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This article originally posted and appeared in  Issue 598

Test Your Knowledge Answer #598

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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Test Your Knowledge Question #597

A 36-year-old woman with type 2 diabetes is seen for a routine follow-up


Test Your Knowledge Question #599

Which of the following abnormalities relating to the incretin pathway...

Check out all of our questions on our Test Your Knowledge pages. 



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This article originally posted 04 November, 2011 and appeared in  Issue 598

Past five issues: Diabetes Clinical Mastery Series Issue 255 | Issue 795 | SGLT-2 Inhibitors Special Edition August 2015 | Diabetes Clinical Mastery Series Issue 254 | GLP-1 Special Editions August 2015 |

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