AEs = Adverse events; CNS = central nervous system.

These agents are used, if required, in addition to stable glycaemic control.

AEs = Adverse events; CNS = central nervous system.

These agents are used, if required, in addition to stable glycaemic control.

well as slowing the relentless progression that typifies the natural history of neuropathy. It is likely that unstable blood glucose control induces neuropathic pain, so stability rather than the actual level of glycaemic control is most important in pain relief.

A large number of drugs have been reported to be useful in the relief of neuropathic pain: these are summarized in table 6. Until we have a greater experience with some of the newer therapies, the tricyclic drugs remain the first-line medications for painful neuropathic symptoms: they have been proven to be effective in several randomized controlled trials. Thus the order of listing of drugs in table 6 is normally the order in which these drugs would be used. The newer agents such as Gabapentin and Tramadol (table 6) are promising and already have proven efficacy in randomized controlled trials.

The limitations of all the drugs listed in table 6 relate to adverse effects which tend to be dose related and predictable. Other therapies such as capsaicin, acupuncture and Opsite may be useful in some cases. Capsaicin is a topical application and tends to be more helpful in localized pain. Acupuncture has been shown to be efficacious in several uncontrolled studies, with reported efficacy in up to 70% of treated cases. As this is without side effects, it is a useful therapy for diabetic neuropathy. Opsite is a transparent dressing which has reported efficacy in an uncontrolled study: it is reported to work through the gate control mechanism of pain.

None of the above listed agents has any affect on the natural history of diabetic sensory-motor neuropathy which, as noted above, is one of slow progression. A number of agents are under investigation that might slow or halt progression in diabetic neuropathy and these include the antioxidant a-lipoic acid, a number of aldose reductase inhibitors, and essential fatty acids such as y-linolenic acid.

Finally, all patients with diabetic sensory peripheral neuropathy must be considered as being at risk of insensitive foot ulceration and should receive education on foot care and if necessary a podiatry referral. These patients require more frequent follow-up, always paying particular attention to foot inspection to reinforce the educational message of the need for regular foot care.

Suggested Reading

Boulton AJM, Malik RA: Diabetic neuropathy. Med Clin North Am 1998;82:909-929.

Boulton AJM, Gries FA, Jervell JA: Guidelines for the diagnosis and outpatient management of diabetic peripheral neuropathy. Diabet Med 1998;15:508-514.

Cabezas-Cerrato J: The prevalence of clinical diabetic polyneuropathy in Spain: A study in primary care and hospital clinic groups. Neuropathy Spanish Study Group of the Spanish Diabetes Society (SDS). Diabetologia 1998;41:1263-1269.

Dyck PJ, Kratz KM, Karnes JL, et al: The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: The Rochester Diabetic Neuropathy Study. Neurology 1993;43:817-824.

Gries FA, Koschinsky T, Tschope D, Ziegler D: Current state and perspective of diabetes research: Chronic complications. Diabetes 1997;46(suppl 2): 1-134.

Kumar S, Ashe HA, Parnell LN, Fernando DJ, Tsigos C, Young RJ, Ward JD, Boulton AJ: The prevalence of foot ulceration and its correlates in type 2 diabetic patients: A population-based study. Diabet Med 1994;11:480-484.

Partanen J, Niskanen L, Lehtinen J, Mervaala E, Siitonen O, Uusitupa M: Natural history of peripheral neuropathy in patients with non-insulin-dependent diabetes mellitus. N Engl J Med 1995;333:89-94.

Tesfaye S, Stevens LK, Stephenson JM, Fuller JH, Plater M, Ionescu-Tirgoviste C, Nuber A, Pozza G, Ward JD: Prevalence of diabetic peripheral neuropathy and its relation to glycaemic control and potential risk factors: The EURODIAB IDDM Complications Study. Diabetologia 1996;39:1377-1384.

Veves A (ed): Clinical Management of Diabetic Neuropathy. Totowa/NJ, Humana Press, 1998.

Prof. A.J.M. Boulton, Department of Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL (UK)

Tel. +44 161 276 4452, Fax +44 161 274 4740, E-Mail [email protected]

Belfiore F, Mogensen CE (eds): New Concepts in Diabetes and Its Treatment. Basel, Karger, 2000, pp 208-217

Chapter XV

Peripheral Neuropathy Natural Treatment Options

Peripheral Neuropathy Natural Treatment Options

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