New AAN guideline details multiple options for reducing diabetic neuropathy pain

The American Academy of Neurology has updated a guideline for treating painful diabetic neuropathy using oral and topical treatments.

The American Association of Neuromuscular & Electrodiagnostic Medicine has endorsed this guideline, which updates a 2011 AAN guideline.

“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,” guideline author Brian C. Callaghan, MD, MS, of the University of Michigan in Ann Arbor and a fellow of the AAN, said in a press release. “Painful diabetic neuropathy is very common, so people with diabetes who have nerve pain should discuss it with their doctor because treatment may help.”

According to the guideline, many oral and topical medications effectively reduce nerve pain. However, before doctors prescribe a treatment, they should first determine whether a patient also has mood or sleep problems because it is important to also treat these conditions. Further, doctors can help reduce nerve pain by offering treatments from several drug classes, including tricyclic antidepressants (eg, amitriptyline, nortriptyline and imipramine), serotonin-norepinephrine reuptake inhibitors (eg, duloxetine, venlafaxine or desvenlafaxine), gabapentinoids (eg, gabapentin or pregabalin) and/or sodium channel blockers (carbamazepine, oxcarbazepine, lamotrigine or lacosamide).

“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,” Callaghan said in the release.

Callaghan and colleagues noted that upon prescribing, doctors should account for a drug’s cost and side effects, as well as the patient’s other medical problems. After a patient has started taking a drug, doctors should ensure there is adequate pain relief and not too many side effects. Doctors should allow patients to try another medication from a different class if the first medication does not offer meaningful improvement or if it has significant side effects.

The authors noted that opioids should not be used as 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,” Callaghan said.

According to the guideline, doctors can offer topical treatments, including capsaicin, glyceryl trinitrate spray or Citrullus colocynthis, for pain reduction. Additional options, such as ginkgo biloba and nondrug treatments like exercise, mindfulness, cognitive behavioral therapy or tai chi, may also be helpful.

“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,” Callaghan said. “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.”