Despite the number of patients affected by diabetic peripheral neuropathic pain (DPNP),
little consensus exists about the pathophysiology, best diagnostic tools, and primary
treatment choices. Theories about the causes of DPNP are inextricably linked with
the causes of diabetic neuropathies, yet most patients with such neuropathies do not
experience pain. The factors that differentiate patients with pain from those without
remain unknown and are the subject of much research. When choosing treatment for patients
with DPNP, physicians are confronted with a myriad of choices, none of which has been
shown to be effective for all patients. This article reviews the evidence for these
treatments and attempts to guide physicians in choosing those treatments based on
evidence from well-designed clinical trials to support their use. Two agents, duloxetine
and pregabalin, are formally approved by the Food and Drug Administration for the
treatment of DPNP. In addition, several other agents, including the tricyclic class
of antidepressants, have been effective in clinical trials. Ultimately, treatment
choice must also include consideration of adverse effects, individual patient factors
such as comorbidities, and often cost.
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REFERENCES
- Clinical characteristics and economic costs of patients with painful neuropathic disorders.J Pain. 2004; 5: 143-149
- Cymbalta [prescribing information]. Eli Lilly and Company, Indianapolis, IndJanuary 2005
- Lyrica [prescribing information]. Pfizer, New York, NY2005 (Accessed December 3, 2005.)
- Antidepressants and anticonvulsants for diabetic neuropathy and postherpetic neuralgia: a quantitative systematic review.J Pain Symptom Manage. 2000; 20: 449-458
- Efficacy of pharmacological treatments of neuropathic pain: an update and effect related to mechanism of drug action.Pain. 1999; 83: 389-400
- Duloxetine vs. placebo in patients with painful diabetic neuropathy.Pain. 2005; 116: 109-118
- A double-blind, randomized multicenter trial comparing duloxetine with placebo in the management of diabetic peripheral neuropathic pain.Pain Med. 2005; 6: 346-356
Robinson MJ, Rosen A, Hardy TA, Prakash A, Shen S, Wernicke JF. Duloxetine for the management of diabetic peripheral neuropathic pain: comparison of safety data in older (age ≥65) and younger (age <65) patients [abstract]. Presented at: 2005 Annual Scientific Meeting of the American Geriatrics Society; Orlando, Fla; May 12, 2005.
- Venlafaxine extended release in the treatment of painful diabetic neuropathy: a double-blind, placebo-controlled study [published correction appears in Pain. 2005;113:248].Pain. 2004; 110: 697-706
- Venlafaxine versus imipramine in painful polyneuropathy: a randomized, controlled trial.Neurology. 2003; 60: 1284-1289
- Amitriptyline relieves diabetic neuropathy pain in patients with normal or depressed mood.Neurology. 1987; 37: 589-596
- Diabetic neuropathy: an intensive review.Am J Health Syst Pharm. 2004; 61: 160-173
- A systematic review of antidepressants in neuropathic pain.Pain. 1996; 68: 217-227
- Antidepressants for neuropathic pain.The Cochrane Database Syst Rev. 2005; 4 (CD005454) (Accessed December 2, 2005.)
- Efficacy of desipramine in painful diabetic neuropathy: a placebo-controlled trial.Pain. 1991; 45: 3-9
- Effects of desipramine, amitriptyline, and fluoxetine on pain in diabetic neuropathy.N Engl J Med. 1992; 326: 1250-1256
- Nortriptyline-fluphenazine vs. carbamazepine in the symptomatic treatment of diabetic neuropathy.Arch Med Res. 1996; 27: 525-529
- Cyclic antidepressants and the risk of sudden cardiac death.Clin Pharmacol Ther. 2004; 75: 234-241
- Pregabalin relieves symptoms of painful diabetic neuropathy: a randomized controlled trial.Neurology. 2004; 63: 2104-2110
- Relief of painful diabetic peripheral neuropathy with pregabalin: a randomized, placebo-controlled trial.J Pain. 2005; 6: 253-260
- Pregabalin for the treatment of painful diabetic peripheral neuropathy: a double-blind, placebo-controlled trial.Pain. 2004; 110: 628-638
- Gabapentin for the symptomatic treatment of painful neuropathy in patients with diabetes mellitus: a randomized controlled trial.JAMA. 1998; 280: 1831-1836
- Gabapentin for the treatment of postherpetic neuralgia: a randomized controlled trial.JAMA. 1998; 280: 1837-1842
- Gabapentin in neuropathic pain syndromes: a randomized, double-blind, placebo-controlled trial.Pain. 2002; 99: 557-566
- Neurontin [prescribing information]. Pfizer, New York, NY2004 (Accessed December 2, 2005.)
