Painful Diabetic Neuropathy
Painful diabetic neuropathy is pain arising as a direct consequence of abnormalities of the somatosensory system in diabetic patients and predominantly affects the feet and legs. Risk factors for development of diabetic peripheral neuropathy include duration of disease, poor glycaemic control, hypertension, hyperlipidaemia, and smoking, but the specific risk factors for painful neuropathy are less clear. Patients often find it difficult to clearly describe the pain—up to 40% have never received treatment. Treatment follows the NICE guidance pathway, with duloxetine and tricyclic antidepressants considered to be first-line agents, but also includes modification of the risk factors for development of neuropathy. Around 347 million people worldwide are estimated to have diabetes mellitus, making it one of the most common chronic diseases. It is associated with considerable morbidity and mortality because of the primary disease and also secondary complications. The incidence has almost doubled in the last three decades in parallel with an increasing trend in ageing and also in obesity worldwide.1 It has a huge impact on quality of life, health resources, and economy. Diabetic neuropathy is the most common long-term complication of the condition and a leading cause of neuropathy in the developed world.2 Both duration of diabetes and degree of glycaemic control are important predictive factors for the development of neuropathy.3 The prevalence of diabetic neuropathy varies considerably among clinical studies because of differences in the study population, design, and diagnostic criteria. Prevalence increases predictably with the duration of diabetes from 10% at diagnosis to as much as 53% after 25 yr of diabetes.4 There is also a proportional increase with age. It is estima Continue reading >>
Guidelines For Treating Painful Diabetic Neuropathy
Evidence-Based Guidelines for Treating Painful Diabetic Neuropathy One of the most important and potentially disabling complications of diabetes is the development of a symmetric, length-dependent polyneuropathy. Approximately 16% of patients with diabetes will suffer from a painful form of neuropathy that can be difficult to treat. Many pharmacologic and nonpharmacologic options exist for physicians caring for these patients, and a recent evidence-based guideline (Bril et al, 2011) published by the American Academy of Neurology (AAN) helps guide physicians regarding the strength of evidence for these various therapies. The guideline involved a systematic review of the literature from 1960 to 2008. A total of 79 relevant articles were identified and rated by members of a panel using standard criteria for evaluating the quality of evidence. Since there was wide variability in the measures used to quantify a reduction in pain, the authors preferred the following outcome measures in order of preference: (1) the difference in the proportion of patients reporting a >3050% change in baseline pain on a Likert or visual analog pain scale compared with no treatment or placebo; (2) the percent change from baseline on a Likert or visual analog scale compared with no treatment or comparative treatment; and (3) other quantitative measures of pain reduction. The only level A recommendation found in the entire review was for the anticonvulsant pregabalin, suggesting it should be offered as a first-line therapy. The number needed to treat for a 50% reduction in pain was 4 at a dose of 600 g/d. Level B treatment recommendations among the anticonvulsants included gabapentin and sodium valproate. Level B recommendations among the anticonvulsants stating that they probably should not be u Continue reading >>
Pathogenesis Of Painful Diabetic Neuropathy
Copyright © 2014 Amir Aslam et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract The prevalence of diabetes is rising globally and, as a result, its associated complications are also rising. Painful diabetic neuropathy (PDN) is a well-known complication of diabetes and the most common cause of all neuropathic pain. About one-third of all diabetes patients suffer from PDN. It has a huge effect on a person’s daily life, both physically and mentally. Despite huge advances in diabetes and neurology, the exact mechanism of pain causation in PDN is still not clear. The origin of pain could be in the peripheral nerves of the central nervous system. In this review, we discuss various possible mechanisms of the pathogenesis of pain in PDN. We discuss the role of hyperglycaemia in altering the physiology of peripheral nerves. We also describe central mechanisms of pain. 1. Introduction Diabetes affects 382 million people wordlwide and its prevalence is expected to increase to 592 million by the year 2035 [1]. Diabetic neuropathy, a well-known, long-term complication of diabetes, can affect almost half of the diabetic population [2] and is associated with higher morbidity and mortality [3]. Diabetic neuropathy encompasses a variety of clinical or subclinical presentations. Painful diabetic neuropathy (PDN) is a common type of diabetic neuropathy and the most common cause of neuropathic pain [4]. The reported prevalence of PDN varied from 11% in Rochester, Minnesota, USA [5], to 53.7% in the Middle East [6]. One UK study published in 2011 reported that the prevalence of PDN was 21.5% in type 2 diabetes p Continue reading >>
