Diabetic Neuropathy: An Intensive Review

Jeremiah John Duby; R. Keith Campbell; Stephen M. Setter; John Raymond White; Kristin A. Rasmussen

Disclosures

Am J Health Syst Pharm. 2004;61(2) 

In This Article

Discussion

Diabetic peripheral neuropathy is a common and diverse complication that adversely affects the quality of life and life expectancy of diabetes patients. The key to the pathology is hyperglycemia, but the cascades that bridge the metabolic state with the secondary pathological changes still represent boundless challenges to basic research and clinical intervention.

Symptom management typically requires careful use of a combination of agents. Current evidence from clinical trials supports the use of desipramine, amitriptyline, capsaicin, tramadol, gabapentin, bupropion, and venlafaxine as preferred medications for the treatment of diabetic sensorimotor neuropathy. Citalo-pram, NSAIDs, and opioid analgesics may be used as adjuvant agents. Lamotrigine, oxcarbazepine, paroxe-tine, levodopa, and α-lipoic acid are alternative considerations. The evidence supporting the use of zonisamide, fluoxetine, mexiletine, dextromethorphan, and phenytoin is considered equivocal, and their risks are generally better defined than their benefits. Transcutaneous electrotherapy and percutaneous electrical nerve stimulation are alternative therapies that have demonstrated efficacy and may represent a hope for patients with severe, refractory pain.

Diabetic autonomic neuropathy is extremely difficult to treat, and the risks and adverse effects frequently outweigh the benefits of most pharmacologic therapies. The symptoms of CAN may be ameliorated with fludrocortisone, clonidine, midodrine, dihydroergotamine or caffeine, octreotide, ACE inhibitors, and β-blockers. Gastroparesis may be improved with metoclopramide or erythromycin, but glycemic control is perhaps the best long-term treatment. Erectile dysfunction may respond to phosphodiesterase inhibitors, vacuum-constriction devices, and intracavernosal injections.

It is critical that all clinical recommendations be based on a thorough patient review to minimize potentially severe adverse effects. Further, all medications should be initiated at low dosages and adjusted to individual efficacy and adverse effects. Ruboxistaurin represents the current hope for future disease-modifying therapies. Glycemic control remains the foundation of prevention and the prerequisite of adequate treatment of diabetic neuropathy.

Diabetic neuropathy is a many-faceted complication of diabetes that can be managed symptomatically with an array of drugs.

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