ADA Releases New Guidelines for Diabetic Peripheral Neuropathy Management
The American Diabetes Association (ADA) has updated its guidelines on the management of diabetic peripheral neuropathy (DPN), with recommendations for FDA-approved drugs and caution against opioids (January 2017; 40: 136-154).
The guidelines, which were last updated in 2005, reflect continual advancements in optimal and novel approaches to managing DPN pain symptoms in patients with diabetes. The primary strategy for managing DPN is prevention through maintaining glycemic control, but no evidence suggests that effective glycemic control can help manage symptoms once DPN already occurs. Therefore, the order of drug interventions that physicians should refer to when managing DPN-related pain symptoms is critical.
The ADA recommends FDA-approved medications such as pregabalin, duloxetine, and gabapentin as first line treatment options for managing symptoms of DPN. Pregabalin, an anticonvulsant, is the most studied agent for distal symmetric polyneuropathy. Various studies have shown the drug’s efficacy in treating pain symptoms with a possible dose-dependent response. Duloxetine, gabapentin, and tricyclic antidepressants (which are not currently FDA-approved for managing symptoms of DPN) are considered viable alternatives to pregabalin, given their availability in cost-effective generic forms.
Other medications, such as alternative anti-convulsants, combining dextromethorphan with memantine or quinidine, and onobotulinum toxin type-A injections, have shown improved outcomes for the treatment of DPN-related pain symptoms. According to Gary W Jay, MD, clinical professor, department of neurology, University of North Carolina, writing in Practical Pain Management, “control of symptoms constitutes a considerable management problem because the efficacy of a single therapeutic agent is not the rule, and simple analgesics are usually inadequate to control the pain” (March 2016; 16). Dr Jay further cites a reduction in pain symptoms for most patients after combination therapy.
The ADA also updated its clinical position concerning the use of opioids to manage DPN-related pain symptoms. The new recommendations suggest that opioids should only be used in the event all other medications fail to treat pain symptoms, citing health-related risks associated with opioid treatment. Those patients who are unresponsive to other medications and may benefit from an add-on opioids should be referred to specialized pain clinics before opioid medications.