Advances In The Diagnosis And Treatment Of Painful Diabetic Neuropathy
Advances in the Diagnosis and Treatment of Painful Diabetic Neuropathy European Endocrinology, 2008; 4:48-51; DOI: Citation European Endocrinology, 2008; 4:48-51; DOI: Symptoms of painful diabetic neuropathy (PDN) occur in 3040% of patients with diabetic neuropathy.1 It is most commonly associated with distal symmetrical neuropathy affecting the lower limbs (especially toes and feet), and patients present with burning, stabbing and tingling sensations. PDN is extremely distressing and significantly reduces the quality of life of patients.2 Hyperglycaemia is clearly important in the genesis of nerve damage, and recent studies suggest that even minimal perturbations in blood glucose in those with impaired glucose tolerance (IGT) may lead to the development of small nerve fibre damage and neuropathic pain.3 The causes and consequences of diabetic neuropathy are complex and not well understood. Several hypotheses have been advocated in an attempt to explain the pathophysiology of diabetic neuropathy and include a combination of increased oxidative stress, advanced glycation, polyol accumulation, decreased nitric oxide and impaired sodium+/ potassium+ (Na+/K+)adenosine triphosphate (ATPase).4 Paradoxically, a lack of treatment for underlying nerve damage has improved our understanding of the natural history of PDN because, although nerve damage may initiate PDN, it is clear that as nerve damage progresses pain may diminish.5 Standard measures of neuropathy such as nerve conduction studies and vibration perception thresholds (VPTs) can be used to detect abnormalities of nerve function, but they focus on large nerve fibres. However, pain is generated and mediated by small c and a fibres. Thus, it is no surprise that VPT does not differ between diabetic patients with painful a Continue reading >>
Pathophysiology And Treatment Of Painful Diabetic Neuropathy
, Volume 12, Issue3 , pp 192197 | Cite as Pathophysiology and treatment of painful diabetic neuropathy Diabetes is the most common cause of peripheral neuropathy, and painful diabetic neuropathy (PDN) affects approximately 30% of diabetic patients with neuropathy. It is extremely distressing for the patient and poses significant management difficulties because no treatment provides total relief, and side effects of therapy are a major limiting factor for titrating therapy. Understanding the pathogenesis of diabetic neuropathy may lead to the development of new treatments to prevent nerve damage, and a better understanding of the mechanisms that modulate pain may lead to more effective relief of painful symptoms. We provide an update on the pathogenesis, diagnosis, and treatment of PDN. Unable to display preview. Download preview PDF. Boulton AJ, Vinik AI, Arezzo JC, et al.: Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care 2005, 28:956962. PubMed CrossRef Google Scholar Zelman DC, Brandenburg NA, Gore M: Sleep impairment in patients with painful diabetic peripheral neuropathy. Clin J Pain 2006, 22:681685. PubMed CrossRef Google Scholar Jensen TS, Backonja MM, Hernndez Jimnez S, et al.: New perspectives on the management of diabetic peripheral neuropathic pain. Diab Vasc Dis Res 2006, 3:108119. PubMed CrossRef Google Scholar Singleton JR, Bixby B, Feldman EL, et al.: Diet and exercise counselling alone does not prevent long term neuropathy progression in IGT neuropathy [abstract]. Neurology 2007, 68:A410. Google Scholar Smith AG, Singleton JR: Impaired glucose tolerance and neuropathy. Neurologist 2008, 14:2329. PubMed CrossRef Google Scholar Tlle T, Xu X, Sadosky AB: Painful diabetic neuropathy: a cross-sectional survey of health st Continue reading >>
Painful Diabetic Neuropathy
Advantage of novel drugs over old drugs? Neuropathic pain exerts a substantial impact on quality of life, particularly by causing considerable interference in sleep, daily activities, and enjoyment of life. Chronic neuropathic pain is present in 13–26% of diabetic patients (1–4). In a recent survey from Augsburg, Germany, the prevalence of painful polyneuropathy was found to be 13.3% in diabetic subjects, 8.7% in individuals with impaired glucose tolerance, 4.2% in individuals with impaired fasting glucose, and 1.2% in individuals with normal glucose tolerance (3). Independent factors significantly associated with diabetic painful neuropathy (DPN) were age, weight, and peripheral arterial disease. Pain is a subjective symptom of major clinical importance, since it is often this complaint that motivates patients to seek health care. However, in a survey from the U.K., only 65% of diabetic patients received treatment for their neuropathic pain, although 96% had reported the pain to their physician. Pain treatment consisted of antidepressants in 43.5% of cases, anticonvulsants in 17.4%, opiates in 39%, and alternative treatments in 30% (combinations possible). Whereas 77% of the patients reported persistent pain over 5 years, 23% were pain free over at least 1 year (1). Thus, neuropathic pain persists in the majority of diabetic patients over periods of several years. MANIFESTATIONS OF PAINFUL NEUROPATHY Chronic DPN with persistent or episodic pain that typically may worsen at night, and improve during walking, is localized predominantly in the feet. The pain is often described as a deep-seated ache, but there may be superimposed lancination, or it may be of burning thermal quality. In a clinical survey including 105 patients with DPN, the following locations of pain w Continue reading >>
