AMA Therapeutic Insights: Painful Diabetic Neuropathy

The full newsletter Painful Diabetic Neuropathy, prescribing information and CME self-assessment are free for both AMA members and nonmembers.

Peripheral diabetic neuropathy (PDN) develops in more than 50% of patients who have diabetes. Furthermore, it is estimated that approximately 79 million (or nearly 1 in 3) Americans have pre-diabetes based on testing of fasting blood glucose and hemoglobin A1c (HbA1c) concentrations, and in U.S. adults aged 65 years and older, the prevalence is even higher at approximately 50%. It is generally agreed that the prevalence of diabetes will increase if current lifestyles and population trends in obesity do not change.

Diabetic sensorimotor polyneuropathy (DSP) is the most common type of polyneuropathy. The pain is often chronic and disabling leading to impaired physical function, reduced work productivity, reduced social interactions, poor sleep, and impaired quality of life. DSP is a chronic disorder that starts insidiously and is characterized by progressive loss of nerve fibers. Painful symptoms can start at any stage of DSP; symptoms are variable, but include pain in the feet (particularly the soles) that is burning, lancinating, needle-like, tingling, freezing, cramping, or associated with aching or numbness. As DSP progresses, the ankle reflexes are lost, and finally motor symptoms develop later in the disorder. Generally, the diagnosis of DSP can be confirmed readily in a family physician’s or endocrinologist’s office using a monofilament or other simple screening test. A more formal assessment, including a full neurological history and examination with particular attention to painful symptoms, can be performed in order to diagnose PDN. When nerve conduction testing is normal, confirmation of PDN can be achieved through small fiber tests.

No effective disease-modifying interventions are generally available for established PDN. It is important to appreciate that improved glycemic control will not result in alleviation of painful symptoms of PDN. Patient expectations need to be managed to avoid disappointment and lack of compliance with a healthier lifestyle. With regard to symptomatic treatment, evidence-based guidelines support the use of certain anticonvulsant drugs [pregabalin and gabapentin], antidepressants [duloxetine and amitriptyline], opioid analgesics, some topical agents [capsaicin cream and isosorbide dinitrate spray] and transcutaneous electrical nerve stimulation in the management of PDN. Among the prescription drugs recommended in the guideline, duloxetine and pregabalin are FDA-approved for PDN.

In Painful Diabetic Neuropathy physicians will learn to:

  • Describe the typical pathophysiology and clinical syndrome comprising painful diabetic neuropathy.

  • Explain complicating and clinical risk factors for painful diabetic neuropathy.

  • Implement strategies for the appropriate diagnosis of painful diabetic neuropathy.

  • Compare his/her current approach to treatment at the national level with professional guideline recommendations.

View the full newsletter Painful Diabetic Neuropathy and learn how to receive CME credit. Newsletters are available to all physicians, not just AMA members.