Prioritizing Pain: Changing Paradigms in Managing Painful Diabetic Peripheral Neuropathy

Supported by an unrestricted educational grant from Pfizer Inc
Saturday, June 11, 2005
6:00-8:00 PM

Chair:
Andrew JM Boulton, MD

Faculty:
Robert J Tanenberg, MD, FACP
Julio Rosenstock, MD
Martin Abrahamson, MD

Reviewed by Kimberly McFarland, PhD

Positive and negative symptoms of diabetic peripheral neuropathy (DPN) adversely impact daily function and quality of life in diabetic patients. Before patients can be appropriately treated, DPN must be diagnosed. Unfortunately, results of the 2005 National Survey indicate that as few as 1 in 4 diabetes patients with symptomatic DPN receive an appropriate diagnosis. However, only patients can inform healthcare providers of painful symptoms. Pain questionnaires may assist healthcare providers in assessing patient pain (Backonja MM, Krause SJ. Clin J Pain. 2003), but communication with the patient is vital.

Several classes of agents are used to treat painful DPN, although duloxetine and pregabalin are currently the only FDA approved agents for this indication. Treatment guidelines and clinical trials provide direction in choosing the appropriate agent. Clinical data support the use of the antidepressants, duloxetine and venlafaxine, for painful DPN, although more results are needed to confirm reproducibility and consistency. Use of pregabalin is also supported by clinical trials. Long-term, controlled studies are still needed for all 3 agents.

Glycemic fluctuations, hyperglycemia, and sudden improvement in blood glucose control (as with initiation of insulin therapy) can all precipitate diabetic neuropathic pain. The algorithm for management of symptomatic DPN, published by Boulton AJ, et al. (Diabetes Care.2005), indicates tricyclic antidepressants as first line treatment, antiepileptic agents as second line treatment, and opioid or opioid-like agents as a third line option. All agents have risks which should be considered along with patient characteristics before prescribing. Combinations of agents may provide optimal pain relief while allowing physicians to prescribe smaller doses of the individual agents. Given the number of options, healthcare providers should feel comfortable in assuring patients that pain associated with DPN can be relieved.