Managing diabetic peripheral neuropathic pain
Neuropathic pain presents a challenging clinical picture due to its diverse aetiologies, symptoms and underlying mechanisms.
A number of pharmacological treatments are used for neuropathic pain. These include:
• Tricyclic antidepressants (TCAs);
• Serotonin–noradrenaline reuptake inhibitors (SNRIs);
• Anticonvulsants such as pregabalin and gabapentin;
• Topical treatments; and
• Opioid analgesics.
Serotonin (5-HT) and noradrenaline (NA) are neurotransmitters involved in the modulation of endogenous analgesic mechanisms via the descending inhibitory pathways of the brain and spinal cord.3 Imbalance of these inhibitory mechanisms may contribute to central sensitisation and hyperexcitability of pain pathways, leading to persistent pain.
Growing evidence suggests that an increase in the levels of 5-HT and NA restores appropriate balance in the descending modulatory pathways, inhibiting pain.
Serotonin-noradrenaline reuptake inhibitors (SNRIs) target both serotonin and noradrenaline pain pathways. Recent National Institute for Health and Clinical Excellence (NICE) guidelines recommend the SNRI - duloxetine - as the first-line treatment for people with diabetic peripheral neuropathic pain (DPNP).
Diabetic peripheral neuropathic pain is a debilitating chronic pain condition that negatively impacts quality of life, and is closely associated with mood disturbances. A holistic approach to managing DPNP is important.
Clinicians should:
• Inform patients about DPNP and the benefits and limitations of treatment;
• Encourage lifestyle interventions such as diet and exercise;
• Optimise glycaemic control and other risk factors such as hypertension and dyslipidemia.
• Consider referral to specialist pain service if satisfactory pain management is not achieved.