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Managing Painful Diabetic Peripheral Neuropathy Without Opioids
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About half of patients with diabetes will get neuropathy, and diabetic neuropathy costs the United States health care system about $10 billion a year.1,2 Opioids are among the treatment options for painful diabetic peripheral neuropathy, but they do carry significant risks.
“Without opioids, how do you manage those patients who are suffering?” asked Shravani Durbhakula, MD, MPH, MBA, in this morning’s session at the American Podiatric Medical Association National Annual Scientific Meeting.
For those patients with diabetes who develop painful diabetic peripheral neuropathy, Dr. Durbhakula stresses there will be significant quality of life issues. Improved glycemic control is the only proven way to prevent or delay neuropathy in patients with type 1 diabetes, or to slow the progression of neuropathy in type 2 diabetes, according to Dr. Durbhakula, an Assistant Professor of Pain Medicine in the Department of Anesthesiology at Vanderbilt University Medical Center. However, she noted treatment options include oral pharmaceuticals, serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, nutraceuticals, modifying health behaviors, and spinal cord stimulation.
Pregabalin is approved by the Food and Drug Administration (FDA) for painful diabetic peripheral neuropathy. Dr. Durbhakula notes there is more evidence for pregabalin compared to gabapentin, and that pregabalin has a faster onset and lower dosing compared to gabapentin. Duloxetine is FDA approved for painful diabetic peripheral neuropathy while venlafaxine is not, noted Dr. Durbhakula. She cited topical options for painful diabetic peripheral neuropathy such as lidocaine and capsaicin patches.
Dr. Durbhakula said nutraceuticals may favorably influence the underlying neuropathic process and its clinical consequences, instead of solely providing pain relief. Specifically, she said alpha-lipoid acid is a treatment option, given that diminishing oxidative stress may favorably influence the course of painful diabetic peripheral neuropathy.
As for health behavior interventions, Dr. Durbhakula emphasized that exercise can increase nerve fiber density and regenerate capacity in people with metabolic syndrome or early type 2 diabetes. She noted diet can improve glucose control.
Spinal cord stimulation consists of stimulating electrodes surgically implanted in the epidural space. Dr. Durbhakula notes this changes the processing of pain signals in the brain and spinal cord.
Opioid options for neuropathic pain include FDA-approved tapentadol, as well as agents such as tramadol, morphine, and oxycodone. Dr. Durbhakula cites risks with opioids including addiction, physical dependency, respiratory depression, falls, constipation, immune suppression, endocrine dysfunction, nausea, dizziness, and vomiting. She stressed that the newest American Academy of Neurology guidelines on painful diabetic peripheral neuropathy from 2022 do not recommend using opioids due to efficacy and side effects.3
“We need better diagnostic tools and predictive tools,” said Dr. Durbhakula. “We need better treatment that is personalized. As we get more personalized, we will be able to better deliver care.”
References
1. Callaghan BC, Cheng HT, Stables CL, Smith AL, Feldman EL. Diabetic neuropathy: clinical manifestations and current treatments. Lancet Neurol. 2012 Jun;11(6):521-34. doi: 10.1016/S1474-4422(12)70065-0. Epub 2012 May 16. PMID: 22608666; PMCID: PMC4254767.
2. Gordois A, Scuffham P, Shearer A, Oglesby A, Tobian JA. The health care costs of diabetic peripheral neuropathy in the US. Diabetes Care. 2003 Jun;26(6):1790-5. doi: 10.2337/diacare.26.6.1790. PMID: 12766111.
3. Price R, Smith D, Franklin G, et al. Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update Summary: Report of the AAN Guideline Subcommittee. Neurology. 2022 Jan 4;98(1):31-43. doi: 10.1212/WNL.0000000000013038. PMID: 34965987.
