Diabetic Neuropathy: Treatment & Medication

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Diabetic Neuropathy: Treatment & Medication
Dianna Quan, MD, Associate Professor of Neurology, Director, Electromyography Laboratory, University of Colorado Health Sciences Center
Updated: Oct 30, 2008
Medscape.com

Treatment
Medical Care
Throughout this discussion on treatment, distinction is made between therapies for symptomatic relief and those that may slow the progression of neuropathy.

* General aspects of treatment
o Consider any patient with clinical evidence of diabetic peripheral neuropathy to be at risk for foot ulceration and provide education on foot care.18 If necessary, a podiatry referral should be provided.
o Patients with diabetic peripheral neuropathy require more frequent follow-up, with particular attention to foot inspection to reinforce the need for regular self-care. The provision of regular foot examinations and reinforcement of the educational message on foot care have been shown in several studies to have a major impact on rates of ulceration and even amputation.19
* Current treatments for pain
o Of all treatments, tight and stable glycemic control is probably the most important for slowing the progression of neuropathy.20 Because rapid swings from hypoglycemia to hyperglycemia have been suggested to aggravate and induce neuropathic pain, the stability of glycemic control may be as important as the actual level of control in relieving neuropathic pain. The DCCT demonstrated that tight blood sugar control in patients with type 1 diabetes decreased the risk of neuropathy by 60% in 5 years.2 The effect of tight glycemic control on polyneuropathy in patients with type 2 diabetes or those with impaired glucose tolerance/impaired fasting glucose is not as clear and requires further prospective study.
o Many medications are available for the treatment of diabetic neuropathic pain. These include tricyclic antidepressants, gabapentin, pregabalin, duloxetine, topical lidocaine, and capsaicin. Other medications such as carbamazepine, oxcarbazepine, phenytoin, lamotrigine, and opioids may also be used. Topical therapy with capsaicin or lidocaine patches may be useful in some patients, especially those with more localized pain or those in whom interactions with existing oral medications is a concern. Any of these medications may be associated with side effects, and patients should be counseled about possible problems before initiating treatment.21
o Alternative and complementary therapies for pain (eg, acupuncture) are under investigation.22
* Treatments for autonomic dysfunction
o Until now, the main therapy for erectile dysfunction of nonvascular or nonpsychological origin has been the intracorporeal injection of vasoactive substances such as papaverine. The oral agent sildenafil and related phosphodiesterase type 5 (PDE5) inhibitors are now available for the treatment of erectile dysfunction of diverse causes, including diabetes. Sildenafil is a selective inhibitor of cyclic guanosine monophosphate-specific PDE5, the predominant isoenzyme in human corpus cavernosum.
o Glycopyrrolate is an antimuscarinic compound that is the first specific treatment for diabetic gustatory sweating. When applied topically to the affected area, it results in a marked reduction in sweating while eating a meal.

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