Conservative Treatment of Peripheral Neuropathy and Neuropathic Pain

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Differential diagnosis

The significance of the diabetic etiology of peripheral neuropathy is easy to recognize when one considers that nearly 1 in 10 American adults has diabetes. Prevalence of neuropathy in these patients ranges from 25% to 100%. The World Health Organization estimates that 220 million people will have diabetes worldwide by 2010 [6].

Many other causes of neuropathy exist and should be considered during the initial patient evaluation. Traumatic and entrapment neuropathies are common and often

Pharmacologic therapy

Pharmacologic management of pain associated with diabetic peripheral neuropathy must be rational and balanced. The underlying pathophysiology of diabetic neuropathy and the mechanism of action of each drug used must be evaluated each time pharmacologic therapy is being considered. The overall goal of therapy is to administer drugs that use different mechanisms of action and that will cause broad and balanced analgesic effects in treated individuals.

Diabetes is a systemic illness, which causes

Nutritional supplements

From a physiologic standpoint, the path to neurotoxic destruction in the hyperglycemic state is broad and wide. Numerous machinations conspire to rob the diabetic patient of a functioning peripheral nervous system. Hyperglycemic lipid dysmetabolism which results in accelerated atherosclerosis of the vasonervorum, accumulation of advanced glycosylation end products, impaired axonal plasmic flow, the production of reactive oxidative species, reduced activity of nitric oxide synthetase, and the

Topical modalities

Once the diagnosis of neuropathy has been established, its etiology should be ascertained by all means possible. Successful amelioration of this condition is dependent upon therapies directed to correct the underlying cause. If the origin of the malady eludes diagnosis, symptomatic treatment can be initiated. In either case, topical therapy can be a safe primary or adjunctive therapy; untoward systemic side effects are unlikely.

Since the time of Dante's inadvertently apt description of

Physical modalities

Although several advances have occurred in the understanding and use of pharmacological agents for treatment of neuropathic pain, dangerous or debilitating side effects, costs, and drug interactions have left many physicians and patients searching for other options. One of the most studied conservative physical modalities has been the application of monochromatic infrared energy [60].

The Anodyne Therapy System (ATS) (Fig. 1, Fig. 2) produces monochromatic infrared energy (MIRE) through therapy

Summary

Although numerous modalities are now available for the treatment of peripheral neuropathy, it can be difficult to find an effective treatment for each particular patient. Fig. 3 shows a suggested treatment algorithm. The intention of this algorithm is not to create a recipe to follow for every situation. Consultation with a pain specialist, neurologist, or peripheral nerve surgeon who has knowledge and training in the latest neuropathy treatments is prudent for cases that are recalcitrant to

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References (70)

  • N. Galeotti

    Menthol: a natural analgesic compound

    Neurosci Lett

    (2002)
  • R.A. Milch

    Neuropathic pain: implications for the surgeon

    Surg Clin N Am

    (2005)
  • J.J. Prendergast et al.

    Reduced sensory impairment in patients with peripheral neuropathy

    Endocr Pract

    (2004)
  • K.R. Biddinger et al.

    The role of surgical decompression for diabetic neuropathy

    Foot Ankle Clin N Am

    (2004)
  • P.J. Dyck et al.

    The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort

    Neurology

    (1993)
  • D.G. Armstrong et al.

    Validation of a diabetic wound classification system: the contribution of depth, infection, and ischemia to risk of amputation

    Diabetes Care

    (1998)
  • P. Low et al.

    Symptom treatment of painful neuropathy

    JAMA

    (1998)
  • National diabetes fact sheet, 2005. Available at: http://www.diabetes.org/uedocuments/NationalDiabetesFactSheetRev.pdf....
  • B. Misha-Miroslav et al.

    Pharmacologic management part I: better-studied neuropathic pain diseases

    Pain Med

    (2004)
  • D. Podwall et al.

    Diabetic neuropathy: clinical features, etiology and therapy

    Curr Neurol Neurosci Rep

    (2004)
  • J.E. Shaw et al.

    The epidemiology of diabetic neuropathy

    Diabetes Rev

    (1999)
  • M. Maizels et al.

    Antidepressants and antiepileptic drugs for chronic non-cancer pain

    Am Fam Physician

    (2005)
  • S.H. Sindrup et al.

    Venlafaxine versus imipramine in painful polyneuropathy: a randomized, controlled trial

    Neurology

    (2003)
  • C.P. Watson et al.

    Nortriptyline versus amitriptyline in postherpetic neuralgia: a randomized trial

    Neurology

    (1998)
  • Goldstein DJ, Lu Y, Iyengar S, et al. Duloxetine in the treatment of the pain associated with diabetic neuropathy....
  • Wernicke JF, Lu Y, D'Souza DN, et al. Duloxetine at doses of 60 mgQD and 60 mg BID is effective treatment of diabetic...
  • Wernicke JF, Rosen A, Lu Y, et al. The safety of Duloxetine in the long-term treatment of diabetic neuropathic pain....
  • A.B. Waitekus et al.

    Duloxetine hydrocloride

    Nat Rev Drug Discov

    (2004)
  • U. Sharma et al.

    Pregabalin effectively relieves pain in patients with diabetic peripheral neuropathy

    Diabetes

    (2000)
  • H. Lesser et al.

    Pregabalin relieves symptoms of painful diabetic neuropathy: a randomized controlled trial

    Neurology

    (2004)
  • R.H. Dworkin et al.

    Pregabalin for the treatment of postherpetic neuralgia: a randomized, placebo-controlled trial

    Neurology

    (2003)
  • R.M. Duhmke et al.

    Tramadol for neuropathic pain

    Cochrane Database Syst Rev

    (2004)
  • R.L. Barbano et al.

    Effectiveness, tolerability, and impact on quality of life of the 5% lidocaine patch in diabetic polyneuropathy

    Arch Neurol

    (2004)
  • Lidoderm prescribing information

    (2004)
  • View full text