Sarah Konigsberg, MDMarch 12, 2016
None to report Frequent off-label medication use
Will note in talk
50% of patients with diabetes will develop neuropathy
Types:
Sensory
Motor
Autonomic▪ Gastroparesis, erectile
dysfunction, low blood pressure
There is a very delicate balance of
1. Increased damage
2.Decreased repair
3. Ischemia
Relative Risk
15
13
11
9
7
5
3
1
HbA1c, %
7 8 9 10 11 12
Neuropathy
Nephropathy
Retinopathy
DCCT Study Group. N Engl J Med. 1993;329:977-986.
Smoking High blood pressure
ACE inhibitors
High cholesterol Heart disease
Exclude other causes
Lumbar radiculopathy
Peripheral vascular disease
Typical symptoms & distribution
Examination
Monofilament, vibration, reflexes
Nerve conduction studies
Hammertoes
Claw Toes
Foot care Improve blood sugars Stop smoking Pain relief
Nonpharmacologic
Pharmacologic
Foot care Improve blood sugars Stop smoking Pain relief
Nonpharmacologic
Pharmacologic
Yearly assessment of sensation, reflexes
Examination of feet at each visit
Assess Circulation Patient education
Toenail care
Smoking cessation
Avoid injury
Wash & check feet daily
? Custom footwear
Foot care Improve blood sugars Exercise Stop smoking Pain relief
Nonpharmacologic
Pharmacologic
Foot care Improve blood sugars Exercise Stop smoking Pain relief
Nonpharmacologic
Pharmacologic
Smoking doubles risk of peripheral neuropathy
Diabetes Care. 1990 Apr;13(4):434-7.
Foot care Improve blood sugars Stop smoking Exercise Pain relief
Nonpharmacologic
Pharmacologic
BALANCE RESISTANCE TRAINING
Sports Med. 2014 Sep;44(9):1289-304
Foot care Improve blood sugars Stop smoking Exercise Pain relief
Nonpharmacologic
Pharmacologic
Foot care Bed cradle Improve blood sugars Stop smoking Exercise Pain relief
Nonpharmacologic
Pharmacologic
Amitriptyline, nortriptyline, desipramine Dose 25-200 mg at bedtime Advantages: Effective, inexpensive Disadvantages: Many side effects (dry mouth,
urinary retention, constipation, low bp), 1/3 patients cannot tolerate
Sedating Use with caution with cardiac disease—can
cause arrhythmias
Gabapentin (Neurontin)
Dose 300-1200 mg three times daily
Side effects: Sedation, dizziness, FDA warning: Increased suicidality (0.4% vs. 0.2% baseline)
Pain relief no different than tricyclics, but better tolerated
Cost: $75/month
Pregabalin (Lyrica)
FDA approved
Dose 50-100 mg three times daily
Side effects: Dizziness, sedation, edema, weight gain (average 2-4% body weight)
Cost $240/month
Carbamazepine (Tegretol) Lamotrigine (Lamictal) Used as second line agents
Duloxetine (Cymbalta)
FDA approved
Dose 60-120 mg/day
Side effects: Nausea, somnolence, dizziness, decreased appetite, and constipation
Helpful for nighttime pain
Cost $ 140/month
Venlafexine (Effexor XR)
Oxycodone CR 10-30 mg twice daily Side effects: Nausea, constipation, headache,
and somnolence Effective Potential for dependence & overdose
unknown
Mexilitine
Antiarrhythmic similar to lidocaine
Dose: 450 mg/day
Can cause arrhythmias so should be used with caution in refractory cases
Lidocaine patch
Natural substance found in hot peppers Applied to painful areas 4 times daily Side effects: Burning (gets better with
repeated use) Can be used with medications Cost: $16/month Over the counter
Antioxidant Dose 600-1800 mg/day Side effects: Hypoglycemia Cost $10/month Over the counter
Reduces oxidative stress Dose: 1000 mg three times daily Shown in one trial, but not another to help
painful neuropathy Over the counter
Pain specialist referral Accupuncture Transcutaneous electrical nerve stimulation
(TENS) Topical nitrate
Figure 2. A TENS unit in use.
Exclude other causes Normalize blood sugars Antidepressants Anticonvulsants Alpha-Lipoic Acid Opiods Pain Clinic Referral
Boulton AJ, Vinik AI, Arezzo JC, et al. Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care 2005; 28:956.
Combine different classes of medications “Success” in clinical trials-usually 30-50%
reduction in pain
Cardiovascular Gastroparesis Bladder dysfunction Erectile dysfunction
Questions?