Treatment Of Painful Diabetic Neuropathy
Go to: Assessment and diagnosis The diagnosis of PDN is primarily clinical, based on a history of neuropathic pain and confirmatory examination findings, establishing deficits associated with neuropathy. Although one might argue that confirming neuropathy using tests which assess large fibre deficits (loss of sensation, monofilament exam, reflexes) are not relevant to painful symptoms which are driven principally by small fibre damage. Patients report intermittent or continuous symptoms of pain described as burning, stabbing, tingling, numb, hot, cold or itching in a distal-to-proximal ‘glove-and-stocking’ distribution, usually beginning in the feet. The pain is typically symmetrical and worsens at night. Abnormal sensory perception, such as reduced or heightened perception of hot, cold, touch or pin-prick sensation, or allodynia, may be present on examination [Callaghan et al. 2012a]. Neuropathic pain scales have been devised to aid diagnosis and these may also provide insight into the severity of the patient’s symptoms [Papanas and Ziegler, 2011]. The Michigan Neuropathy Screening Instrument (MNSI) and Neuropathy Disability Score (NDS) are designed to assess neuropathic impairment and can act as screening tools for DSPN [Feldman et al. 1994; Weintrob et al. 2007]. The severity of pain in PDN can be assessed through pain scores such as the Brief Pain Inventory and the Neuropathic Pain Questionnaire (NPQ) [Cleeland and Ryan, 1994; Krause and Backonja, 2003]. The NPQ can also be used to follow up patients along with the Neuropathic Pain Symptom Inventory, a 10-item questionnaire to quantify and evaluate symptoms of neuropathic pain [Kelly et al. 2005]. In addition, the quality of life can be assessed through neuropathy-specific quality of life scores such as the Ne Continue reading >>
Diagnosis
Print Diabetic neuropathy is usually diagnosed based on your symptoms, your medical history and a physical exam. During the exam, your doctor is likely to check your muscle strength and tone, tendon reflexes, and sensitivity to touch, temperature and vibration. Your doctor may also conduct tests that include: Filament test. Sensitivity to touch may be tested using a soft nylon fiber called a monofilament. Nerve conduction studies. This test measures how quickly the nerves in your arms and legs conduct electrical signals. It's often used to diagnose carpal tunnel syndrome. Electromyography (EMG). Often performed along with nerve conduction studies, electromyography measures the electrical discharges produced in your muscles. Quantitative sensory testing. This noninvasive test is used to assess how your nerves respond to vibration and changes in temperature. Autonomic testing. If you have symptoms of autonomic neuropathy, your doctor may request special tests to look at your blood pressure in different positions and assess your ability to sweat. The American Diabetes Association recommends that all people with diabetes have a comprehensive foot exam — either by a doctor or by a foot specialist (podiatrist) — at least once a year. In addition, your feet should be checked for sores, cracked skin, calluses, blisters, and bone and joint abnormalities at every office visit. Treatment Diabetic neuropathy has no known cure. Treatment for diabetic neuropathy focuses on: Slowing progression of the disease Relieving pain Managing complications and restoring function Slowing progression of the disease Consistently keeping blood sugar within a target range can help prevent or delay the progression of diabetic neuropathy and may even improve some of the symptoms you already have. Continue reading >>
Painful Diabetic Neuropathy
Amanda Peltier, assistant professor of neurology 1 , Stephen A Goutman, assistant professor of neurology 2 , Brian C Callaghan, assistant professor of neurology 2 1Department of Neurology, Vanderbilt University, Nashville, TN, USA 2Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA Correspondence to: B Callaghan bcallagh{at}med.umich.edu Diabetes is a worldwide epidemic, and associated neuropathy is its most costly and disabling complication. Given the rising prevalence of painful diabetic neuropathy, it is increasingly important that we understand the best ways to diagnose and treat this condition. Diagnostic tests in this field are evolving rapidly. These include the use of skin biopsies to measure small unmyelinated fibers, as well as even newer techniques that can measure both small unmyelinated fibers and large myelinated fibers in the same biopsy. The main treatments for painful diabetic neuropathy remain management of the underlying diabetes and drugs for the relief of pain. However, emerging evidence points to major differences between type 1 and type 2 diabetes, including the ability of glycemic control to prevent neuropathy. Enhanced glucose control is much more effective at preventing neuropathy in patients with type 1 diabetes than in those with type 2 disease. This dichotomy emphasizes the need to study the pathophysiologic differences between the two types of diabetes, because different treatments may be needed for each condition. The impact of the metabolic syndrome on neuropathy in patients with type 2 diabetes may account for the difference between the two types of diabetes and requires further study. Finally, neuropathic pain is under-recognized and undertreated despite an ever evolving list of effective drugs. Evidence exists t Continue reading >>
