Pain in Primary Care

Her Burning Feet: What to Try Next for Peripheral Neuropathy

Charles P. Vega, MD


March 24, 2022

To focus on issues of pain management in primary care, I'll put before you a clinical scenario involving a woman with diabetes-related peripheral neuropathy. I'll tell you what I plan to do, but I'm most interested in crowdsourcing a response from all of you to collectively determine best practice. So please answer the polling question and contribute your thoughts in the comments, whether you agree or disagree with my approach.

The Case

Maria, a 68-year-old woman, complains of pain in her feet and ankles that is "so strong I just want to cut them off." Alternating between burning and "electricity," these sensations have been gradually increasing for 3 years. Maria also has chronic numbness and tingling in her feet, and even socks are becoming less comfortable.

Maria had previously tried nonsteroidal anti-inflammatory drugs (NSAIDs) for the pain, with little relief. Gabapentin, prescribed 2 years ago, was effective for a year before she felt it no longer helped and she discontinued it. She tried amitriptyline last year but side effects prompted her to stop taking it. Finally, a prescription for venlafaxine XR went unfilled because she had lost faith in her clinician.

Maria's medical history is long: poorly controlled type 2 diabetes, hypertension, obesity, gastroesophageal reflux disease (GERD), osteoarthritis, and depression. She currently takes dulaglutide, metformin, lisinopril-hydrochlorothiazide, omeprazole, glucosamine, and escitalopram.

A physical examination reveals normal-appearing lower extremities, with no edema, good pedal pulses, and capillary refill < 2 seconds. Her strength is normal in the knees and ankles, but a monofilament test reveals bilateral loss of sensation. I diagnosed Maria with painful diabetic neuropathy.


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