Symptomatic treatments

The first step in management of patients with DPN should be to aim for stable and optimal glycemic control. Although controlled trial evidence is lacking, several observational studies suggest that neuropathic symptoms improve not only with optimization of control but also with the avoidance of extreme blood glucose fluctuations. Most patients will require pharmacological treatment for painful symptoms (see Figure 5.11).

Tricyclic drugs

The usefulness of the tricyclic drugs such as amitriptyline and imipramine has been confirmed in several randomized controlled trials [16-18], although

Figure 5.11 Key symptomatic treatments Autonomic neuropathy

Gastroparesis: metoclopramide, cisapride, erythromycin Diarrhea: loperamide, tetracyclines, clonidine, octreotide Incontinence - urinary: bethanechol chloride, oxybutynin, self-catheterization

Painful/paresthetic neuropathy

Pre-gabelin, duloxetine, tricyclics, capsaicin, carbamazepine, mexiletine, gabapentin Erectile dysfunction

Phosphodiesterase type 5 inhibitor, vacuum pump, prostaglandins, prosthesis

Orthostatic hypotension

Salt, fludrocortisone, proamatine they do not have formal FDA approval for this condition. Although cheap and generally efficacious in the management of neuropathic pain, side effects limit their use in many patients. Tricylcic drugs may also exacerbate some autonomic symptoms such as gastroparesis.

Anticonvulsants

Gabapentin is a commonly prescribed anticonvulsant that has been shown to be efficacious in the treatment of neuropathic pain [19], although not approved for this condition. It is advisable to start at a small dose and then increase over days to weeks to the dosage that is well tolerated and produces symptomatic relief. The structurally-related compound pregabalin is longer acting, has also been confirmed to be useful in painful diabetic neuropathy, and is approved for use in this condition [20, 21]. Other anticonvulsant drugs may also be efficacious in the management of neuropathic pain.

Other agents

The 5-hydroxytryptamine and norepinephrine reuptake inhibitor duloxetine has been approved by the FDA for treatment of neuropathic pain [22].

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