Diabetic peripheral neuropathy

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Background

  • Diagnosis of exclusion
  • Most prevalent chronic complication of diabetes, risk of injuries due to insensate feet
  • Ultimately need follow up with primary care, not to be managed in the ED

Categories

  • Distal symmetric polyneuropathy (DSPN), most common at 75% of all neuropathies
  • Mononeuropathies (cranial nerves, radiculopathy)
  • Diabetic autonomic neuropathies
    • Cardiovascular (tachycardia, orthostatic hypotension, malignant arrhythmia)
    • Gastrointestional (gastroparesis, diabetic enteropathy with diarrhea, colonic hypomotility with constipation)
    • Urogenital (neurogenic bladder, erectile dysfunction)
    • Sudomotor (hypohydrosis, anhidrosis)

Clinical Features

  • Spectrum of sensation from numbness to paresthesias to pain
  • Autonomic symptoms as above

Differential Diagnosis

Hyperglycemia

Evaluation

  • Clinical diagnosis
  • Blood glucose level
  • See diabetes

Management

  • Optimize glucose control
  • First-line medications per ADA position paper 2017[1]
    • Pregabalin 50 - 100 mg PO TID, starting at 50 mg TID, increasing to 100 mg TID after 1 week, max dose 600 mg/day[2]
      • More rapid onset of action and less titration necessary as compared to gabapentin[3]
      • However, extremely cost prohibitive for self-pay
    • Duloxetine at 60 - 120 mg/day, starting 30 mg PO BID, increasing to goal after 1 week, max 120 mg/day
      • SNRI, anti-depressant, not as cost-prohibitive as pregabalin
      • Does not appear to be associated with significant cardiovascular risk[4]
  • Gabapentin is a questionably effective medication, but is low cost and has a relatively tolerable side effect profile
    • March 2017 systematic review revealed gabapentin is not beneficial[5]
    • Gabapentin 300 mg QHS, increased to 300 mg BID, increased to 300 mg TID over 2-3 weeks
    • Graduation titration to 1800 - 3600 mg/day is necessary for it to be clinically effective[6][7]

Disposition

  • Follow up with primary care for long-term management and up-titration of medications if started in the ED
  • Admission for severe complications, such as severe diabetic foot infection

See Also

References

  1. Pop-Busui R et al. Diabetic Neuropathy: A Position Statement by the American Diabetes Association. Diabetes Care 2017 Jan; 40(1): 136-154.
  2. Freeman R, Durso-Decruz E, Emir B. Efficacy, safety, and tolerability of pregabalin treatment for painful diabetic peripheral neuropathy: findings from seven randomized, controlled trials across a range of doses. Diabetes Care 2008;31:1448–1454.
  3. Moore RA, Straube S, Wiffen PJ, Derry S, McQuay HJ. Pregabalin for acute and chronic pain in adults. Cochrane Database Syst Rev 2009;3).
  4. Wernicke J et al. An evaluation of the cardiovascular safety profile of duloxetine: findings from 42 placebo-controlled studies. Drug Saf. 2007;30(5):437-55.
  5. Waldfogel et al. Pharmacotherapy for diabetic peripheral neuropathy pain and quality of life. ublished online before print March 24, 2017, doi: http:/​/​dx.​doi.​org/​10.​1212/​WNL.​0000000000003882 Neurology.
  6. Backonja M, Glanzman RL. Gabapentin dosing for neuropathic pain: evidence from randomized, placebo-controlled clinical trials. Clin Ther 2003;25:81–104.
  7. Dworkin RH, O’Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain 2007;132:237–251