- Randomized double-blind study comparing the efficacy of gabapentin with amitriptyline on diabetic peripheral neuropathy pain.Arch Intern Med. 1999; 159: 1931-1937
- Morphine, gabapentin, or their combination for neuropathic pain.N Engl J Med. 2005; 352: 1324-1334
- Symptomatic treatment of peripheral diabetic neuropathy with carbamazepine (Tegretol): double blind crossover trial.Diabetologia. 1969; 5: 215-218
- Tegretol in the treatment of diabetic neuropathy.S Afr Med J. 1974; 48: 869-872
- Lamotrigine reduced painful diabetic neuropathy: a randomized, controlled study.Neurology. 2001; 57: 505-509
- Lamotrigine for HIV-associated painful sensory neuropathies: a placebo-controlled trial.Neurology. 2003; 60: 1508-1514
- A placebo-controlled trial of lamotrigine for painful HIV-associated neuropathy.Neurology. 2000; 54: 2115-2119
- Controlled-release oxycodone for pain in diabetic neuropathy: a randomized controlled trial.Neurology. 2003; 60: 927-934
- Controlled-release oxycodone relieves neuropathic pain: a randomized controlled trial in painful diabetic neuropathy.Pain. 2003; 105: 71-78
- Double-blind randomized trial of tramadol for the treatment of the pain of diabetic neuropathy.Neurology. 1998; 50: 1842-1846
- Tramadol relieves pain and allodynia in polyneuropathy: a randomised, double-blind, controlled trial.Pain. 1999; 83: 85-90
- The time course of epidermal nerve fibre regeneration: studies in normal controls and in people with diabetes, with and without neuropathy.Brain. 2004; 127: 1606-1615
- Effect of treatment with capsaicin on daily activities of patients with painful diabetic neuropathy.Diabetes Care. 1992; 15: 159-165
- Treatment of painful diabetic neuropathy with topical capsaicin: a multicenter, double-blind, vehicle-controlled study.Arch Intern Med. 1991; 151: 2225-2229
- Topical capsaicin in painful diabetic neuropathy: controlled study with long-term follow-up.Diabetes Care. 1992; 15: 8-14
- Efficacy of lidocaine patch 5% in the treatment of focal peripheral neuropathic pain syndromes: a randomized, double-blind, placebo-controlled study.Pain. 2003; 106: 151-158
- Effectiveness of the lidocaine patch 5% on pain qualities in three chronic pain states: assessment with the Neuropathic Pain Scale.Curr Med Res Opin. 2004; 20: S21-S28
- Effectiveness, tolerability, and impact on quality of life of the 5% lidocaine patch in diabetic polyneuropathy.Arch Neurol. 2004; 61: 914-918
- Topiramate vs placebo in painful diabetic neuropathy: analgesic and metabolic effects.Neurology. 2004; 63: 865-873
- Double-blind, randomized trial of bupropion SR for the treatment of neuropathic pain.Neurology. 2001; 57: 1583-1588
- The selective serotonin reuptake inhibitor citalopram relieves the symptoms of diabetic neuropathy.Clin Pharmacol Ther. 1992; 52: 547-552
- Low-dose methadone has an analgesic effect in neuropathic pain: a double-blind randomized controlled crossover trial.Palliat Med. 2003; 17: 576-587
- High-dose oral dextromethorphan versus placebo in painful diabetic neuropathy and postherpetic neuralgia.Neurology. 1997; 48: 1212-1218
- Dextromethorphan and memantine in painful diabetic neuropathy and postherpetic neuralgia: efficacy and dose-response trials.Anesthesiology. 2002; 96: 1053-1061
