Test Your Knowledge Answer #598

Answer and Critique (Correct Answer =A)

This patient has painful peripheral neuropathy that is affecting his quality of life. Two drugs have recently been approved for diabetic neuropathic pain -- duloxetine (a selective norepinephrine reuptake inhibitor) and pregabalin (an antiepileptic agent). In a recent statement on diabetic neuropathy, the American Diabetes Association has recommended a stepwise approach to management that includes the stabilization of glucose control (because hyperglycemia reduces pain thresholds) followed by the addition of antidepressants and then antiepileptic agents; if these treatments fail to control the pain, the use of opioid drugs and a referral to a pain clinic are recommended.

Key Points

• Painful neuropathy in patients with diabetes is treated with a stepwise approach that includes use of antidepressants and anticonvulsants.

This patient has suboptimal glycemic control; hence, the most appropriate treatment would be to stabilize or improve glucose control and attempt to control the pain with a selective norepinephrine reuptake inhibitor, such as duloxetine, or an anti-epileptic drug. Using an opioid or opioid-like drug, such as oxycodone or tramadol, as the initial treatment for the pain is not appropriate. There is no evidence that topical capsaicin treatment is effective for the management of severe painful neuropathy.

1. Boulton AJM, Vinik AI, Arezzo JC, Bril V, Feldman EL, Freeman R, et al; American Diabetes Association. Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care. 2005;28:956-62. [PMID: 15793206] [PubMed] 

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