Diabetic Neuropathy: The Latest Facts

What is the treatment for diabetic neuropathy?

The best way to prevent and treat diabetic neuropathy is to strictly control blood sugar levels, which can also prevent other “microvascular” (retinopathy, nephropathy) or “macrovascular” (heart attack, stroke) complications of diabetes.

In most cases, this will mean intensifying antidiabetic treatment with insulin for type 1 diabetes, drugs or even insulin therapy for type 2 diabetes.

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When blood glucose levels are better controlled, some patients find that the pain worsens over time and then decreases.

How is pain treated in diabetic neuropathy?

Conventional analgesics are not usually effective for neurogenic pain, except for morphine in moderate doses, bearing in mind that the aim is to avoid prescribing these drugs for too long because of the risk of addiction and dependency. Tramadol is an interesting molecule because of its double action: action on mu-brain receptors and monoaminergic action at the level of the spinal cord.

Several drugs are being diverted from their original indication because studies have also shown that they are equally effective in controlling pain associated with nerve damage (“neuropathic pain”).

These include tricyclic antidepressants (like amitriptyline or nortriptyline), antidepressants that inhibit the reuptake of serotonin and norepinephrine (like venlafaxine or duloxetine), and gabapentin or pregabalin. The most serious studies have been conducted with these last molecules.

The antidepressants used for neurogenic pain are usually old tricyclic molecules (amitriptyline, clomipramine, imipramine), which have a proven effect on peripheral neurogenic pain. Their side effects are dose-dependent (dry mouth, constipation, sweating, visual disturbances, palpitations, urinary retention, cognitive disorders, confusion, orthostatic hypotension with the risk of falling, especially in the elderly). The effectiveness of selective serotonin and norepinephrine inhibitors (venlafaxine, duloxetine) has been demonstrated in the treatment of diabetes-related peripheral neuropathies (especially duloxetine). The most common side effects of duloxetine include nausea, constipation or diarrhea, loss of appetite, sometimes dry mouth and drowsiness. Some cases of elevated liver enzymes elevated blood pressure, and glycated hemoglobin has been reported.

Among antiepileptic drugs, the efficacy of pregabalin and gabapentin in peripheral and central neurogenic pain in adults is well established. These treatments probably work by reducing central sensitization. The most common side effects include dizziness, drowsiness, fatigue, weight gain, peripheral edema, headache, and dry mouth.

In some cases gels, creams or patches containing a local anesthetic such as lidocaine have been shown to be effective.

Transcutaneous neurostimulation has been shown to be effective in some cases.

Some patients find alternative treatments such as acupuncture or relaxation useful.

To some extent, with blood sugar levels under control, it is possible to stabilize or reverse the complications of diabetes, especially diabetic neuropathy.

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