- The selective serotonin reuptake inhibitor paroxetine is effective in the treatment of diabetic neuropathy symptoms.Pain. 1990; 42: 135-144
- Intravenous infusion of phenytoin relieves neuropathic pain: a randomized, double-blinded, placebo-controlled, crossover study.Anesth Analg. 1999; 89: 985-988
- Topiramate in painful diabetic polyneuropathy: findings from three double-blind placebo-controlled trials.Acta Neurol Scand. 2004; 110: 221-231
- Acupuncture for the treatment of chronic painful peripheral diabetic neuropathy: a long-term study.Diabetes Res Clin Pract. 1998; 39: 115-121
- Electrical spinal-cord stimulation for painful diabetic peripheral neuropathy.Lancet. 1996; 348: 1698-1701
- Effectiveness of frequency-modulated electromagnetic neural stimulation in the treatment of painful diabetic neuropathy.Diabetologia. 2005; 48: 817-823
Article info
Footnotes
Dr Argoff receives grant and research support from Endo Pharmaceuticals, UCB Pharma, and Cephalon, Inc. He is a consultant to GlaxoWellcome, Eli Lilly and Company, Endo Pharmaceuticals, Pfizer Inc, UCB Pharma, and Allergan. Dr Backonja receives grant and research support from Pfizer Inc, NeurogesX Inc, and Avanir Pharmaceuticals. He is a consultant to Pfizer Inc and Eli Lilly and Company. Dr Bennett receives grant and research support from Endo Pharmaceuticals, Guilford Pharmaceuticals, and Pfizer Inc. He is a consultant to Amgen, Avigen Inc, NeurogesX Inc, Neuromed Technologies Inc, and Pfizer Pharmaceuticals Nagoya. He also receives honoraria from Eli Lilly and Company. Dr Belgrade receives honoraria from Eli Lilly and Company. Dr Clark receives honoraria from Eli Lilly and Company, Ligand Pharmaceuticals Inc, Organon, Pfizer Inc, and Wyeth. Dr Cole receives honoraria from Eli Lilly and Company and Ligand Pharmaceuticals, Inc. Dr Fishbain receives honoraria from Eli Lilly and Company and Endo Pharmaceuticals. Dr Irving receives grant and research support from Celgene Corporation and is a consultant to Pfizer Inc, Eli Lilly and Company, and Depomed, Inc. He also receives honoraria from Eli Lilly and Company and Pfizer Inc. Dr McCarberg receives honoraria from Janssen Pharmaceutica, Purdue Pharma LP, Eli Lilly and Company, Pfizer Inc, Ligand Pharmaceuticals Inc, Endo Pharmaceuticals, and Ortho-McNeil. Dr McLean receives grants and research support from Abbott, Pfizer Inc, Novartis, and Ortho-McNeil and is a consultant to Pfizer Inc, Xenoport, GlaxoWellcome, Novartis, Ortho-McNeil, and Shire Pharmaceuticals. He also receives honoraria from Pfizer Inc, Ortho-McNeil, Eisai, Novartis, and Shire Pharmaceuticals.
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© 2006 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
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- CORRECTIONMayo Clinic ProceedingsVol. 81Issue 6
- PreviewIncorrect word: In the Supplement article by Argoff et al entitled “Consensus Guidelines: Treatment Planning and Options,” published with the April 2006 issue of Mayo Clinic Proceedings (Mayo Clin Proc. 2006;81[4, suppl]:S12-S25), an incorrect word appeared in Table 2 under the heading “Class” and the entry “Opioids.” The word “block” should be replaced by the words “bind to.” Thus, the entry should read as follows: “Opioids (bind to opioid receptors).”
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