Treatment Of Diabetic Neuropathy
INTRODUCTION Peripheral and autonomic neuropathies are a major cause of morbidity in patients with diabetes mellitus. (See "Clinical manifestations and diagnosis of diabetic polyneuropathy" and "Diabetic autonomic neuropathy".) The treatment of diabetic peripheral neuropathy will be reviewed here. There are three main elements in the treatment regimen: Glycemic control Foot care Treatment of pain To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you: The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc. Dy SM, Bennett WL, Sharma R, et al. Preventing complications and treating symptoms of diabetic peripheral neuropathy. Comparative Effectiveness Review No. 187. AHRQ Publication No. 17-EHC005-EF. Rockville, MD: Agency for Healthcare Research and Quality; March 2017. (Accessed on April 06, 2017). 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. Bril V, England J, Franklin GM, et al. Evidence-based guideline: Treatment of painful diabetic neuropathy: report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology Continue reading >>
Treating Painful Diabetic Peripheral Neuropathy: An Update
Painful diabetic peripheral neuropathy occurs in approximately 25% of patients with diabetes mellitus who are treated in the office setting and significantly affects quality of life. It typically causes burning pain, paresthesias, and numbness in a stocking-glove pattern that progresses proximally from the feet and hands. Clinicians should carefully consider the patient's goals and functional status and potential adverse effects of medication when choosing a treatment for painful diabetic peripheral neuropathy. Pregabalin and duloxetine are the only medications approved by the U.S. Food and Drug Administration for treating this disorder. Based on current practice guidelines, these medications, with gabapentin and amitriptyline, should be considered for the initial treatment. Second-line therapy includes opioid-like medications (tramadol and tapentadol), venlafaxine, desvenlafaxine, and topical agents (lidocaine patches and capsaicin cream). Isosorbide dinitrate spray and transcutaneous electrical nerve stimulation may provide relief in some patients and can be considered at any point during therapy. Opioids and selective serotonin reuptake inhibitors are optional third-line medications. Acupuncture, traditional Chinese medicine, alpha lipoic acid, acetyl-l-carnitine, primrose oil, and electromagnetic field application lack high-quality evidence to support their use. Painful diabetic peripheral neuropathy (DPN) occurs in approximately 30% of patients with diabetes mellitus who are hospitalized and in 25% of patients with diabetes who are treated in the office setting.1 It develops as a late manifestation of uncontrolled or long-standing diabetes.1 As many as 12% of patients with painful DPN do not report symptoms, and 39% of patients with the disorder do not receive any Continue reading >>
Aan Issues New Treatment Guideline For Painful Diabetic Neuropathy
AAN Issues New Treatment Guideline for Painful Diabetic Neuropathy Bril V, England J, Franklin GM, et al. Evidence-based guideline: treatment of painful diabetic neuropathy. Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2011 Apr 11; [Epub ahead of print]. HONOLULUA new evidence-based guideline regarding the pharmacologic and nonpharmacologic treatment of painful diabetic neuropathy (PDN) was presented at the 63rd Annual Meeting of the American Academy of Neurology (AAN). The guideline, prepared by the AAN in collaboration with the American Association of Neuromuscular and Electrodiagnostic Medicine and the American Academy of Physical Medicine and Rehabilitation, reports strong evidence for the use of pregabalin in patients with PDN, if clinically appropriate. Venlafaxine, duloxetine, amitriptyline, gabapentin, valproate, opioids, and capsaicin, as well as percutaneous electrical nerve stimulation, are probably effective and therefore should be considered as treatment, according to the recommendations, which were also published in the April 11 online Neurology and in the April issues of Muscle and Nerve and Physical Medicine and Rehabilitation. This is a major problem for patients with diabetes, said lead author Vera Bril, MD, Professor of Neurology at the University of Toronto. As many as 16% of them have PDN, and many of them dont have proper treatment. As we emphasize the use of evidence-based guidelines to treat different disorders, it becomes clear that this field is very confusing, because of the volume of literature. So the guideline has been developed and will provide a framework for physicians to use when they ar Continue reading >>
