We need you! Join our contributor community and become a WikEM editor through our open and transparent promotion process.
Diabetic peripheral neuropathy
From WikEM
Contents
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
Hyperglycemia
- Diabetic foot infection
- Diabetic ketoacidosis (DKA)
- Diabetic ketoacidosis (peds)
- Hemochromatosis
- Hyperosmolar hyperglycemic state (HONC)
- Iron toxicity
- New onset diabetes mellitus
- Diabetic peripheral neuropathy
- Nonketotic hyperglycemia
- Sepsis
Workup
- 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]
- 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]
- 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]
- Effective treatments include duloxetine, venlafaxine, pregabalin, oxcarbazepine, TCAs, atypical opioids (tapentadol)
- Ineffective treatments include dextromethorphan, gabapentin, typical opioids (oxycodone), topical capsaicin
- 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]
- March 2017 systematic review revealed gabapentin is not beneficial[5]
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
Sources
- ↑ Pop-Busui R et al. Diabetic Neuropathy: A Position Statement by the American Diabetes Association. Diabetes Care 2017 Jan; 40(1): 136-154.
- ↑ 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.
- ↑ Moore RA, Straube S, Wiffen PJ, Derry S, McQuay HJ. Pregabalin for acute and chronic pain in adults. Cochrane Database Syst Rev 2009;3).
- ↑ 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.
- ↑ 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.
- ↑ Backonja M, Glanzman RL. Gabapentin dosing for neuropathic pain: evidence from randomized, placebo-controlled clinical trials. Clin Ther 2003;25:81–104.
- ↑ Dworkin RH, O’Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain 2007;132:237–251
