SUMMARY

Up to 50% of patients with chronic sensorimotor diabetic neuropathy will experience painful or uncomfortable symptoms, and of these a significant minority may require pharmacological therapy. As painful symptomatology may be worsened by a sudden change in glycaemic control, the first step in management should be the quest for stable, near normal glycaemic control avoiding glycaemic flux. Of all the disease-modifying treatments, only alpha-lipoic acid appears to be promising in the management of neuropathic pain, although this only licensed in certain European countries. Several groups of pharmacological agents have been proved to be efficacious in symptomatic relief in diabetic neuropathy: these include the tricyclic drugs, a number of anti-convulsants, and certain other pharmacological treatments. Although helpful in many cases, the tricyclic drugs are plagued by frequent and predictable side effects. The anti-convulsants, gabapentin and pregabalin are useful in the management of neuropathic pain, and the dual 5-HT and norepinephrine reuptake inhibitor duloxetine has also demonstrated efficacy. Although many topical and non-pharmacological treatments have been proposed, few have proven efficacy in appropriately designed controlled trials.

Key Words: Diabetic neuropathy; pain; tricyclic drugs; anti-convulsants. INTRODUCTION

The painful symptomatology of diabetic neuropathy has been recognized for many years and one of the first descriptions of neuropathic pain is attributed to Rollo (1), who described pain and paraesthesiae in the legs of a diabetic patient in the 18th century. Painful symptoms are common in many of the neuropathic syndromes of diabetes described elsewhere in this book: these include both focal and multifocal neuropathies, proximal motor neuropathy or amytrophy, and the symmetrical sensory polyneuropathies. A simple definition of diabetic neuropathy, agreed by an international consensus group, is "the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes" (2). This definition refers to the chronic sensori-motor diabetic neuropathy, which is truly a paradoxical condition as up to 50% of patients might experience painful or uncomfortable symptomatology, whereas the remaining 50% might experience no pain whatsoever putting them at risk of foot ulceration and other late sequalae of neuropathy including Charcot neuroarthropathy (3). Thus, one patient

From: Contemporary Diabetes: Diabetic Neuropathy: Clinical Management, Second Edition Edited by: A. Veves and R. Malik © Humana Press Inc., Totowa, NJ

Table 1

Diabetic Neuropathies Associated With Pain

Focal and multifocal neuropathies Cranial, for example, third or sixth nerve

Focal limb, for example, entrapment or spontaneous mononeuropathy Amyotrophy (proximal motor neuropathy) Truncal radiculoneuropathy Generalized symmetrical polyneuropathies Acute sensory (invariably accompanied by pain) Chronic sensorimotor with sensorimotor neuropathy might experience severe pain vividly described by Pavy (4) in 1887 as being "of a burning and unremitting character," whereas another patient with the same deficit might be completely asymptomatic: patients such as the latter one lack what Dr. Paul Brand described as "the gift of pain" (5).

In this chapter, after a brief description of those neuropathies associated with painful symptoms, the methods of assessment of neuropathic pain will be discussed. This will be followed by a description of the impact of painful neuropathy on quality of life (QoL) and then some of the problems and pitfalls of clinical trial design for studies of new therapies for painful neuropathy. Subsequently, the role of blood glucose control in the management of painful neuropathy will be followed by a discussion of pharmacological treatments and finally by nonpharmacological therapies, such as acupuncture and topical therapies.

In medicine there are few cures, but many treatments, so it is hoped that by the end of this chapter the reader will appreciate that the question asked in an editorial in 1983 "can we do anything about diabetic neuropathy or do we just have to document it and commiserate with the patient?" (6), is no longer rhetorical: there are indeed a number of effective therapies for the painful symptomatology of diabetic neuropathy.

Peripheral Neuropathy Natural Treatment Options

Peripheral Neuropathy Natural Treatment Options

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