A Study For The Treatment Of Painful Diabetic Neuropathy
You have reached the maximum number of saved studies (100). Please remove one or more studies before adding more. A Study for the Treatment of Painful Diabetic Neuropathy The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. ClinicalTrials.gov Identifier: NCT00058968 The purpose of the study is to determine if duloxetine can help patients with painful diabetic neuropathy. Drug: Duloxetine hydrochloride Drug: placebo The protocol will assess the efficacy and safety of duloxetine. It will also look at how duloxetine affects quality of life. Duloxetine Versus Placebo in the Treatment of Patients With Painful Diabetic Neuropathy Reduction in average pain severity as measured by an 11-point Likert scale. Pain severity for worst pain and night pain as measured by an 11-point Likert scale. Clinical Global Impression of Severity scale to measure severity of illness at the time of assessment. Patient Global Impression of Improvement scale to measure the degree of improvement at the time of assessment. Brief Pain Inventory to measure the severity of pain. Sensory Portion of the Short Form McGill pain questionnaire measures severity of 11 pain descriptors. Hamilton Depression Rating Scale (17 item) used to assess severity of depression symptoms during the course of therapy. Dynamic Allodynia measure to elicit the pain severity to a normally non-painful stimulus. Study Description Study Design Arms and Interventions Outcome Measures Eligibility Criteria Contacts and Locations More Information Information from the National Library of Medicine Choosing to participate in a study is an important personal decision. Continue reading >>
Diabetic Neuropathy And Painful Diabetic Neuropathy In The Middle East And North Africa (mena) Region: Much Work Needs To Be Done - Sciencedirect
Volume 11, Issue 4 , August 2016, Pages 284-294 Diabetic neuropathy and painful diabetic neuropathy in the Middle East and North Africa (MENA) region: Much work needs to be done The prevalence of diabetic peripheral neuropathy and painful diabetic peripheral neuropathy in the Middle East shows huge variability. This reflects the differing diagnostic techniques employed to diagnose neuropathy, but also the heterogeneity of the populations studied and the selection of populations from primary and secondary care. The treatment of diabetic neuropathy per se is inadequate as reflected by the poor control of risk factors such as glucose control, blood pressure and lipids in this region, which translates into the high rates of foot ulceration and amputation. In relation to symptomatic treatment, recommendations based on trials conducted in the West are without question, endorsed for the treatment of populations in the Middle East. Surely the demographics and patient responses both in terms of efficacy and side effects differ and therefore warrant local clinical trials. There is an over reliance on the prescription of B vitamins with the claim that they induce nerve repair. Whilst there is evidence for the relief of neuropathic symptoms with both vitamin B and D, again clinical trials are required in this region to establish their role in the treatment of diabetic neuropathy and painful diabetic neuropathy. Continue reading >>
Frontiers | A Systematic Review Of Treatment Of Painful Diabetic Neuropathy By Pain Phenotype Versus Treatment Based On Medical Comorbidities | Neurology
Front. Neurol., 20 June 2017 | A Systematic Review of Treatment of Painful Diabetic Neuropathy by Pain Phenotype versus Treatment Based on Medical Comorbidities 1Endocrinology Division, Diabetes Center of Universidade Federal de So Paulo (UNIFESP), Escola Paulista de Medicina, So Paulo, Brazil 2Brazilian Cochrane Center of Universidade Federal de So Paulo (UNIFESP), Escola Paulista de Medicina, So Paulo, Brazil Background: Painful diabetic neuropathy (PDN) is a serious, polymorphic, and prevalent complication of diabetes mellitus. Most PDN treatment guidelines recommend a selection of drugs based on patient comorbidities. Despite the large numbers of medications available, most randomized clinical trials (RCTs) conducted so far have yielded unsatisfactory outcomes. Therefore, treatment may require a personalized approach based on pain phenotype or comorbidities. Methods: To evaluate whether or not a patients pain phenotype or comorbidities can influence the response to a specific PDN treatment, we conducted a systematic review using two different approaches: pain phenotype and associated comorbidities-based treatment. Results: Out of 45 identified papers, 7 were thoroughly reviewed. We found four RCTs stratified according to pain phenotype with three main results: (1) paroxysmal pain had a better response to pregabalin; (2) the preservation of thermal sensation or nociception anticipated a positive response to the topical treatment of pain; and, (3) after a failure to duloxetine (60 mg/day), the patients with evoked pain or severe deep pain had a better response to association of duloxetine/pregabalin while those with paresthesia/dysesthesia benefited from duloxetine monotherapy (120 mg/day). By contrast, the other three papers provided weak and even contradictory evid Continue reading >>
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