AAN issues new guideline on oral and topical treatments for painful diabetic neuropathy

Diabetic neuropathy refers to nerve damage due to diabetes and it may lead to pain and numbness, most often in the hands and feet. To help neurologists and other doctors determine the best treatment for people with diabetic neuropathy, the American Academy of Neurology (AAN) has issued a guideline on oral and topical treatments for painful diabetic neuropathy.

The guideline is published in the December 27, 2021, online issue of Neurology^®, the medical journal of the AAN, and is endorsed by the American Association of Neuromuscular & Electrodiagnostic Medicine. This guideline updates the 2011 AAN guideline on the treatment of painful diabetic neuropathy.

Living with pain can greatly affect a person's quality of life, so this guideline aims to help neurologists and other doctors provide the highest quality patient care based on the latest evidence. Painful diabetic neuropathy is very common, so people with diabetes who have nerve pain should discuss it with their doctor because treatment may help."

Brian C. Callaghan, MD, MS, Guideline Author, University of Michigan in Ann Arbor and a Fellow of the American Academy of Neurology

The guideline states that there are many oral and topical medications that are effective in reducing nerve pain. Before prescribing a treatment, it says a doctor should first determine if a person also has mood or sleep problems since treatment for these conditions is also important.

To reduce nerve pain, the guideline recommends that doctors may offer treatments from the following drug classes: tricyclic antidepressants (TCAs) such as amitriptyline, nortriptyline and imipramine; serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine, venlafaxine or desvenlafaxine; gabapentinoids such as gabapentin or pregabalin; and/or sodium channel blockers such as carbamazepine, oxcarbazepine, lamotrigine, or lacosamide. Evidence shows these medications may all reduce nerve pain.

"New studies on sodium channel blockers published since the last guideline have resulted in these drugs now being recommended and considered as effective at providing pain relief as the other drug classes recommended in this guideline," said Callaghan.

When prescribing, the guideline says doctors should consider the cost of a drug, side effects as well as other medical problems the person may have. Once taking a drug, people should be checked by their doctors to determine if there is enough pain relief or too many side effects.

If the first medication tried does not provide meaningful improvement, or if there are significant side effects, the guideline states that doctors should offer patients a trial of another medication from a different class.

The guideline states that opioids should not be considered for treatment.

"Current evidence suggests that the risks of the use of opioids for painful diabetic neuropathy therapy outweigh the benefits, so they should not be prescribed," said Callaghan.

The guideline states that doctors may offer topical treatments such as capsaicin, glyceryl trinitrate spray or Citrullus colocynthis to reduce pain. It also says ginkgo biloba may be helpful, as well as non-drug treatments such as exercise, mindfulness, cognitive behavioral therapy or tai chi.

"It is important to note that the recommended drugs and topical treatments in this guideline may not eliminate pain, but they have been shown to reduce pain," said Callaghan. "The good news is there are many treatment options for painful diabetic neuropathy, so a treatment plan can be tailored specifically to each person living with this condition."

To further assist neurologists and other doctors with treating painful diabetic neuropathy, the AAN has also published a new AAN Polyneuropathy Quality Measurement Set to accompany this guideline. A quality measurement set is a tool doctors can use to improve the ways care is delivered to patients.