit lasts for
months. 4 Up-titration may be necessary. One RCT found that the average
daily dose of tramadol required for significant relief of DN was 210 mg. 5
As noted in other chapters of this text, the tricyclic antidepressants (TCAs)
are among the most consistently effective therapy for neuropathic pain.
Systematic review of studies including patients with DN (among others)