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?